>> I THINK ON THE PHYSICIAN SIDE, THE MISCONCEPTION IS
THAT CAT SCRATCH IS THE ONLY BARTONELLA DISEASE.
I THINK THE REASON THIS IS SOMEWHAT PREVALENT IS
THAT CAT SCRATCH HAS BEEN QUOTE THE TURN FOR BARCALOSIS [PHONETIC]
OVER THE YEARS, 50 YEARS AGO, AT LEAST UNDER THIS TERM.
AND NOW WE KNOW MUCH MORE ABOUT BARTONELLA
AND WE HAVE MUCH BETTER DIAGNOSTICS.
>> SO THIS IS ACTUALLY WHERE WE STAND TODAY.
IF YOU'RE NOT COMPLETELY UP TO DATE, THERE ARE 25 SPECIES
AND 3 SUBSPECIES THAT ARE OFFICIALLY RECOGNIZED.
AND IF ANY OF YOU ARE RESPONSIBLE FOR THESE GUYS,
IF YOU COULD GET THEM OFFICIALLY RECOGNIZED,
THAT WOULD BE REALLY SUPER.
>> I'M NOT GOING TO SPEND ANY TIME TODAY ON THE FACT
THAT A LOT OF DISEASES, PARTICULARLY
IN VETERINARY MEDICINE,
WHERE THESE VECTOR BORNE ORGANISMS PERSIST
FOR YEARS RESULT AS A CONSEQUENCE OF CO-INFECTIONS,
OR AS A RESULT OF AN IMMUNOLOGIC IMBALANCE
THAT ULTIMATELY THE IMMUNE SYSTEM STARTS DESTROYING THE
ERYTHROCYTES, PLATELETS, OR OTHER CELLS IN THE BODY.
BUT I THINK THESE ARE ALL IMPORTANT CONCEPTS
THAT AS WE CONSIDER THE OVERALL DIAGNOSIS,
WE HAVE TO KEEP IN MIND.
>> SO WHEN YOU LOOK AT THE CLINICAL MANIFESTATIONS
IN HUMANS, CATS, AND DOGS. B. henselae AND ALSO B. vinsonii berkhoffii
IN DOGS, I THINK YOU CAN SEE THAT THERE'S SOME COMMON THEMES.
LYMPHADINITUS [PHONETIC], BATHLERANGIMATOSIS [PHONETIC]
IN HUMANS, AND A COUPLE CASES IN DOGS, UVEITIS
AND OCULAR LESIONS VERY COMMON IN HUMANS
WITH CAT SCRATCH DISEASE, SEEN OCCASIONALLY IN CATS AND DOGS,
AND CHRONIC BACTEREMIA, IT DOESN'T OCCUR TOO MUCH
IN HUMANS, BUT CATS OF COURSE CAN BE INFECTED FOR LIFE.
IN TERMS OF ENDOCARDITIS, MYOCARDITIS,
THERE IS A PREDILECTION FOR BARTONELLA [PHONETIC] SPECIES
FOR CARDIAC TISSUE, AND THAT'S BEEN WELL DESCRIBED IN HUMANS,
ESPECIALLY FOR QUINTANA, SEEN RELATIVELY LESS
IN CATS, BUT SEEN IN DOGS.
PROLONGED FEVER, CERTAINLY IN HUMANS,
AND THIS OCCURS MOST FREQUENTLY
WHEN HUMANS ARE IMMUNOCOMPROMISED, AND INFECTED
WITH A HETEROLOGOUS STRAIN, NOT A HUMAN TROPIC STRAIN.
LETHARGY, WEIGHT LOSS, ANOREXIA, NEUROLOGIC SYMPTOMS VERY COMMON
IN PEOPLE WITH CAT SCRATCH DISEASE.
ENCEPHALITIS IS LESS COMMON, BUT OFTEN SEEN.
ARTHRITIS AND JOINT PAIN, GLUMERIONEPHRITIS [PHONETIC],
AND REPRODUCTIVE DISORDERS HAVE BEEN DEMONSTRATED
BY BRUNO CHOMEL IN CATS.
BUT --
WHU IS BARTONELLA IMPORTANT?
>> SO MY LAST SLIDE, I JUST WOULD LIKE TO CONCLUDE BY SAYING
THAT I CONSIDER BARTONELLA THE MOST IMPORTANT INFECTIOUS
DISEASE PROBLEM FOR VETERINARY MEDICINE.
AND I BELIEVE THAT BECAUSE OF A LARGE NUMBER OF VECTORS,
A LARGE NUMBER OF RESERVOIR HOSTS THAT ARE VECTOR-COMPETENT,
AND BECAUSE THIS IS A SELF-PACKAGING [PHONETIC]
THAT IS EXTREMELY DIFFICULT TO DETECT
IN BOTH ANIMALS AND PEOPLE.
AND AGAIN, MANY, MANY VETERINARIANS SITTING
IN THIS AUDIENCE ARE VERY CONCERNED
ABOUT THE OVERALL IMPACT OF THIS INFORMATION ON THE ANIMALS
THAT WE TAKE CARE OF IN OUR PROFESSION.
>> WHY IS BARTONELLA SUCH A PROBLEM?
IT'S SUCH A PROBLEM BECAUSE IT'S SO HARD TO DIAGNOSE,
AND IT LOOKS LIKE A LOT OF OTHER DISEASES.
>> VERY SHORT WITH ROUND.
I DON'T PROBABLY CONVINCE YOU TO GET UPSET AT PROBABLY,
BARTONELLA INDICARDITIS [PHONETIC].
IT'S PROBABLY THE MOST SEVERE FORM OF BARTONELLA INFECTIOUS,
AND IMMUNOCOMPETENT INFECTIONS.
DOCTOR BRANSLER [PHONETIC] TRIED TO PROTECT, BARTONELLA SAYING
THAT THEY'RE NOT
SO BAD. THEY USUALLY DON'T KILL PEOPLE.
BUT THE BARTONELLA INDICARDITIS [PHONETIC] DOES KILL PEOPLE,
AND EVEN IN AMONG THIS SMALL GROUP OF LIMITED GROUP
OF PATIENTS, STILL WE HAVE SOME FATAL CASES.
>> AND SO I THINK IT'S SORT OF IMPORTANT TO COMMENT
ON THE UTILITY THAT BASED THEORIES ON BOTH CULTURE-NEGATIVE ENDOCARDITIS
OR BECAUSE OF THE FORCE OF THIS, IT MAKES THE ACT
OF PRACTICING [INAUDIBLE] DISEASE PHYSICIAN
CONSIDERED [INAUDIBLE].
AND WE WILL ALWAYS NOW PUT A QUESTION CULTURE-NEGATIVE ENDOCARDITIS
IN ADDITION.
HOW IS BARTONELLA DETECTED?
>> IN THE CONTEXT OF BARTONELLA IN THIS SLIDE,
I THINK THERE'S TWO THINGS THAT ARE IMPORTANT DIAGNOSTICALLY.
ONE, IF THEORETICALLY A PATIENT SAMPLE
THAT WE PROCESS TODAY HAD JUST ONE BARTONELLA IN IT,
TOMORROW IT'LL HAVE TWO, THE NEXT DAY IT'LL HAVE FOUR --
AND OBVIOUSLY MOST SAMPLES ARE NOT GOING TO START
OUT WITH ONE ORGANISM, BUT WHAT HAS MADE THIS
GENIUS SO DIFFICULT IS THIS LONG DIVIDING TIME.
SO FORTUNATELY, I THINK NOT BEING TRAINED
AS A MICROBIOLOGIST, IN CONJUNCTION
WITH A POST-OP SCIENTIST, Dr. SUSHAMA SONTAKKE
WE ASKED THE QUESTION,
IF ALL THE GOOD BARTONELLA RESEARCHERS WERE FINDING
THAT SHEEP KEDS [PHONETIC], DEER KEDS, SAND FLIES, FLEAS, LICE,
AND ULTIMATELY MOST RECENTLY TICKS MIGHT BE VECTOR-COMPETENT
FOR TRANSMITTING THESE ORGANISMS,
WOULD THEY BE HAPPIER, AND WOULD THEY GROW BETTER
IN AN INSECT BIOCHEMICAL COMPOSITION,
AS COMPARED TO A MAMMALIAN GROWTH MEDIA.
AND I THINK FORTUNATELY, THE ANSWER TO THAT QUESTION WAS YES.
SO IF WE BACK UP JUST A BIT, I THINK IT'S IMPORTANT
TO ACKNOWLEDGE, REGARDLESS OF THE TARGETED ORGANISM,
ALL INFECTIOUS DISEASE DIAGNOSTIC TESTS
HAVE LIMITATIONS.
AND IT'S CLEARLY IMPORTANT FOR THE CLINICIAN
AND THE DIAGNOSTICIAN TO UNDERSTAND THESE LIMITATIONS.
SO SOME OF THE LIMITATIONS IN GENERAL,
WHENEVER WE'RE APPROACHING -- IN PARTICULAR,
AS JANE SHOWED YESTERDAY,
IF YOU HAVE AN IMMUNOCOMPROMISED PATIENT,
MOST OF THE BARTONELLAS ARE EXTRACELLULAR.
I THINK IN AN IMMUNOCOMPETENT [PHONETIC] PATIENT,
WE REALLY DON'T KNOW WHETHER THESE BACTERIA ARE
INTRACELLULAR, EXTRACELLULAR, OR BOTH AT THIS POINT IN TIME.
SEROLOGY CERTAINLY SHOULD BE DONE IN MY OPINION
IN ALL PATIENTS IN WHICH WE'RE CONTEMPLATING A DIAGNOSIS,
BUT AS WE ALL KNOW, IT DOESN'T CONFIRM ACTIVE INFECTION.
WE'LL TALK ABOUT THE FACT THAT BOTH IN DOGS
AND IN PEOPLE WE ARE AMAZED AT THE NUMBER
OF INFECTED INDIVIDUALS THAT ARE SERAL NEGATIVE,
AND WHETHER THIS IS A MANIFESTATION
OF USING THE WRONG ANTIGENS, OR A MANIFESTATION
THAT SOME INDIVIDUALS ARE ACTUALLY ENERGIC
AND DO NOT PRODUCE ANTIBODIES IS YET TO BE DETERMINED.
I DON'T THINK WE'RE EVER GOING TO HAVE AN ANTIGEN TEST
FOR BARTONELLA, BECAUSE I DON'T THINK IT'S EVER GOING
TO BE SENSITIVE ENOUGH.
AND OBVIOUSLY, PCR DEMONSTRATES ACTIVE INFECTION,
BUT WHAT WE'VE FOUND IS IN AND OF ITSELF,
IT IS NOT ALWAYS SENSITIVE ENOUGH
TO DETECT IN PATIENT SAMPLES.
SO FROM THAT, ONCE WE FIGURED
OUT THAT THIS INSECT MEDIA MIGHT GROW BARTONELLA BETTER
AND ENHANCE OUR ABILITY TO FIND IT IN PATIENT SAMPLES,
ASHLEY DUNCAN [PHONETIC], THE PHD STUDENT IN THE LAB WORKING
WITH RICARDO MAGI [PHONETIC],
DESCRIBED WHAT WE CALL THE BAPGM PLATFORM.
I WOULD GUESS THAT THIS MAY BE
AS COMPLICATED A DIAGNOSTIC PLATFORM TO CONFIRM INFECTION
WITH AN INFECTIOUS AGENT THAT NOW EXISTS,
BECAUSE FROM EVERY SAMPLE WE EXTRACT DNA,
AND FOR ALL HUMAN SAMPLES,
AS DOCTOR MOZAYENI SHOWED YOU YESTERDAY,
THAT INCLUDES INDEPENDENT PCRS FROM BOTH BLOOD AND SERUM.
BLOOD AND SERUM ARE BOTH INCUBATED
INTO BAPGMENRICHMENT CULTURE, AND AT 7 DAYS
AND 14 DAYS DNA IS EXTRACTED AND THE PCR IS DONE.
AND AT 7 AND 14 DAYS WE SUBCULTURE
ON AN AGAR PLATE.
AND AT THAT POINT, IF SOMETHING ACTUALLY GROWS,
A BARTONELLA-SPECIFIC PCR IS DONE.
HOW IS BARTONELLA TREATED?
>> SO WITH [INAUDIBLE] ANTIBIOTIC CHOICES,
MOST OF YOU KNOW THIS INTRACELLULAR ANTIBODIES
FROM [INAUDIBLE].
GENO [INAUDIBLE] FOR THE TIME BEING HAS A TOXICITY
AND [INAUDIBLE], AND WE CAN'T USE IT LONG-TERM.
SO, YOU KNOW, I BELIEVE PERSONALLY [INAUDIBLE] NO ROLE
FOR [INAUDIBLE] THERAPY,
AND I DON'T EVEN BELIEVE IT'S NECESSARY GOING TO BE HELPFUL,
BECAUSE THERE'S EVEN THEORETICAL SUBMERSION
IN [INAUDIBLE] TISSUE, AS WELL AS BEING [INAUDIBLE].
AS IF [INAUDIBLE] ARE CONCERNED, YOU KNOW,
IN ANIMALS THAT THE SYSTEM DEVELOPS VERY [INAUDIBLE],
I'VE BEEN USING [INAUDIBLE] HAND IN HAND, OR [INAUDIBLE].
AND THE ANTIBODY [INAUDIBLE] IS JUST AN ABSOLUTE MUST
IN MANAGING THESE PATIENTS [INAUDIBLE].
[INAUDIBLE], JUST LIKE THERE ARE [INAUDIBLE] PHYSICIANS
THAT ARE [INAUDIBLE] PHYSICIANS, AND IT'S IMPORTANT
TO EVALUATE [INAUDIBLE] ENZYMES
FOR THOSE ASPIRIN [INAUDIBLE] ISSUES.
SO FAR -- AND I THINK THERE'LL BE MORE,
BUT WE HAVE FOUR WELL-DOCUMENTED CASES OF PERSISTENCE AFTER MORE
THAN 6 MONTHS OF [INAUDIBLE].
[INAUDIBLE] PATIENT GOING TO BE FINE, SO I --
IT TAKES A LITTLE WORK, BUT I CONVINCED THEM
THAT HAVING BARTONELLA
AND FEELING WELL IS AN ACCEPTABLE SITUATION,
AND WE DON'T HAVE TO BE SO OBSESSIVE THAT WE GET
INTO TROUBLE WITH ONGOING ANTIBODY [INAUDIBLE].
SO THERE IS A THING, THERE IS A HEALTHY CARRIER STATE.
BUT WHAT WE DON'T KNOW IS WHAT THE LONG-TERM [INAUDIBLE] ARE
AROUND SOME [INAUDIBLE].
IF THE [INAUDIBLE] WERE EASIER, FASTER, [INAUDIBLE], OR SAFER,
WE COULD JUST TREAT THESE FOLKS.
BUT GIVEN HOW LONG AND COMPLICATED COURSES
OF TREATMENT ARE TODAY, I THINK IT DOESN'T MAKE SENSE,
IF SOMEONE'S HEALTHY AND [INAUDIBLE]
TO [INAUDIBLE] TREATMENT,
OTHER THAN MAYBE SOME [INAUDIBLE] APPROACHES.