ESCMID Online Lecture Library. by author

Transcription

1 ESCMID Postgraduate Technical Workshop Intracellular bacteria: from biology to clinic Villars-sur-Ollon, August 2013 Bartonella pathogenesis Pierre-Edouard Fournier Centre National de éférence des rickettsioses, de la fièvre Q et des bartonelloses Genus Bartonella Aerobic, Gram-negative bacteria Stained with the Gimenez method Size x 1.0 µ G+C%: Facultative intracellular (Maurin M et al. Eur. J. Clin. Microb.Infect. Dis. 1997) Target cells = endothelial cells and erythrocytes Highly fastidious Emerging pathogens sub-division of Proteobacteria Methanococcus spp. Staphylococcus spp. Bacillus spp. Streptococcus spp. Clostridium spp. Mycoplasma spp. Bacteroides spp. Fusobacterium spp. Mycobacterium spp. Borrelia spp. Chlamydia spp. Brucella spp. Bartonella spp. Campylobacter spp. Neisseria spp. Coxiella burnetii Pseudomonas spp. Acinetobacter spp. Vibrio spp. Entérobacteriaceae Archaebacteria Gram positive bacteria, low G+C% Bacteroides-Cytophaga Fusobacteria Gram positive bacteria, high G+C% Spirochetes Chlamydia Proteobacteria 6 th century Pre-Columbian huaca representation of verruga peruana Ecuador (Alexander. Am J trop Med hyg. 1995;52:354-9) 2,000 BC B. quintana in 16 th century B. bacilliformis WWI Trench fever Human teeth outbreaks in Spanish Byam et al. Oxford France soldiers niversity Press Peru (Drancourt et al. Clin Infect Dis. 2005;191:607-11) (Alexander. Am J trop Med hyg. 1995;52:354-9) 19 th century Oroya fever, Peru (Schultz. Am J trop Med hyg. 1968;17:503-15) 1889 Parinaud s conjunctivitis (Parinaud. Ann Occul. 1889;101:252-3) Bartonella genus (Strong et al. JAMA. 1915;64:806-8) 1950 Cat scratch disease (Debre et al. Soc Med Trop Paris. 1950;66:76-9) Taxonomy 1990s B. henselae and B. quintana in bacillary angiomatosis and endocarditis Bartonella species, incl. 14 human pathogens (elman et al. N Engl J Med. 1990;323: Drancourt et al. N Engl J Med. 1995;332:419-23) -proteobacteria 1984: Order ickettsiales, family ickettsiaceae (Bergey s manual) 1993: nification of the genera Bartonella and ochalimaea (Brenner et al. Int J Syst Bacteriol. 1993;43:777-86) 1995: nification of the genera Bartonella and Grahamella (Birtles et al. Int J Syst Bacteriol.1995;45:1-8) 2013: 29 species 3 subspecies in B. vinsonii Zoonoses => A complex ecology Humans (B. bacilliformis, B. quintana, B. elizabethae) Cats (B. henselae, B. clarridgeiae, B. koehlerae, B. bovis, B. quintana) Dogs (B. vinsonii, B. quintana, B. clarridgeiae, B. rochalimae, B. washoensis, B. bovis, B. henselae) odents (B.alsatica,B.grahamii,B.vinsonii,B.peromysci, B. talpae, B. tribocorum, B. birtlesii, B. doshiae, B. taylorii, B. japonica, B. silvatica, B. rattaustraliani, B. coopersplainsensis, B. queenslandensis) Cattle (B. bovis, B. henselae), deers (B. bovis, B. schoenbuchensis), horses(b. henselae) Other: raccoons, wild felids, dolphins, monkeys, bats, sea otters, marsupials 1 1

2 Vectors = A complex ecology Fleas (B. henselae++, B. koehlerae, B. clarridgeiae, B. doshiae, B. taylorii, B. quintana) Lice (B. quintana) Sandflies (B. bacilliformis) Biting flies (B. schonbuchensis, B. bovis, B. henselae) Ticks (B. henselae, B. quintana, B. washoensis, B. vinsonii) B. bacilliformis Lutzomia verrucarum Inhabitants of Andean areas 500-3,000 m above sea level Acute infection (Alexander. Am J Trop Med Hyg. 1995;52:354-9) Oroya fever Verruga peruana Biphasic infections B. quintana Pediculus humanus corporis Chronic infection B. henselae Cat Homeless Immunocompromised Immunocompetent patients patients Trench fever Cat scratch disease Endocarditis Bacillary Peliosis hepatis Chronic angiomatosis bacteremia Cat scratch disease B. henselae +++, B. clarridgeiae, B. koehlerae Kittens The most frequent Bartonella infection ~ 24,000 cases yearly in SA (Jackson et al. Am J Public Health. 1993:83: ) (Debre et al. Soc Med Trop Paris. 1950;66:76-9 Wear et al. Science. 1983;221:1403-5) 80% <18 years, worldwide (?) Mild disease (Carithers. Am J Dis Child. 1985;139: ) Primary inoculation lesion egional lymphadenopathy (90% of cases) Axilla > neck > groin Self limited, 2 6 months (Margileth. Adv Pediatr Infect Dis. 1993;8:1-21) (Gouriet al. BMC Infect Dis. 2007;7:30) Pathogenesis Adhesion to erythrocytes (T4SS [Trw]) Intra-erythrocytic parasitism => persistant bacteremia Proliferation of microvascular endothelial cells and neovascularization (angiogenesis) Activation of the alternative complement pathway eduction of the oxydative response of PMNs (Leboit et al. Am J Surg Pathol. 1989;10: ; Jacomo et al. Clin Diagn Lab Immunol. 2002;9:8-18) (Vayssier-Taussat.PLoS Pathogens 2010;6:e Manifestations vary according to the host status (immunocompromised, valvular defects) and the species 14 pathogenic species: B. henselae, B. quintana, B. bacilliformis, B. elizabethae, B. clarridgeiae, B. grahamii, B. vinsonii, B. koehlerae, B. alsatica, B. tamiae, B. washoensis, B. rochalimae Carrion s disease (Alexander. Am J trop Med hyg. 1995;52:354-9) Or bartonellosis Bartonella bacilliformis estricted to the Andes mountains Lutzomia verrucarum Oroya fever: acute hemolytic anemia, 35% superinfection, 40% mortality Verruga peruana (Peruvian warts) Cat scratch disease 50% fever < 39 C, malaise, weakness 10%: local suppuration => needle aspiration are forms: bacteremia, hepatic or splenic abscess, osteomyelitis, pneumonia, erythema nodosum, meningo-encephalitis, Parinaud s syndrome (unilateral conjunctivitis + pre-auricular adenitis), Leber s neuroretinitis (stellate macular (eed et al. Ophtalmology. 1998;105: exudates) Suhler et al. Ophtalmology. 2000:107:871-6) Neurological complications ~ 1-2% (Carithers. Am J Dis Child. 1985;139: of CSD cases Carithers & margileth. Am J Dis Child. 1991;145:98-101) 2 2

3 Trench fever (Byam et al. Oxford niversity Press. 1919) Or Volhynia fever, Meuse fever, His-Werner disease, shinbone fever, shank fever, quintan fever B. quintana Pediculus humanus corporis WWI Incubation : days May be asymptomatic Most cases: fever with a brutal onset, headache and invalidating muscle pain, sweats, and conjunctive injection 4-5 days episodes, separated by 4-5 days intervals 3-8 relapses, attenuation of symptoms during recurrences arely, passage to a chronic disease, with weight loss, cardiac arrythmia, dyspnea, anemia, and depression Bartonella endocarditis Microorganism Present Marseille study current study (n (n = 718) 676) France 2005 (n = 348) Medicine 2005; France (n = 88) Clin Infect Dis 1995; Great Britain (n = 63) Heart 2003; 89: Algeria (n = 62) Emerg Infect Dis 2005; 84: : : Bartonella C. burnetii sp Brucella Bartonella melitensis sp Chlamydia Streptococcus sp. sp Staphylococcus sp Corynebacterium sp T. whipplei C. burnetii Corynebacterium sp Enterobacteriaceae Enterobacteriaceae HACEK bacteria HACEK bacteria Staphylococcus sp Brucella melitensis Streptococcus Chlamydia sp. sp Other T. whipplei bacteria Fungi Other bacteria No aetiology Fungi No aetiology Bartonella endocarditis B. quintana++, B. henselae +, B. vinsonii, B. elizabethae, B. koehlerae, B. alsatica Males > females aortic valve > mitral valve No specific clinical presentation extensive valvular damage B. henselae B. quintana mean age sex ratio M/F previous 90 % 39,5 % valvulopathy homeless 0 57,8 % body lice 0 36,1 % alcoholism 0 60,5 % contact with cats 70 % 0 Valvular surgery 90 % 97 % Death 10 % 8 % (Fournier PE al. Medicine 2001; 80: aoult et al. Arch. Intern. Med. 2003;163:226-30) The return of trench fever Industrialized countries: homeless people Infested with body lice Fever and weight loss Persistant bacteremia for months without treatment 5.3% of homeless in Marseille (Brouqui et al. Medicine. 2005;84:61-8) Outbreaks in war refugees (aoult et al. Lancet. 1998;352:353-8) (Spach et al. N Engl j Med. 1995;332:424-8 Stein & aoult. Lancet. 1995;345:450-1 Brouqui et al. N Engl J Med. 1999;340:184-9) Bartonella endocarditis ~3% of I.E., 2 nd cause of blood culture-negative endocarditis North-South prevalence gradient Brouqui and aoult. FEMS Immunol. Med. Microbiol. 2006;47:1-13 Bacillary angiomatosis Stoler et al. Am J Clin Pathol. 1983;80:714-8 Koehler et al. Clin Infect Dis. 1993;17: B. henselae and B. quintana Mohle-Boetani et al. Clin Infect Dis. 1996;22: Immunocompromised patients (AIDS ++) Initial symptoms : 50% cutaneous lesions, 20% abdominal pain, 20% adenopathy and fever. nique or multiple papules, most often red, sometimes ulcerated, bleeding, frequent satellite adenopathies Progressive increase of lesion size 3 3

4 Bacillary angiomatosis Peliosis hepatis Oral, respiratory, anal, and gastro-intestinal mucosa involvement Visceral involvement : liver, spleen, lymph nodes (B. henselae), bone (B. quintana), brain, heart, muscle, bone marrow Koehler et al. Clin Infect Dis. 1993;17: Without treatment, the evolution is most often fatal Few cases of spontaneous cure With antibiotics: quasi-constant cure Differential diagnosis : Kaposi sarcoma, angioma, bacterial granuloma, cutaneous cancers Other manifestations B. henselae: prolonged fever, chronic bacteremia (Slater et al. N Engl J Med. 1990;323: ), encephalitis with dementia in HIV+, maculo-papular eruption, septic shock, thyroïditis, urethritis, mammary tumor, lymphoedema (Lamas et al. Mem Inst Oswaldo Cruz. 2008;103:221-35) B. quintana: chronic lymphadenopathy (aoult et al. Lancet. 1994;343: 977), pericarditis (J Clin Microbiol. 2003;41:5291-3) B. grahamii: uveitis B. washoensis: myocarditis B. rochalimae: bacteremia B. tamiae: isolated fever Cross-reactions Cross-reactions between Bartonella, Chlamydia, and Coxiella burnetii (Maurin et al. J Clin microbiol. 1997;35: La Scola et al. J Clin Microbiol. 1996;34:2270-4) Western blot with cross-adsorption (Houpikian and aoult. Clin Diagn Lab Immunol. 2003:10:95-102) Non adsorbed Adsorbed Bq Adsorbed Bh B. henselae Immunocompromised Initially described as a visceral manifestation of bacillary angiomatosis Vascular proliferation => cystic blood-filled spaces in the liver and/or spleen Fever, abdominal pain, nausea, and diarrhea are inconstant Frequent hepatomegaly +/- splenomegaly Disseminated hypodense hepatic lesions are observed using CT Diagnosis of Bartonella infections Serology Cat scratch disease 1:50 < IgG < 1:400 The sensitivity varies depending on the method: 50 88% in CSD Chronic bacteremia IgG < 1:400 Endocarditis IgG > 1:800 PPV : 97% in endocarditis (Fournier et al. Clin. Diagn. Lab. Immunol. 2002;9: ) Culture Samples : Heparinized blood, skin, lymph node, cardiac valve or organ biopsies, arthropods... Culture on blood agar 5% blood, 5% CO 2 Improved by cell lysis or freezing of clinical specimens La Scola and aoult. J. Clin. Microbiol. 1999;37: Temperature : 37 C except for B. bacilliformis (28 C) 1. B. quintana «Fuller» 2. B. henselae «Houston» 3. B. vinsonii subsp. berkhoffii 4. B. elizabethae Fastidious bacteria =>primoculture : days 4 4

5 Cell culture (endothelial cells) Microculture using the shell vial method Inoculation by centrifugation Six weeks Cell culture evelation by Gimenez staining, indirect immunofluorescence, and/or PC Mass spectrometric identification MALDI-TOF MS Fast, cost-effective, reproducible Enables discrimination of all species Spectra available in the MS database (Fournier et al. J Med Microbiol. 2009;58:1154-9) B. henselae B. quintana Histology Molecular detection Samples: arthropods, EDTA blood, skin biopsies, hepatic biopsy, cardiac valve and lymph nodes Genes : 16-23S ITS citrate synthase groel PAP31 Fournier PE al. Medicine 2001; 80: Walls et al. J. Paediatr. Child Health. 2006;42: Identification of Bartonella strains Sequencing or species-specific T-PC assays Histology Lymph node, hepatic, cutaneous, cardiac valve biopsies. Silver staining (Warthin-Starry) Immunohistochemistry (mono- or polyclonal antibodies) Fresh or fixed fragments Cat scratch disease: nodular abscessed lymphadenitis Histology Bacillary angiomatosis: Endothelial cell proliferation Hepatic peliosis: Dilatation of hepatic sinusoids 5 5

6 Histology Treatment of Bartonella infections Endocarditis: Small vegetations Severe fibrosis Lepidi H et al. Am. J. Clin. Pathol. 2000;114:880-9 Warthin-Starry HPS Treatment HPS IHC No single treatment for all Bartonella infections Cat scratch disease without complication No antibiotic, or azithromycin, 500 mg, 1st day, then 250 mg/d, 4 days Bass JW et al. Pediatr Infect Dis J. 1998;17: Neurological involvement, retinitis Doxycycline 200 and rifampin 600 mg/d, 6 weeks Trench fever Gentamicin 3 mg/kg/d, 2 weeks and doxycycline 200 mg/d, 4 weeks Conclusions Penicillin G / Amoxicilline : 0.06 µg/ml Cefotaxime : 0.25 µg/ml Imipeneme : 0.5 µg/ml Gentamicin : 1 µg/ml Doxycycline : 0.12 µg/ml ifampicine : 0.25 µg/ml Erythromycine : 0.12 µg/ml Clarithromycine : µg/ml Sparfloxacine : 0.12 µg/ml Sulfamethoxazole : 5 µg/ml MICs correlate poorly with in vivo efficacy Only aminoglycosides are bactericidal (Musso et al. J Antimicrob Chemother. 1995;36:101-8 olain et al. J. Antimicron Chemother. 2000;46:811-4) Treatment Bacillary angiomatosis, peliosis hepatis Double effect: anti-microbial and anti-angiogenic (Meghari et al. J Infect Dis. 2006;193:380-6) Erythromycin 500 mg x 4/d, 3 months (BA), 4 months (PH) Endocarditis, bacteremia gentamicin 3mg/kg/d, 2 to 3 weeks + doxycycline 200 mg/d or amoxicillin 200mg/kg/d, 6 weeks Bartonella sp. are emerging and reemerging pathogens Zoonotic agents 12 human pathogens, more to discover? A wide array of clinical manifestations Mild (CSD) to severe (Oroya fever, BA, endocarditis) Specific antibiotic regimens 6 6