Cutaneous lesions of bacillary angiomatosis

A 23-year-old man presented with a 1-month history of fever and a generalized body rash. The patient had an underlying human immunodeficiency virus (HIV) infection with a recent cluster of differentiation (CD) 4 T-cells count of 8 cells/mL and HIV-1 ribonucleic acid (RNA) 83,111 c/mL. Skin examination revealed numerous red-purplish skin papules and exophytic nodules (Figure 1A), with the largest measuring 3 cm in diameter (Figure 1B), distributed over whole-body surfaces. Hematoxylin and eosin (H&E) staining of biopsy specimens from skin lesions showed a circumscribed mass composed of proliferating capillaries with marked edema and necrosis on the surface (Figure 1C). Multiple bacilli were present throughout the mass and showed positive staining on Gram, Warthin-Starry (Figure 1D), and Giemsa. A diagnosis of bacillary angiomatosis (BA) was established following a skin biopsy. The skin lesions improved after a month of treatment.

FIGURE 1A:
Multiple skin nodules present over the trunk.

FIGURE 1B:
Skin biopsy is done from this nodule.

FIGURE 1C:
Multiple small blood vessels and ecstatic vessels filled with red blood cells (arrows) are seen under a microscope with hematoxylin and eosin (H&E) stain.

FIGURE 1D:
Multiple bacilli (arrows) are seen under a microscope with Warthin-Starry stain.

BA is an opportunistic infection in immunocompromised patients, such as those with HIV, who are undergoing chemotherapy or post-transplantation. It is caused by the aerobic Gram-negative bacilli Bartonella henselae and B. quintana¹. Skin lesions of BA can be mistaken for Kaposi’s sarcoma or pyogenic granuloma. Thus, a skin biopsy is paramount to establishing a diagnosis. Diagnosis can also be rapidly established using polymerase chain reaction assays, serologic testing, or electron microscopy. The drugs of choice for the treatment of BA are usually doxycycline or macrolides². Combination therapy may be necessary for patients with severe diseases.

ACKNOWLEDGMENTS

We express our deepest gratitude to the staff at Hospital Melaka who were involved in the care of the patient.

REFERENCES

• ¹
  Rose SR, Koehler JE. Chapter 236: Bartonella, including cat-scratch disease. In: Bennett JE, Dolin R, Blaser MJ, editors. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Disease. 9th ed. Philadelphia, PA: Elsevier Press; 2020. p. 2824-43.
• ²
  Panel on Opportunistic Infections in Adults and Adolescents with HIV. Chapter C: Bartonellosis. In: Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents: Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. [cited October 2021]. Available from: https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/bartonellosis-0?view=full
  » https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/bartonellosis-0?view=full

• Financial Support: None.

Publication Dates

• Publication in this collection
  12 Aug 2022
• Date of issue
  2022

History

• Received
  15 Mar 2022
• Accepted
  24 May 2022