A CLAW TO THE LUNG: A PULMONARY MANIFESTATION OF DISSEMINATED BARTONELLA HENSELAE

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Infection from Bartonella henselae typically produces a localized cutaneous lymphadenitis. However, disseminated disease may occur and can be life-threatening. Pulmonary manifestations of Bartonella range from solitary nodules to pneumonia and ARDS. CASE PRESENTATION: A 44-year-old man with type 2 diabetes presented with 3 weeks of fever, weight loss, and nonproductive cough. He was otherwise healthy, used no illicit substances, had not traveled recently, but he owned several cats. On arrival, he was afebrile, hypotensive, and mildly hypoxic on room air. His lung exam revealed diffuse fine inspiratory crackles and diminished breath sounds at the bases. His spleen was enlarged and there were no skin lesions. Notable labs included white blood count 2,700/mm3, hemoglobin 9 g/dl, platelets 50,000 /mm3. Chest X-ray showed diffuse bilateral opacities and effusions and testing for HIV was negative. CT chest/abdomen further demonstrated marked splenomegaly, 2.7 cm splenic lesion, a 1.9 cm left upper lobe pulmonary nodule, and prominent mesenteric, mediastinal, and hilar lymph nodes. Bone marrow biopsy revealed normocellular marrow with erythroid hyperplasia, no abnormal B-cell clones or blasts. Subsequently, wedge resection of the pulmonary nodule and sampling of the mediastinal lymph nodes was performed via video assisted thoracoscopic surgery. Post-operatively, despite Vancomycin, Meropenem, Doxycycline, and Rifampin, fevers persisted, and he developed ARDS, ultimately necessitating veno-venous ECMO. Despite these measures, he died one week after admission. All cultures remained negative, however serologies returned positive for Bartonella henselae IgG at a titer >1:1024 and IgM of 1:128. The mediastinal lymph node biopsy demonstrated microorganisms on Warthin-Starry stain consistent with Bartonella. DISCUSSION: Bartonella henselae is a fastidious and fragile organism, thus very difficult to isolate in cultures. Patients are typically diagnosed with disseminated bartonellosis based on serologies or special stains in the context of typical clinical features such as our patient’s lymphadenopathy, splenic lesions, pancytopenia, and cat exposure. Most reports of disseminated bartonellosis occur in those immunocompromised after solid organ transplant or with advanced HIV, in whom mortality rates are 10-40% even with appropriate anti-microbials. Disseminated disease in immunocompetent hosts occurs rarely and does not commonly involve the lungs. Of 16 cases of Bartonella infections with pulmonary manifestations, 80% occurred in immunocompromised adults in whom nodules were more common manifestations than pneumonia or effusions, and only one individual developed ARDS (1). CONCLUSIONS: Because of its rarity, there are no previous reports describing ECMO to treat Bartonella-associated ARDS, emphasizing the importance of further studies. Reference #1: 1. Bandyopadhyay, Anuja, et al. “Pulmonary Nodules in an Immunocompetent Child with Cat Scratch Disease.” The Pediatric Infectious Disease Journal, U.S. National Library of Medicine, Dec. 2013, www.ncbi.nlm.nih.gov/pubmed/24030347. DISCLOSURES: No relevant relationships by Thomas Baudendistel, source=Web Response No relevant relationships by Tess Knudson-Fitzpatrick, source=Web Response