What is Bartonella?

What is Bartonella? When one forays into the world of chronic Lyme disease the word Bartonella immediately comes up. What is it? I have written about it from time to time and treated it for a long time. What do we know?  Medical textbooks and published papers are at odds with “Lyme” literature. Bartonella is classified as a new and emerging infectious disease. Clinical infection is largely seen as opportunistic. This means that Bartonella under normal circumstances is unlikely to cause clinical disease: it has low pathogenicity. Commercial laboratories only offer serological tests for two species, B. henselae and B. quintana.  Newer information informs us that numerous other species, including: B. koehlerae, B. vinsonii and B. berkhoffi have been found in the blood of Lyme patients. Doctors have known about the prevalence of Bartonella species in some populations for some time. A study published in 1996 looked at the incidence of three species of Bartonella found in inner-city IV drug users in Baltimore: 33% showed antibodies for Bartonella elizabethae, 11% B. henselae and 10% B. quintanta. This population was not tested for scores of other Bartonella species; infection may be universal in this population. Unlike Lyme, it is well known that Bartonella is transmitted by other biting insects, fleas, flies and mosquitoes, not just ticks. IDSA types still like to argue about whether or not Bartonella is a tickborne illness. Some people like to argue about everything. It is fact, not conjecture, that Bartonella may be transmitted by tick bite. Severe forms of the disease are well described by mainstream medicine: cat scratch fever, trench fever, angiomatosis, endocarditis and others. The more nuanced forms of disease, including those seen in Lyme sufferers, are invisible to mainstream medicine. Mainstream doctors need to look a little closer.  In 2007 a paper in “Infection,” described vasculitis and polyneuropathy caused by B. henselae. A well-known paper published in a CDC journal in 2012 made connections between Bartonella and Lyme. The paper connected non-specific symptoms: fatigue, neurologic and neurocognitive abnormalities and joint and muscle pain previously described in occupationally at-risk patient populations.  The Bartonella I think of has greater specificity. A characteristic rash, shown below, parallel red lines or discolored stretch marks, is not described in mainstream medical literature. Red bumps or papules may be seen in life-threatening disease (angiomatosis) according to the usual sources, not the rash pictured below. The Bartonella which causes tendinitis, typically plantar fasciitis (pain on the bottom of the feet) and shin splints is not described in mainstream medical literature. 

 Bartonella, as I know it, is frequently associated with specific neuropsychiatric symptoms, which may include:  irritability, anxiety, rage and many others. This too is not described in mainstream literature. Bartonella as a potential cause of other medical syndromes, for example, interstitial cystitis is also not described in mainstream in medical literature. Then there is the issue of treatment. Bartonella is supposed to respond to tetracycalines and Biaxin according to standard sources. In my world Bartonella responds best to Rifampin and the other drugs do not work.

Although many think of Bartonella as primarily a red blood cell bacteria, it actually primarily resides primarily within endothelial cells, the cells that line the inside of blood vessels. The bacteria is transmitted by an influx of red blood cells which play a role in its life-cycle.  Because of its intracellular locus Bartonella can be as intractable as the other Lyme-associated microbes. 

Here is a snapshot from one of my patients last week. 

This 30 year old male had been in clinical remission from Lyme disease for over a year, after 2 years of extensive treatment. A perfect storm of emotionally stressful events occurred in his life and symptoms returned. He complained of severe fatigue, cognitive difficulties, muscle and joint pains and severe depression. He suffered with anxiety, most Lyme patients do, but he denied irritability, anger, rage and foot pain. And, he had never had a rash like this before. He does have a history of a prior Bull’s eye rash.

Bartonella causes inflammation of blood vessels, a form of vasculitis which likely causes this characteristic rash, undiscovered by mainstream medicine. Vasculitis in the brain is well known to cause neuropsychiatric symptoms, for example, lupus vasculitis. The mechanism of synergy, by which Lyme and Bartonella seem to cause specific psychiatric symptoms is unknown. 

In this patient, Bartonella was always there, even though clinical Lyme was conquered.  Unfortunately, emotional stress weakened the immune system and the tiger got of the cage. 

Specific treatment may not always be needed; therapy decisions are based on the clinical scenario of the patient undergoing treatment.

Here are some general pointers regarding treatment. I have found that rifampin works the best. It must always be given with another antibiotic (to prevent rapidly occurring resistance). Commonly prescribed co-therapies include Zithromax, doxycycline and Bactrim. Bactrim has mild anti-Bartonella effects and is a good add on to rifampin.  Quinolones, including the widely touted Levaquin may be used. I do not like to use this class of drugs because of side effects, which include: spontaneous tendon rupture and high rate of causing C. diff colitis. When I do use a quinolone I usually reach for Cipro because it is a little less toxic and can be started at lower doses and gradually ramped up. When these measure failure, gentamycin or tobramycin are usually very effective. These drugs can only been given IV or IM, have toxicity and requiring close monitoring. 

Atypical syndromes, like interstitial cystitis, may respond best to combinations of Zithromax, rifampin and doxycycline or minocycline. 

The question, “what is Bartonella?” has certainly not fully been answered. But, clinical approaches to what I like to call “Bartonella syndrome,” have evolved and generally perform well in the clinical setting. 

Much of this piece is based on the clinical experience of many doctors and patients, not what is considered medical "evidence." A patient I spoke with last week thought this kind of information constituted evidence as defined by evidence based medicine. "Evidence based medicine," which underpins mainstream medical practices relies on published studies but primarily on the opinion of experts who have interpreted the published studies, especially the ones they like.