The apparently limited geographical distribution and ecology of Bartonella bacilliformis present an opportunity for disease elimination if a. Bartonella bacilliformis is the causative agent of Carrion's disease, a highly endemic human bartonellosis in Peru. We performed a. Bartonella bacilliformis is the etiologic agent of Carrión's disease or Oroya fever. B. bacilliformis Bartonella bacilliformis is a member of the alpha-2 subgroup.
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Article · Figures & Data · Info & Metrics · PDF Human bartonellosis is caused by infection with Bartonella bacilliformis, a motile, aerobic, gram-negative. PDF | Background Carrion's disease affects small Andean ecology of Bartonella bacilliformis present an opportunity for disease. PDF | Bartonella bacilliformis has caused debilitating illness since pre-Incan times, but relatively little is known about its epidemiology.
Abstract Background Carrion's disease affects small Andean communities in Peru, Colombia and Ecuador and is characterized by two distinct disease manifestations: an abrupt acute bacteraemic illness Oroya fever and an indolent cutaneous eruptive condition verruga Peruana. Despite being an ancient disease that has affected populations since pre-Inca times, research in this area has been limited and diagnostic and treatment guidelines are based on very low evidence reports. The apparently limited geographical distribution and ecology of Bartonella bacilliformis may present an opportunity for disease elimination if a clear understanding of the epidemiology and optimal case and outbreak management can be gained. Methods All available databases were searched for English and Spanish language articles on Carrion's disease. In addition, experts in the field were consulted for recent un-published work and conference papers. The highest level evidence studies in the fields of diagnostics, treatment, vector control and epidemiology were critically reviewed and allocated a level of evidence, using the Oxford Centre for Evidence-Based Medicine CEBM guidelines. Results A total of 44 studies were considered to be of sufficient quality to be included in the analysis.
This outbreak occurred during months of low incidence which may suggest that more cases of Bartonellosis could be confirmed if molecular tests such as PCR were applied to samples obtained during the months of high incidence. The co-infection with Mycobacterium spp.
The incidence of pulmonary tuberculosis is high in developing countries, therefore the rate of co-infection with B. Limitations The sampled population is small and located in one particular region of Peru, and therefore results cannot be extrapolated to other areas endemic to B.
Furthermore, due to the nature of the febrile surveillance program, patient follow-was not possible after the initial management, creating gaps of knowledge regarding treatment success rates, complication rates and outcomes amongst co-infected patients.
However, this study represents the first molecularly confirmed co-infection of B. JdVM, DL was responsible for obtaining funding and laboratory work supervision. All authors critically revised the manuscript for intellectual content. All authors read and approved the final manuscript.
Competing interests On behalf of all authors, the corresponding author states that there are no Competing interests or funding related to this study.
Consent to publish Not applicable. Ethics approval and consent to participate This study has been approved by two independent Ethics Committees from Hospital Regional Docente de Cajamarca. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
References 1. Oroya fever and verruga peruana: bartonelloses unique to South America. Bartonellosis: new and old. Infect Dis Clin N Am. CrossRef Google Scholar 3.
Caceres A. Angelakis E, Raoult D. Pathogenicity and treatment of Bartonella infections. Int J Antimicrob Agents. Clin Infect Dis.
Natural history of infection with Bartonella bacilliformis in a nonendemic population. J Infect Dis. Google Scholar 9. Infect Dis Poverty. Rev Med Hered.
CrossRef Google Scholar PubMed Google Scholar Molecular method for Bartonella species identification in clinical and environmental samples. J Clin Microbiol. Outbreak caused by Acinetobacter strain RUH in an intensive care unit. The first report of a patient in the high forest was described by LOJA et al. The case described the acute phase, in Quillabamba Cuzco , found in a patient who lived at 1, meters above sea level Our patient was from the high forest in the Pichanaki district Chanchamayo, Junin , located at meters above sea level.
This area was previously known as a non-endemic area. The first epidemic cluster that showed the presence of the Carrion's disease in the Peruvian forest occurred between October and April in the Aguarunas communities in the province of San Ignacio Cajamarca.
Seven patients were detected who had peripheral blood smears consistent with infection by B. No patient presented in the eruptive phase.
Between and a bartonellosis cluster was found in the department of Amazonas, where several cases of Peruvian wart were confirmed with histopathology However, the cases originated more commonly from mountainous districts rather than the forest of Peru. Because of the lack of information about the exact origin of the wart cases, our report constitutes the first case confirmed in the Peruvian Forest.
In recent years, Carrion's disease clusters continued to be detected in Peru. Between April and June of there were 26 reported cases confirmed in the Sacred Valley of the Incas Cuzco , the majority of which were children. On the other hand, between January and December of there were 71 reported cases of the acute phase and in the eruptive phase in the province of Antonio Raymondi Ancash 7.
The recognition of a new endemic area of Carrion's disease has an enormous epidemiological significance.
In the district where our patient lives, there are approximately 3, families: 3, in urban zones 16, inhabitants , and in rural areas 24, inhabitants. All this population is therefore at risk to acquire the illness. At the present time, there have been reported cases of Carrion's disease clusters in 12 of the 24 departments of Peru.
Ancash is the area with the highest number of cases in both acute hemolytic phase and the eruptive one, as well as the highest rates of incidence12,14,16, The acute phase of Carrion's disease has also been described in other non-endemic areas.
Both are coastal cities, out of the traditional ecological niches for bartonellosis. These findings present the possibility of the extension of Carrion's disease not only to the forest of Peru, as it establishes of final form our report, but also to the Peruvian coast, in areas situated at less than m above sea level, suggesting important epidemiological changes.
Carrion's disease evolves through several phases. On the other hand, the acute hemolytic phase does not represent a sine qua non condition for the presence of the eruptive phase. This partially explains why the complete cycle of the illness had not been described in the Peruvian forest. Finally, as confirmed in our report, the inhabitants of endemic areas can develop the eruptive phase as the only manifestation of the illness10, The clinical manifestations of Carrion's disease have been well-studied2,12,13,20, Characteristically, the lesions of the eruptive phase are found predominantly on the upper and lower extremities and on the face The clinical presentation of our patient, with miliary, mulaire and nodule subdermal lesions, distributed in a disseminated form is unusual.
The observation of mucosal lesions is also infrequent. The lesions were found on oral and nasal mucosa and on the ocular conjunctiva13,16,21, The diagnosis of Carrion's disease requires clinical, epidemiological and laboratory information. The laboratory methods used frequently are peripheral blood smears and histopathologic studies.
The final diagnosis in the acute phase uses the peripheral blood smears, which shows parasitized red cells with the bacillary forms of B. The Romanovski, Giemsa and Wright stains facilitate the identification of the microorganisms2,12,13, The final diagnosis of the eruptive phase requires the demonstration of characteristic histopathological changes such as proliferation of endothelial cells, monocytes and macrophages, capillary proliferation, and in some cases, cellular atypia3,4, The Warthin-Starry stain confirms the diagnosis, allowing visualization of the bacteria.
Other techniques include electron microscopy and immunohistochemistry5. The differential diagnosis of the eruptive phase of Carrion's disease, depending on the type of lesion, includes bacillary angiomatosis, Kaposi's sarcoma, pyogenic granuloma, hemangioma, fibrosarcoma, epithelial sarcoma, cutaneous lymphoma, histioid phase of Hansen's disease and juvenile melanoma Spitz tumor 2,13,20, The treatment of Carrion's disease depends on the stage.
In the acute phase, the treatment of choice is chloramphenicol for 10 to 14 days. Quinolones, especially ciprofloxacin are alternative drugs Chloramphenicol and ciprofloxacin have intracellular activity and antibacterial effect against Gram-negative germs like Salmonella typhi and non-typhoid species that usually complicate the course of the illness In the eruptive phase, the treatment of choice is rifampin for days.
Erythromycin, azithromycin, ciprofloxacin, and streptomycin have also been used C. As seen in our patient, ciprofloxacin represents a good alternative, for a period of days13,16, Treatment during this phase produces a decrease in size of the lesions in 7 days range: 4 days and complete disappearance in 27 days range: days In spite of good therapeutic results, larger clinical trials are still necessary, which is often limited by the availability of patients in the eruptive phase.
The lesions are benign and spontaneously remit without leaving a scar within months. Our report shows extension of Carrion's disease and its presence in the Peruvian forest, probably due to the continuous commerce carried out among that region with settlers from in adjacent endemic zones. On the other hand, it is also possible that the sandfly vector Lutzomyia verrucarum and other species of Lutzomyia, potential transmitters of the illness, have evolved.
For these reasons, implementation of control measures for this disease are necessary in Peru, including strategies of entomological control, seroepidemiologic studies, and training of the technical personnel and health workers in these areas. Folia Derm.