Bacillary angiomatosis is a vascular disease which results from Bartonella bacteria and is most prevalent among those with compromised immune systems, including those with AIDS or those who have received organ transplants. The condition was first identified in 1983 and may also be present in people with no underlying diseases, although this is not very common. It manifests in the form of nodules in different organs and can be easily treated by oral antibiotics such as erythromycin and other related antibiotics. Although treatable, bacillary angiomatosis can be fatal to patients if not well handled; moreover, it is the most prevalent reason behind angiomatous skin changes within HIV positive patients. 

Bacillary angiomatosis has been identified in over 45 states within the United States with increased occurrences in geographical areas with high HIV prevalence such as Florida, Texas, New York, and San Francisco. Globally, the disease is less prevalent in Europe than in North America; however, it has been described in other continents, including Africa, South America, Asia, and Australia. A number of people in Andalucía, an area in the south of Spain had antibodies to Bartonella species within their blood which prove that the infection is prevalent within the area. 

In the U.S., the disease is presented among people of different race, 40% of the patients are white, 40% are black and 20% are of Hispanic origin. Majority of cases are seen in males, which may be attributed to the high incidence of HIV positive among male patients. The symptoms of bacillary angiomatosis may occur at any age but are not common in children. 

Bartonella henselae is primarily carried by cats as they healthy infected cats can perpetuate the bacterium through flea vectors. Bartonella can be acquired through a cat scratch or bite, while B. quintana is transmitted through body louse infestation especially among the needy such as the homeless and those who are poor. 

Fleas and ticks are potential vectors; however, the direct transmission of Bartonella from fleas to humans has not been documented. After entering the human body, these bacteria cause infections in various cells such as the red blood cells and the endothelial cells where they adhere to the cells and invade them through several mechanisms. These bacteria can enter the cells and subvert them manipulating immune system and the formation of long-term asymptomatic infections. Furthermore, Bartonella can make changes to promote arterial development and perpetuation throughout the host. 

Bacillary angiomatosis is caused by two species of the Bartonella genus: Bartonella henselae and Bartonella quintana. Although both can cause skin lesions, B quintana has greater pathogenicity for subcutaneous and bone lesions, while B henselae has greater affinity for hepatic and splenic peliosis. B. henselae is an aerobic, oxidase negative, gram negative, slightly curved rod-shaped bacteria that has optimal growth temperature of 37°C. Its colonies are rough and powdery and morphologically are like cauliflower while the bacteria are about two microns in length. B. henselae is known to have a circular chromosome which is 1. They found that the rat chromosome 9 Mbp, which is slightly larger than the 1. This project will focus on comparative analysis of B. quintana complete 5 Mbp genome. 

B.quintana is a slow-growing, gram-negative bacterium with a short, spiral shape, measuring approximately 0. 4 microns wide and 1. 5 microns in length. The initial isolation of B. quintana lasts for 12 to 14 days sometimes up to 45days. Some of the related bacterias are, for instance, Bartonella bacilliformis and the present B. henselae and B. quintana and while other species of Bartonella have flagella, which are absent in B. henselae and B. quintana. However, they swim by bending in an undulating motion with the help of small protuberances called fimbriae.

The prognosis of bacillary angiomatosis is good since most of the patients respond to antibiotics; there is the complete clearing of the lesion. However, Inflammatory signs and symptoms usually resolve soon after onset but hyperpigmentation or minor induration at the site of the lesions may persist indefinitely. Recurrent symptoms may appear in patients, and this is mostly true in cases with compromised immune system after treatment has been completed. 

The other determinant of the prognosis is early recognition and management of the condition in addition to the degree of immunosuppression present in the patient. If the diagnosis is made later then it hampers the proper treatment, and one must take a greater number of antibiotics which takes more time. If untreated, bacillary angiomatosis may progress and become serious condition that could result to death. 

Age Group 

Pediatric: Bacillary angiomatosis has been reported in few cases in childhood, there are cases in children include a 12-year-old acute leukemia boy who had chemotherapy and a healthy 6-year-old girl. 

Adults: Predominantly experienced in the adult population and particularly in immunocompromised individuals including HIV positive people or those on immunosuppressive drugs. 

Skin and Subcutaneous Lesions: May be solitary (single) or multiple in nature and most often appear red, purple, or flesh colored and can form papules, nodules, or large pedunculated masses. Scales are present and, in some cases, lesions may look like raised, darkened patches of skin, typically on extremities. 

Dermoscopy: They may present oval shapes with red zones and telangiectasias on a grayish background. Lesions may be single or multiple and some may be tender while others may even ulcerate, discharge or bleed. Subcutaneous nodules may become friable and develop secondary infection. This is because skin lesions may well be suggestive of probable organ involvement. 

Mucosal Lesions: It may affect the mouth, eye, nose, anus or genitals. 

Ocular Involvement: Ranging from slight affection of the eyeld to more grave conditions such as papillitis of neuritis of the optic nerve. 

Immunocompromised Individuals: This condition is commonly correlated with HIV/AIDS, other organ transplant, or other diseases which cause immunodeficiency. 

Other Conditions: The diagnosis of bacillary angiomatosis is also possible in patients with malignancies like leukemia or immunosuppressed individuals receiving intensive treatments. 

Flea Exposure: Although not a direct association but it is a fact that cats which are infested by fleas especially Ctenocephalides felis are carriers of the bacteria. 

Acute: These lesions can occur acutely and may worsen sharply depending on the overall states of the immune system of the patient. It is associated with cutaneous, subcutaneous, and osseous forms depending on the species of Bartonella causing the disease. 

Chronic: Some symptoms may manifest slowly and are chronic, more so in cases where treatment is not sought, or where the patient was treated inadequately with bacillary angiomatosis. 

Severe: If the disease is not treated early enough and appropriately, it becomes worse and it starts affecting other parts of the body and this may be fatal. 

1. Treatment Paradigm 

Antibiotic Therapy: 

First-Line Treatment: Oral erythromycin is the treatment of choice for bacillary angiomatosis/clinically resolves in most patients. The general treatment course is 500 mg to 1000 mg by mouth every 6 hours for 6 to 12 weeks with possible decrease by the severity of the case. 

Management of Complications: In the case of ulcerated or bleeding lesions management, skin care and local therapy could be required. Patients with visceral or systemic bacillary angiomatosis are likely to receive higher doses of antibiotics, larger numbers of antibiotics or longer durations of antimicrobial therapy. 

Monitoring and Follow-Up: Following up is also required to assess the healing up of the lesions and side effects of antibiotics if any. 

Management of Underlying Conditions: Treat or at least control other immunosuppressive conditions that may facilitate the development of bacillary angiomatosis like HIV or others. 

Infectious Disease

Improving Immunocompetence: Enhance management of such diseases as HIV & AIDS and ensure patients’ compliance to ART. 

Wound Care: Ensure that the lesions are clean and protected from other opportunistic infections. 

Nutritional Support: Ensure the patient gets an adequate diet with the appropriate supplement if required during the healing process. 

Regular Monitoring: Make periodic check-ups to see the progress of the diseases and changes in treatments. 

Infectious Disease

Tetracycline: The mode of action is by interacting with a 30S ribosomal subunit with some interaction with the 50S one to prevent bacterial protein synthesis. It is mainly an antibacterial agent that is not primarily bactericidal and has anti-inflammatory effects. They are active against many gram-positive and gram-negative bacteria and are effective for both systemic and local infections. 

Erythromycin: This macrolide antibacterial agent interacts with the 50S ribosomal subunit and inhibits microbial protein synthesis. Erythromycin has activity between the two groups of Penicillin and Tetracyclines but well recognized for its bacteriostatic. 

Clarithromycin: Clarithromycin is a semi-synthetic macrolide that acts on bacteria by interfering with the process of release of the peptidyl tRNA from its ribosome so that protein synthesis which occurs through transcription of mRNA to RNA is prevented. Against cocci it is similar to erythromycin, but it is more effective against gram positive bacteria and has a similar spectrum to tetracyclines. 

Azithromycin: It interacts with the 50S ribosomal subunit and therefore, interrupts the synthesis of protein. Penicillin and tetracyclines are two types of antibiotics and erythromycin is a other Bacteriostatic macrolide antibiotic with a spectrum between Penicillin and tetracyclines. 

Doxycycline: This tetracycline antibiotic and bacteriostat interferes with bacterial protein synthesis by binding to 30S ribosomal unit, and perhaps the 50S unit, and depresses bacterial growth. It works given that it is administered two times per day. 

Rifampin: A bactericidal antibiotic that acts against bacterial DNA dependent RNA polymerase and thus leads to inhibition of bacterial proteins synthesis. This is especially true where there is extensive infection in immunocompromised persons. 

Trimethoprim and Sulfamethoxazole: This combination product works by preventing bacterial synthesis through the action of inhibiting dihydrofolic acid that is vital in bacterial DNA formation. 

Infectious Disease

Surgical Excision: Localized or symptomatic lesions, which may produce pain, or which might be threatened by complications. An operation may solve the problem and give some relief and stop the illness from progressing any further. 

Laser Therapy: Sometimes laser may be used for the treatment of skin lesions especially where the lesion is large or has socially sensitive location. Laser therapy has also been reported as useful in the reduction of size and visibility of these lesions. 

Cryotherapy: Superficial lesion may sometimes be treated through cryotherapy which involves freezing of the lesion using liquid nitrogen; this however is rare and only used when other measures cannot be used. 

Infectious Disease

Bacillary angiomatosis is managed through an organized strategy that is in phases. In the first place, critically evaluate the patient and obtain the clinical diagnosis; in addition, determine the severity of the disease. Treat with first-line antibiotics, give anxiolytics and other supportive care and observe the patient’s treatment progress. Procedure intervention should be performed on any complicating factors or localized lesion when needed. For long-term management, use of antibiotic as indicated, follow up for relapse and apply patient’s enzyme on importance of compliance. Last, the effectiveness of treatment should be assessed, and the treatment plan modified accordingly, while continuing monitoring essential especially for high-risk patients.