A 48–year–old man with AIDS and a CD4 count of 68 presented with two weeks of fevers, night sweats, nausea and decreased appetite. He had been well until two months earlier when he was diagnosed with strongyloids and treated. One month later he presented with fever, leukopenia, anorexia, and fifteen–pound weight loss. He was referred to an outpatient HIV clinic two weeks prior to admission and was started on anti–retroviral therapy. On admission, he had a temperature of 102.4°F; the remaining vital signs were normal. His cardiac, pulmonary, neurologic and skin examinations were normal. He had a palpable spleen and nonfixed, nontender cervical, supraclavicular and inguinal lymphadenopathy. Initial laboratory studies revealed a hemoglobin of 9.2 g/dL, 162,000 platelets, and 1,700 white blood cells, with an absolute neutrophil count of 992. His chest X–ray was normal and abdominal and pelvic CT revealed only hepatosplenomegaly. Cultures of his blood, urine and bone marrow aspirate were negative for bacteria, fungus and AFB. His serum cytomegalovirus, cryptococcus antigens and a urine histoplasma antigen were all negative. Culture and serology for bartonella were performed in addition to a modified tissue silver stain. The patient was discharged and, a few weeks later, serology from the CDC returned positive for bartonella quintana. His primary HIV care provider was notified and he was treated.
Hospitalists are seeing an increase in the number of patients with HIV, and a greater diversity of conditions referable to opportunitistic infections. Fever of unknown origin and unexplained hepatosplenomegaly/lymphadenopathy, as was the case with our patient, are two of the most common conditions. Bartonella quintana is a facultative, intracellular gram–negative rod transmitted via body lice. As the body louse nests in clothing, and must feed on a daily basis, it is almost unheard of to see body lice in patients that change their clothes more than once per week. Bartonella quintana is also commonly seen in HIV patients as a manifestation of late–stage AIDS.
B. quintana usually manifests with bacillary angiomatoses, however it also can cause isolated bacteremia with symptoms of fever, abdominal pain, pancytopenia, lymphadenopathy and hepatosplenomegaly that are nonspecific and make diagnosis a challenge. The hospitalist’s clinical suspicion is critical, as confirming the diagnosis requires persistence: Bartonella is a bacteria that is difficult to culture and must be collected in a tube containing EDTA, as this is required for conducting the silver stain. Once the diagnosis is confirmed, the patient can be treated with erythromycin or doxycycline, often with resolution of symptoms within a week. Treatment should be continued for at least three months in immunocompromised patients. For those with persistent relapses and a CD4 count less than 200, antibiotic prophylaxis can be utilized.