DERMATOPATHOLOGY CASES: Self-Assessment Cases: Editor - Dr Sampurna Roy MD

Digital Images of interesting cases that will include the full spectrum of Dermatopathology, presented in the form of quiz.

The answer of the cases include related links and recent abstracts of articles.

Wednesday, January 20, 2010

Answer of Dermatopathology Case 34

Bacillary Angiomatosis

Visit: Pathology of bacillary angiomatosis
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Bartonellosis. Clin Dermatol. 2009 May-Jun;27(3):271-80.
Bartonella spp are fastidious bacteria that occur in the blood of man and mammals; they are usually vector borne but can also be transmitted by animal scratches and bites. The bartonelloses of medical importance comprise Carrión's disease, trench fever, cat-scratch disease, bacillary angiomatosis, and peliosis hepatis. Carrión's disease, known as Oroya fever in the acute phase and verruga peruana (Peruvian wart) in its chronic form, has curious manifestations that,until recently, have been restricted in their geographic distribution to dwellers of the high, dry Andean valleys, but new sites of disease are emerging. Trench fever is associated with louse-borne disease and homelessness. Cat-scratch disease, bacillary angiomatosis, and peliosis hepatis are increasingly being recognized as causes of human disease, especially in susceptible population groups such as HIV-infected persons. The Bartonella spp are considered emerging human pathogens. The clinical manifestations, differential diagnosis, laboratory diagnosis, and treatment of these conditions are discussed.

Bacillary angiomatosis.J Dtsch Dermatol Ges. 2009 Sep;7(9):767-69.
An infection with Bartonella henselae transmitted from domestic cats to humans by scratching normally leads to cat-scratch disease. When the human host has severe immunosuppression or HIV infection, the potentially life-threatening disease bacillary angiomatosis can develop. A 79-year-old man presented with livid-erythematous, angioma-like skin lesions. We considered a cutaneous infiltrate from his known chronic lymphocytic leukemia, Merkel cell carcinoma, cutaneous metastases of internal tumors, cutaneous sarcoidosis, mycobacterial infection and even atypical herpes simplex infection. The correct diagnosis was proven histologically and by PCR. Because of increasing numbers of immunosuppressed and HIV-positive patients, as well as an infection rate of 13% for B. henselae in domestic cats in Germany, one must be alert to the presence of bacillary angiomatosis.

Bacillary angiomatosis: microbiology, histopathology, clinical presentation, diagnosis and management.Bol Asoc Med P R. 1996 Apr-Jun;88(4-6):46-51.
Bacillary angiomatosis is known to be caused by a rickettsial organism; Rochalimaea henselae. This causative agent has been compared with different microorganisms and clinical conditions that appear in similar settings but thathave been clearly differentiated from them; i.e. Cat-scratch disease (Afipiafelis), Bartonella bacilliformis, other Rochalimaea sp., Kaposi's sarcoma, Lobular capillary hemangioma, Angiosarcoma, and Epithelioid hemangioma. Clinically the bacillary angiomatosis (BA) skin lesions vary from a single lesionto thousands. The cutaneous lesion appears as a bright-red round papule, subcutaneous nodule, or as a cellulitic plaque. When the lesion is biopsied it tends to blanch-out, bleed, and cause pain. The patient might present with signs and symptoms of chills, headaches, fever, malaise, and anorexia with or without weight loss. The extracutaneous lesions found in BA tend to be from multiple organs affecting from the oral lesions to anal mucosal lesions to widespread visceral lesions. The sites of preferences for BA lesion manifestation tend to be the liver, spleen , lymph nodes, and bone. To diagnose bacillary angiomatosis the physician should prepare a differential diagnosis based primarily on its histopathological and clinical characteristics. To confirm the results from the stain, electron microscopy can identify the bacillus and pin-point the diagnosis of bacillary angiomatosis. The lesions presented by BA respond well to therapy with erythromycin 500mg four times daily for a duration of 2 weeks to 2 months. In case of intolerance to erythromycin the second line of drug that successfully treats the BA bacillus is doxycycline. If relapses of the BA lesion recur, then a prolonged antibiotic therapy is necessary and in AIDS patients the duration maybe extended as life-long suppressive therapy.