Multi systemic compromise due to Bartonella henselae in a child

ABSTRACT

Currently, at least 22 species of Bartonella are known to cause diseases in humans, with Bartonella henselae being the main one. Among the clinical manifestations associated with bartonellosis, cutaneous vasculitis is rare, but it can be severe. We report the case of a 9-year-old child who presented with cervical lymphadenopathy, arthritis, epididymitis, and cutaneous vasculitis as clinical manifestations of systemic bartonellosis, with positive detection of B. henselae in blood and skin fragment using species-specific conventional polymerase chain reaction (PCR) techniques. Vasculitis caused by Bartonella spp. occurs due to the endothelial tropism of the bacteria and can mimic systemic vasculitis with positive anti-neutrophil cytoplasmic antibodies (ANCA). Furthermore, we found just one previous report about epididymitis related to B. henselae infection, and arthritis is also considered an unusual manifestation of the infection. This case emphasizes the need to consider bartonellosis among differential diagnoses when faced with presentations of purpura, cutaneous vasculitis, arthritis, or epididymitis.

KEYWORDS:
Bartonella; Vasculitis; Epididymitis; Arthritis; Bartonella infections

INTRODUCTION

Bartonella species are intracellular bacilli responsible for prolonged and recurrent infections¹. Currently, at least 22 pathogenic species are known for infecting humans, with Bartonella henselae being the most relevant agent²,³. The main vectors of these bacteria are hematophagous arthropods, such as fleas and ticks. Felines and canines serve as reservoirs for this species; having contact with these animals is considered a risk factor for infection, which can manifest asymptomatically or even result in death⁴–⁶. Clinical manifestations associated with bartonellosis include fever, anemia, hepatitis, serositis, endocarditis, lymphadenopathy, uveitis, retinitis, neuritis etc. Dermatological manifestations are diverse, including purpura, vasculitis, maculopapular rash, urticaria, erythema nodosum, erythema marginatum, erythema multiforme, granuloma annulare, as well as granulomatous and angioproliferative reactions⁴. The objective of this study is to report the case of a child who presented cutaneous vasculitis, arthritis, and epididymitis associated with B. henselae infection, which was cured after appropriate antibiotic therapy.

CASE REPORT

The patient, a 9-year-old boy, was admitted with complaints of pain in the lower limbs, swelling in the right cervical region, and lesions that progressed from the lower to the upper limbs, with onset 10 days prior. He did not report recent weight loss. The patient and his family were previously healthy and lived in a rural area of Brazil, having contact with cats, dogs, pigs, chickens, and wild animals. He denied any history of scratches or bites from animals. On physical examination, a palpable cervical mass was observed, non-adherent, fibroelastic, painful, approximately 5 cm in diameter on the right side, with palpable, mobile lymph nodes about 1 cm in diameter on the left side. In the upper and lower limbs, palpable and non-palpable purpura were noted (Figure 1). Furthermore, the patient presented edema, local warmth, and pain on mobilization of the right ankle and knee. The left testicle showed increased volume and tenderness on palpation. During hospitalization, the patient experienced a low-grade fever episode. The ultrasound of the scrotum revealed a retractile testicle on the right, with no visualization of the right epididymis and evidence of left epididymitis. The computed tomography of the neck demonstrated bilateral cervical lymphadenopathy, especially at levels II to IV, with several cervical lymph nodes showing necrotic areas and moderate retropharyngeal edema. Rapid testing for Sars-CoV-2, two blood cultures, and a urine culture were negative. Serologies for toxoplasmosis, cytomegalovirus, and mononucleosis were non-reactive (IgG and IgM). Leukocytosis of 24,160 cells/μL with a left shift and c-reactive protein (CRP) level of 215 mg/L were noted, with no other significant laboratory alterations. The anatomopathological examination of the skin fragment revealed extravasated erythrocytes and the presence of neutrophils and eosinophils in the perivascular region (Figure 2). Direct immunofluorescence showed negative results for IgA, IgG, C1q, and C3, with IgM demonstrating adsorption in sparse apoptotic keratinocytes. The detection of B. henselae in blood and skin fragments by conventional PCR, specific for the gltA gene, identified the target DNA in both samples, confirming the diagnosis of cutaneous vasculitis associated with B. henselae infection. Treatment during hospitalization included doxycycline 5 mg/kg/day, clindamycin 40 mg/kg/day, and amikacin 15 mg/kg/day for 8 days. The patient was discharged with doxycycline 10 mg/kg/day for three months. He progressed with complete improvement of cervical lymphadenopathy, purpuric lesions, arthritis, and epididymitis (Figure 3). Currently, he has regular outpatient follow-up and has not experienced recurrences of the condition 20 months after completing treatment.

Figure 1
Initial clinical presentation: (A) Right cervical lymphadenopathy; (B, C, and D) palpable and nonpalpable purpura on the left elbow, right lower limb, and left lower limb, respectively.

Figure 2
Histopathological examination of skin fragment showing extravasated red blood cells (black arrows), sparse neutrophils (red arrows) and eosinophils (blue arrow) in the perivascular region.

Figure 3
Clinical presentation after treatment, with improvement of cervical lymphadenopathy and purpura in the lower limbs.

The case was conducted in accordance with the Ethics Code of the World Medical Association (Declaration of Helsinki). The minor's legal guardian signed the informed consent form and the child signed the informed assent form.

DISCUSSION

In B. henselae infection, purpura, although rare, can be severe and associated with fever and lymphadenopathy, which were present in our patient⁷. Vasculitis caused by Bartonella spp. occurs due to the endovascular tropism of the bacteria and can simulate systemic vasculitis with positive antineutrophil cytoplasmic antibodies (ANCA)³,⁷. Although this test was requested for our patient, it could not be performed at the hospital.

Bartonella spp. can cause asymptomatic cyclic bacteremia in humans and animals⁴,⁸. Approximately 31% of endocarditis cases are culture-negative, and of these, up to 30% are caused by Bartonella spp.⁹,¹⁰. In renal involvement associated with B. henselae infections, the most common pattern is that of diffuse proliferative post-infectious glomerulonephritis secondary to immune complex deposition, typically linked to native-valve endocarditis¹¹. The investigation for renal involvement was conducted in our patient and no alterations were found.

The laboratory diagnosis of infections caused by Bartonella spp. is challenging. Serology with indirect immunofluorescence may indicate past infection and can present cross-reactivity with other pathogens, leading to false-positive results. Additionally, the antigens in commercial kits are restricted to a few species, resulting in false-negative outcomes as well¹²,¹³. However, indirect immunofluorescence is recommended in settings in which molecular tests are not routinely available¹⁴. Histology can diagnose classic bartonellosis, such as bacillary angiomatosis or cat scratch disease⁴. Culture requires special conditions, and even under these conditions, primary isolation is rare and it can take six to eight weeks to obtain the isolate¹⁵. Detection of Bartonella spp. using the PCR technique (from blood or tissue) provides a faster result and enables species identification, as in the reported case, in which the result was positive in both the blood and skin fragment, identifying B. henselae¹⁶. Multiple techniques should be used in combination to avoid false-negative results⁹. These difficulties are another factor that contribute to misdiagnosing the condition⁴.

There is no treatment that guarantees eradication of the agent from the host. Systemic disease, similar to endocarditis caused by these agents, could be treated with an aminoglycoside for two weeks and doxycycline for six weeks to six months, although there are no studies supporting this or other therapeutic regimens³. Other treatment options include macrolides, sulfas, and rifampicin¹⁷. Our patient received clindamycin and amikacin for eight days and doxycycline for three months, showing no recurrence of the condition after medication cessation in 20 months of follow-up.

Vasculitis caused by Bartonella spp. can mimic primary vasculitis, a possibility that should be considered in the differential diagnosis of purpura or vasculitis.⁷ Furthermore, the authors found just one previous report about epididymitis related to B. henselae infection, and arthritis is also considered an unusual manifestation of the infection¹⁸,¹⁹.

CONCLUSION

The reported case involves a child with an epidemiological background for bartonellosis, cervical lymphadenopathy, low fever, arthritis, epididymitis, and cutaneous vasculitis. The disease was considered as a differential diagnosis, appropriate diagnostic techniques were utilized, and the correct therapy was instituted, resulting in the resolution of the condition. Definitive diagnosis of bartonellosis remains challenging due to technical and analytical limitations, as well as the condition often being overlooked in clinical settings.

• FUNDING
  This research received no external funding.

ACKNOWLEDGMENTS

We thank the Laboratory of Applied Research in Dermatology and Bartonella Infection for the diagnosis support in this case.

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Publication Dates

• Publication in this collection
  18 July 2025
• Date of issue
  2025

History

• Received
  22 Jan 2025
• Accepted
  20 May 2025