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Bartonella quintana has episodically emerged as a cause of infection among distinct and diverse populations during the 20th century. The organism was first identified as an important human pathogen during World War I when it caused epidemics of louse-borne trench fever that affected an estimated 1 million troops in Europe (1, 2). Trench fever was characterized by fever, rash, bone pain, and splenomegaly and ranged in severity from a mild flulike illness to a more severe, relapsing disease. B. quintana infections were rarely recognized from the end of World War II until the 1980s when the organism reemerged as an opportunistic pathogen among HIV-infected persons. In this population, B. quintana has been identified as a cause of bacillary angiomatosis, endocarditis, and bacteremia (3-5) and has been isolated from AIDS patients in France (6) and the United States (3-5). In the 1990s, B. quintana has emerged among homeless persons in North America and Europe. In 1993, the organism was isolated from the blood specimens of 10 patients at a single hospital in Seattle, Washington, within a 6-month period (7). These patients had illnesses characterized by fever and persistent bacteremia.Endocarditis developed in two patients, one of whom required a heart valve replacement. All 10 patients had chronic alcoholism, eight were homeless, and the six who were tested for HIV infection were HIV-negative. These six were the first cases of invasive B. quintana infection among HIV-negative persons reported in the United States. Results of a case-control study indicated that the patients with Bartonella bacteremia were more likely than controls (other hospitalized patients from whom blood specimens were obtained at approximately the same time) to be homeless (p = 0.001), to have a history of alcohol abuse (p = 0.001), and to be nonwhite (p = 0.007). The isolates from the 10 patients were identical by polymerase chain reaction restriction-fragment-length polymorphism testing,which further suggests that the cases were epidemiologically linked. Patients’ characteristics were obtained by retrospective medical record review, and at the time they sought treatment, three patients reported a recent cat scratch, five had scabies, and one had lice. More complete information, however, on patients’ past exposures to animals and ectoparasites was not available. In 1995, Drancourt and co-workers reported three cases of B. quintana endocarditis among HIV-negative, homeless, alcoholic men in France (8). One of the patients had reported contact with a dog, and one had reported contact with dogs and cats; however, a current or past history of infection with lice or scabies was not documented for any of the patients. In 1995, Stein and Raoult also reported serologic evidence of B. quintana infection in an HIV-negative, homeless man from Marseilles, who had a relapsing febrile illness and a history of louse infestation (9). As a follow-up to the 1993 B. quintana outbreak in Seattle in 1994, we conducted a seroprevalence study of anti-Bartonella antibodies among patients at a community clinic in the “skid row” section of Seattle, which serves a primarily homeless and indigent population (10). The median age of the 192 patients included in the study was 45 years, 156 (81%) of the 192 were male, and 126 (66%) were classified as homeless.B. quintana IgG titers ≥ 64 were detected by an indirect fluorescence antibody assay (11) in 39 (20%) of the 192 clinic patients. In contrast, only 4 (2%) of 199 banked blood specimens from an age-matched and sex-matched comparison group of Seattle volunteer blood donors had titers≥ 64 (p < 0.001).Among clinic patients, seropositivity (titer ≥ 64) was associated by univariate analysis with older age,homelessness (relative risk [RR] 2.0; 95% confidence interval [CI] 1.0-4.1), alcohol abuse (RR, 2.5; 95% CI 1.4-4.2), smoking (RR, 2.0; 95% CI 1.2 -3.4), and injection drug use (RR, 2.5; 95% CI 1.3-4.8). By multivariate analysis, only alcohol abuse remained independently associated with seropositivity (odds ratio 3.3; 95% CI 1.6-6.9), and of 39 seropositive patients, 21 (54%) had a history of chronic alcoholism. Reliable data on past exposure to animals or ectoparasites were also not available for patients in this study. The study was limited by the well-described cross-reactivity of the assay between Bartonella species (12, 13), and most (62%) clinic patients with B. quintana titers ≥ 64 also had titers ≥ 64 to B. henselae. It is, therefore, possible that some of the seropositive patients may have been exposed Dispatches

Emergence of Bartonella quintana Infection among Homeless Persons