[Recurrent intracerebral haemorrhage in a 24-year-old female patient]

Bartonella quintana Endocarditis Complicated by Cerebral Stroke: A Case Report

Bartonella quintana is rarely associated with neurological manifestations. This report describes a rare case of endocarditis complicated by a cerebral stroke caused by B. quintana. We also briefly reviewed the neurological clinical spectrum of B. quintana disease described in the literature. Serology tests were performed using the VIRCLIA®-system (chemiluminescence assay, Vircell, Spain) and immunofluorescence assay (IFA; Focus Diagnostics, USA). Cerebrospinal fluid (CSF) was tested using the BioFire-CSF-FilmArray-Meningitis/Encephalitis Panel (bioMérieux, France). CSF, plasma, and biopsy samples were tested using Bartonella-qPCR combined with Sanger-sequencing. A 23-year-old male Afghan refugee residing in Belgium presented with persistent fatigue and cough. A calcified aortic bicuspid with severe insufficiency and moderately associated stenosis was diagnosed. A transesophageal echocardiogram revealed a shrinking valve and a mobile mass attached to the calcification of the free edge at the aorta. He developed fever, a moderate inflammatory syndrome with normocytic anemia, and renal failure with hematuria and proteinuria, indicating probable glomerulonephritis. He met the Duke criteria for infective endocarditis, though blood cultures were initially negative. Bartonella serology later returned positive. He developed a fever and intense headache. CSF showed moderate pleiocytosis, but a negative-FilmArray. Neurovascular MR-angiography revealed a multifocal ischemic stroke. His aortic valve was replaced (Ross procedure). The biopsy showed nodular and degenerative fibro-calcified rearrangements. B.  quintana presence was confirmed in CSF, blood, and mitral valve samples. Our report underlines that B. quintana is a rare but a possible cause of endocarditis and neurological damage, and emphasizes the need for effective healthcare access, which is often limited in the countries of origin of migrants and even for migrants residing in high-resource countries.

Bartonella quintana Endocarditis: A Systematic Review of Individual Cases

BACKGROUND

Bartonella quintana is a louse-borne bacterium that remains a neglected cause of endocarditis in low-resource settings. Our understanding of risk factors, clinical manifestations, and treatment of B. quintana endocarditis are biased by older studies from high-income countries.

METHODS

We searched Pubmed Central, Medline, Scopus, Embase, EBSCO (CABI) Global Health, Web of Science and international trial registers for articles published before March 2023 with terms related to Bartonella quintana endocarditis. We included articles containing case-level information on B. quintana endocarditis and extracted data related to patient demographics, clinical features, diagnostic testing, treatment, and outcome.

RESULTS

A total of 975 records were identified, of which 569 duplicates were removed prior to screening. In total, 84 articles were eligible for inclusion, describing a total of 167 cases. Infections were acquired in 40 different countries; 62 cases (37.1%) were acquired in low- and middle-income countries (LMICs). Disproportionately more female and pediatric patients were from LMICs. More patients presented with heart failure (n = 70/167 [41.9%]) than fever (n = 65/167 [38.9%]). Mean time from symptom onset to presentation was 5.1 months. Also, 25.7% of cases (n = 43/167) were associated with embolization, most commonly to the spleen and brain; 65.5% of antimicrobial regimens included doxycycline. The vast majority of cases underwent valve replacement surgery (n = 154/167, [98.0%]). Overall case fatality rate was 9.6% (n = 16/167).

CONCLUSIONS

B. quintana endocarditis has a global distribution, and long delays between symptom onset and presentation frequently occur. Improved clinician education and diagnostic capacity are needed to screen at-risk populations and identify infection before endocarditis develops.