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• W1833866520 abstract "Bacillary angiomatosis (BA) is a neovascular proliferative disorder due to Bartonella henselae or Bartonella quintana, originally described as involving the skin and lymph nodes of human immunodeficiency virus (HIV)-infected patients [1Anderson BE Neuman Ma Bartonella spp. as emerging human pathogens.Clin Microbiol Rev. 1997; 10: 203-219PubMed Google Scholar, 2Koehler JE Sanchez MA Garrido CS et al.Molecular epidemiology of Bartonella infections in patients with bacillary angiomatosis‐peliosis.N Engl J Med. 1997; 337: 1876-1883Crossref PubMed Scopus (257) Google Scholar]. BA has rarely been reported in patients with cancer [3Liston TE Koehler Je Granulomatous hepatitis and necrotizing splenitis due to Bartonella henselae in a patient with cancer: case report and review of hepatosplenic manifestations of Bartonella infection.Clin Infect Dis. 1996; 22: 951-957Crossref PubMed Scopus (52) Google Scholar] or in immunocompetent individuals [4Tappero JW Koehler JE Berger TG et al.Bacillary angiomatosis and bacillary splenitis in immunocompetent adults.Ann Intern Med. 1993; 118: 363-365Crossref PubMed Scopus (118) Google Scholar]. Rhodococcus equi is an aerobic, Gram-positive, facultative intracellular pathogen, mostly responsible for necrotizing pneumonia, intestinal ulcerations and lymphadenitis [5Verville TD Huycke MM Greenfield RA Fine DP Kuhls TL Slater Ln Rhodococcus equi infections of humans. 12 cases and a review of the literature.Medicine (Baltimore). 1994; 73: 119-132Crossref PubMed Scopus (147) Google Scholar], in association with marked impairment of cell-mediated immunity [6Prescott Jf Rhodococcus equi: an animal and human pathogen.Clin Microbiol Rev. 1991; 4: 20-34Crossref PubMed Scopus (513) Google Scholar]. We report the consecutive occurrence of B. henselae bacillary angiomatosis and R. equi bacteremia in a severely neutropenic HIV-negative adult with acute myeloblastic leukemia. A 60-year-old HIV-negative man was admitted to our unit in July 1994 for the treatment of chronic myeloid leukemia transformed into acute myeloblastic leukemia. Initial evaluation did not detect any other remarkable medical condition. The patient owned a dog but denied having any particular contact with cats or farm animals. From July 1991 to June 1994, he received chemotherapy consisting of hydroxyurea and subcutaneous injections of recombinant interferon-α and cytosine-arabinoside. In July 1994, he received one cycle of intravenous idarubicin and cytosine-arabinoside, which was again started on 10 August (day 1), because hematologic remission was not obtained. Profound neutropenia (<100 neutrophils/mm3) started at day 10; piperacillin and amikacin had been started on day 16 because of unexplained fever. On day 18, the patient developed multiple dome-shaped purple nodular lesions on his face, right arm and left thigh, for which intravenous teicoplanin (500 mg/day) and fusidic acid (500 mg three times a day) were added to the initial antibacterial combination from day 18 to day 28 up to the neutrophil recovery. Histologic examination of two skin biopsies fixed in 10% formalin and embedded in paraffin was compatible with the diagnosis of cutaneous BA, although Grocott-Gomori and Whartin-Starry failed to reveal any microorganism. In September, the patient was readmitted for uncontrolled leukemia necessitating treatment with intravenous chemotherapy. At that time, skin lesions had completely disappeared. A non-bacteriologically documented episode of febrile neutropenia rapidly developed which again required intravenous piperacillin and amikacin. Fever regressed shortly thereafter, but a new episode of sepsis occurred in October for which the patient received intravenous imipenem–cilastatin in combination with amikacin and teicoplanin, which transiently controlled fever. At that time, three Dupont-Isolator blood cultures were performed. The patient died shortly thereafter of uncontrolled leukemia. No autopsy was performed. After 6 weeks of subculture on horse blood agar, one of the last lysis–centrifugation blood cultures grew Gram-positive bacilli identified as R. equi (Api coryné, Biomérieux, Marcy l’Étoile, France; and Laboratoire des Identifications, Institut Pasteur, Paris, France). The strain was susceptible to all the antibiotics usually active against corynebacteria, including penicillin. Molecular detection of B. henselae was performed on serum that had been frozen or from sections of formalin-fixed, paraffin-embedded skin-biopsy specimens by PCR amplification and sequencing of the citrate synthase gene as previously described [7La Scola B Raoult D Culture of Bartonella quintana and Bartonella henselae from human samples: a 5‐year experience (1993–98).J Clin Microbiol. 1999; 37: 1899-1905PubMed Google Scholar]. DNA extracts suitable for use as templates in PCRs were prepared from crushed skin-biopsy specimens and serum using QIAmp tissue kit (Qiagen, Hilden, Germany) according to the manufacturer's instructions. B. henselae DNA was detected in both skin and serum samples. The immunofluorescence assays to detect serum antibodies directed against B. henselae, B. quintana and Afipia felis were negative. Our patient reported no known exposure to cats, a factor recorded in one-third of the patients with BA [8Tappero JW Mohle‐Boetani J Koehler JE et al.The epidemiology of bacillary angiomatosis and bacillary peliosis.JAMA. 1993; 269: 770-775Crossref PubMed Scopus (176) Google Scholar], but he owned a dog. Interestingly, it has been shown that Ctenocephalides felis, the cat-flea, may be culture and DNA positive for B. henselae [9Koehler JE Glaser CA Tappero Jw Rochalimea henselae infection. A new zoonosis with the domestic cat as reservoir.JAMA. 1994; 271: 531-535Crossref PubMed Scopus (426) Google Scholar] and that C. felis also commonly infests dogs, the latter perpetuating the flea life cycle [10Tompkins Ls Rochalimea infections. Are they zoonoses?.JAMA. 1994; 271: 553-554Crossref PubMed Scopus (21) Google Scholar]. However, a recent study by Koehler et al found that exposure to dog-flea bite was similar in patients infected with B. henselae and their matched controls [2Koehler JE Sanchez MA Garrido CS et al.Molecular epidemiology of Bartonella infections in patients with bacillary angiomatosis‐peliosis.N Engl J Med. 1997; 337: 1876-1883Crossref PubMed Scopus (257) Google Scholar]. Three recent reports described cutaneous BA in patients with chronic (n = 2) or acute (n = 1) leukemia [11Myers SA Prose NS Garcia JA Wilson KH Dunsmore KP Kamino H Bacillary angiomatosis in a child undergoing chemotherapy.J Pediatrics. 1992; 121: 574-578Abstract Full Text PDF PubMed Scopus (47) Google Scholar, 12Török L Viragh SZ Borka I Tapai M Bacillary angiomatosis in a patient with lymphocytic leukaemia.Br J Dermatol. 1994; 130: 665-668Crossref PubMed Scopus (26) Google Scholar, 13Milde P Brunner M Borchard F et al.Cutaneous bacillary angiomatosis in a patient with chronic lymphocytic leukemia.Arch Dermatol. 1995; 131: 933-936Crossref PubMed Scopus (17) Google Scholar] (Table 1). Our patient was seronegative at the time of BA diagnosis. This lack of antibody detection may reflect the profound immunosuppression observed in our patient and is in accordance with the previous experience of the Center for Rickettsial Reference in Marseille [7La Scola B Raoult D Culture of Bartonella quintana and Bartonella henselae from human samples: a 5‐year experience (1993–98).J Clin Microbiol. 1999; 37: 1899-1905PubMed Google Scholar, 14Gasquet S Maurin M Brouqui P Lepidi H Raoult D Bacillary angiomatosis in immunocompromised patients: a clinicopathological and microbiologic study of seven cases and review of the literature.AIDS. 1998; 12: 1793-1803Crossref PubMed Scopus (76) Google Scholar]. In contrast, PCR offers a rapid and specific means to detect the organism [1Anderson BE Neuman Ma Bartonella spp. as emerging human pathogens.Clin Microbiol Rev. 1997; 10: 203-219PubMed Google Scholar]. B. henselae DNA was detected in our patient's serum, while blood cultures analyzed with an automated system failed to isolate the organism. Bacteremic episodes were reported in non-HIV-infected persons, either immunocompromised, or immunocompetent [15Slater LN Welch DF Hensel D Coody Dw A newly recognized fastidious Gram‐negative pathogen as a cause of fever and bacteremia.N Engl J Med. 1990; 323: 1587-1593Crossref PubMed Scopus (242) Google Scholar]. The clinical improvement that we observed in our patient could probably be ascribed to amikacin. Indeed, although Bartonella spp. have been reported to be highly susceptible to antibiotics, only the aminoglycosides were bactericidal on either axenic or cell line-cultured organisms [16Musso D Drancourt M Raoult D Lack of bactericidal effect of antibiotics except aminoglycosides on Bartonella (Rochalimea) henselae.J Antimicrob Chemother. 1995; 36: 101-108Crossref PubMed Scopus (76) Google Scholar]. The lack of relapse during the following 2 months can probably be attributed to the reintroduction of several antibiotics.Table 1Description of four male HIV-negative patients with leukemia who developed bacillary angiomatosis during chemotherapyRef.Age (years)Underlying risk factorsContact with catsNeutrophil count (/mm3)Lymphocyte count (/mm3)BA diagnosisTreatmentOutcome(11)12ALL steroid chemotherapyUnknown820820Histology + EM + PCR in skinErythromycinComplete resolution(12)78CLL diabetesYes (cat scratch)243024 300Histology + EMErythromycinComplete resolutionsteroid, chemotherapy(13)55CLL steroid, chemotherapyNo730110Histology + EMClarithromycinComplete resolutionThis report60AML chemotherapyNo< 100< 100HistologyaSilver impregnation including Warthin–Starry stain were negative. PCR in serum and skinPiperacillin + amikacinComplete resolutionCLL, chronic lymphocytic leukemia; AML, acute myeloblastic leukemia; ALL, acute lymphoblastic leukemia; BA, bacillary angiomatosis; PCR, polymerase chain reaction; EM, electron microscopy.a Silver impregnation including Warthin–Starry stain were negative. Open table in a new tab CLL, chronic lymphocytic leukemia; AML, acute myeloblastic leukemia; ALL, acute lymphoblastic leukemia; BA, bacillary angiomatosis; PCR, polymerase chain reaction; EM, electron microscopy. R. equi infections have rarely been reported in patients reporting contact with dogs as in our case [17Farina C Ferruzzi S Mamprin F Vailati F Rhodococcus equi infection in non‐HIV‐infected patients. Two case reports and review.Clin Microbiol Infect. 1997; 3: 12-18Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. Pertinently, although rare, R. equi skin lesions and fecal carriage have been reported in dogs [6Prescott Jf Rhodococcus equi: an animal and human pathogen.Clin Microbiol Rev. 1991; 4: 20-34Crossref PubMed Scopus (513) Google Scholar], thereby raising the possibility of direct transmission of the bacteria from this domestic animal to immunocompromised hosts. Although blood cultures were positive in 65% of HIV-infected patients in one report [5Verville TD Huycke MM Greenfield RA Fine DP Kuhls TL Slater Ln Rhodococcus equi infections of humans. 12 cases and a review of the literature.Medicine (Baltimore). 1994; 73: 119-132Crossref PubMed Scopus (147) Google Scholar], positivity was also reported in 17 non-HIV-infected patients, including 10 with hematologic malignancies [17Farina C Ferruzzi S Mamprin F Vailati F Rhodococcus equi infection in non‐HIV‐infected patients. Two case reports and review.Clin Microbiol Infect. 1997; 3: 12-18Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. It should be noted that the frequency of R. equi bacteremia is probably underestimated, as blood cultures were never allowed to grow for as long as ours (6 weeks). Among these 17 patients, 13 were cured of their bacteremic episode [17Farina C Ferruzzi S Mamprin F Vailati F Rhodococcus equi infection in non‐HIV‐infected patients. Two case reports and review.Clin Microbiol Infect. 1997; 3: 12-18Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. R. equi is usually sensitive to glycopeptides, imipenem and aminoglycosides [18Nordmann P Ronco E In‐vitro antimicrobial susceptibility of Rhodococcus equi.J Antimicrob Chemother. 1992; 29: 383-393Crossref PubMed Scopus (83) Google Scholar], and all of these antibiotics were empirically given in combination to our patient. Finally, it should be noted that the R. equi strain isolated from our patient was susceptible to penicillin. This susceptibility was found for isolates from soil and animals, but human strains were reported to be invariably resistant to penicillin [19Emmons W Reichwein B Winslow Dl Rhodococcus equi infection in the patient with AIDS: literature review and report of an unusual case.Rev Infect Dis. 1991; 13: 91-96Crossref PubMed Scopus (89) Google Scholar], with MICs ranging from 2 to 16 mg/L [18Nordmann P Ronco E In‐vitro antimicrobial susceptibility of Rhodococcus equi.J Antimicrob Chemother. 1992; 29: 383-393Crossref PubMed Scopus (83) Google Scholar]. Our case report emphasizes that zoonoses may cause fever in HIV-negative neutropenic patients with hematologic malignancies." @default.
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• W1833866520 title "Consecutive bacillary angiomatosis and Rhodococcus equi bacteremia during acute leukemia: zoonoses may cause fever in neutropenic patients" @default.
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