1. NICHOLAS SEELIGER, MD Carrion’s disease

2. Epidemiology Endemic in Andes mountains  Peru, Columbia, and Ecuador  “verruga zone” Dependant on environmental requirements  Vector is L verrucarum Risk factors for infection  Tourist  Transient workers  Children less than 5

3. Clinical Manifestations Biphasic Illness Acute febrile illness (Oroya fever)  40 percent mortality if untreated  3 weeks after inoculation  Onset of mild fever, HA, anorexia, and malaise  Anemia leading to  infectious and noninfectious complications Chronic cutaneous phase (verruga peruana)  Lesions appear 2-8 weeks after fever  Miliary, nodular, or mular lesions  2 months

5. Disease Diagnosis Blood cultures  Can be delayed 2 weeks  Positive 10-15 % after acute phase ID on Giemsa-stain  blood smears  skin biopsy Serology  Antibody testing  Immunoblot  IFA

6. Disease Treatment Prompt initiation of antimicrobial therapy Oroya fever  Chloramphenicol + B-lactam agent  Cipro Verruga peruana  Rifampin  Streptomycin (best alternative)

7. Disease Transmission Bartonella bacilliformis Transmitted by sandflies of genus  Phlebotomus

8. Worldwide Distribution Andean Mountains  Peru  Ecuador  Columbia

9. Prevention Prevent transmission by blocking inoculation Skin protection  Repellant  Protective clothing  Bed netting

10. Disease Control No vaccine available Prevention focused on blocking inoculation Correct identification of infection crucial Accurate reporting of infection required

11. Outbreaks Cajamarca – 2002  80 % under age 18 Cusco – 1998  38.5 % age 6-14  Mortality = 23% Aguaruna – 1992

12. References Alexander B., A review of bartonellosis in Ecuador and Colombia. American J Tropical Medicine and Hygeine 1995; 52:354-9. Chamberlin J, Laughlin LW, Romero S, et al. Epidemiology of endemic Bartonella bacilliformis: a prospective cohort study in a Peruvian mountain valley community. J Infect Dis 2002; 186:983. Eremeeva ME, Gerns HL, Lydy SL, et al. Bacteremia, fever, and splenomegaly caused by a newly recognized bartonella species. N Engl J Med 2007; 356:2381. Montoya M., Maguiña C., Vigo B., et al. Bartonellosis en el valle sagrado de los Incas (Cusco). Bol Soc Per Med Interna 1998;11:170-6. Maguiña C. Bartonellosis o Enfermedad de Carrión, nuevos aspectos de una vieja enfermedad. A.F.A Editores Importadores SA, Lima-Peru, 1998. Pachas P. La Bartonelosis en el Perú. Módulos Técnicos, Oficina General de Epidemiología – Instituto Nacional de Salud. Lima, 2000.