Volume 18, Number 11—November 2012
Letter
Bartonella spp. Bacteremia and Rheumatic Symptoms in Patients from Lyme Disease–endemic Region
To the Editor: We believe the recent article by Maggi et al. (1) contains serious flaws in content and underlying message, including a poorly defined study population, lack of appropriate controls, improper use of the term bacteremia, and incongruent laboratory findings. Selection criteria were vague: the authors state only that participants were a “biased” collection of “patients selected by a rheumatologist,” with no control population included for comparison. The diagnosis of Lyme disease and other previously diagnosed conditions was solely by self-report. Although blood samples were collected from every participant, the authors apparently neglected to perform standardized testing for Borrelia burgdorferi or other conditions.
The term “bacteremia” signifies presence of viable bacteria in the bloodstream, which is not substantiated solely by a positive PCR result. True bacteremia was documented in only 1.7% of participants from whom a viable Bartonella species isolate was cultured, rather than the purported 41.1% of participants.
Surprisingly, many participants whose PCR results were positive for Bartonella spp. had no serologic evidence of infection (e.g., 82.5% of samples that had positive PCR results for Bartonella henselae were not seroreactive). Although anergy has been reported, samples from most immunocompetent and immunocompromised patients infected with Bartonella spp. are seroreactive (2–4), calling into question the authors’ findings. Furthermore, 24% of samples that were positive by PCR revealed no identifiable Bartonella spp. by DNA sequencing; these participants should have been excluded from analysis.
Maggi et al. hypothesize that Bartonella spp. infection is causally related to a variety of chronic ailments. In fact, there was no association within the study population between positive Bartonella spp. PCR results and chronic illness, self-reported Lyme disease, or even a prior diagnosis of bartonellosis.
Efforts to define the clinical and public health importance of Bartonella spp. require scientific rigor. The above issues challenge the validity of the study, and results should be interpreted with caution.
References
- Maggi RG, Mozayeni BR, Pultorak EL, Hegarty BC, Bradley JM, Correa M, Bartonella spp. bacteremia and rheumatic symptoms in patients from Lyme disease–endemic region. Emerg Infect Dis. 2012;18:783–91. DOIPubMedGoogle Scholar
- Dalton MJ, Robinson LE, Cooper J, Regnery RL, Olson JG, Childs JE. Use of Bartonella antigens for serologic diagnosis of cat-scratch disease at a national referral center. Arch Intern Med. 1995;155:1670–6. DOIPubMedGoogle Scholar
- Zangwill KM, Hamilton DH, Perkins BA, Regnery RL, Plikaytis BD, Hadler JL, Cat scratch disease in Connecticut. Epidemiology, risk factors, and evaluation of a new diagnostic test. N Engl J Med. 1993;329:8–13. DOIPubMedGoogle Scholar
- Koehler JE, Sanchez MA, Tye S, Garrido-Rowland CS, Chen FM, Maurer T, Prevalence of Bartonella infection among human immunodeficiency virus–infected patients with fever. Clin Infect Dis. 2003;37:559–66. DOIPubMedGoogle Scholar
Related Links
To the Editor: Some chronic diseases, including multiple sclerosis, chronic arthritis (1), cognitive disorders, and chronic fatigue remain unexplained, yet patients and patient advocacy groups are anxious to find an explanation and a cure. For 50 years, zoonotic agents have been wrongly considered as the cause of many of these diseases because diagnoses were based on results of serologic tests with low specificity. In France, at the beginning of my career, serologic testing for rickettsia was used as a diagnostic tool for many of these diseases and prompted inappropriate antimicrobial drug use because micro-agglutination on a slide is a nonspecific serologic technique (2). I had a hard time reversing this practice.
Results of serologic testing for nanobacteria were also unconfirmed because they were based on nonspecific antibodies (3). Results of Lyme disease serologic tests lacking specificity were also associated with these chronic diseases and led to the same results and conflicts between the Infectious Diseases Society of America and alternative users of Borrelia burgdorferi diagnostic tests (4). Currently, Google search pages display more results for alternative interpretations than for scientific information. Again, I have tried to limit the damages in France without success (5).
Now the Bartonella spp. appear as the new candidates to explain chronic illness (1). Once more, I am confronted with the problem in France. Some patients whose test results are negative in my laboratory were tested at the College of Veterinary Medicine, North Carolina State University, Raleigh, NC, USA (3) and received positive results (using a technique that I have not been able to reproduce). Now one of my patients is arguing and menacing because I do not confirm his infection by Bartonella spp.
We need to follow rigorous standards of causal influence before claiming that a bacterium is causing an unexplained chronic disease, to avoid facing the same problem that we had with Lyme disease: a mess with open conflicts between most scientists and some atypical investigators and patient advocacy groups.
References
- Maggi RG, Mozayeni BR, Pultorak EL, Hegarty BC, Bradley JM, Correa M, Bartonella spp. bacteremia and rheumatic symptoms in patients from Lyme disease–endemic region. Emerg Infect Dis. 2012;18:783–91. DOIPubMedGoogle Scholar
- Raoult D, Edlinger E. The rickettsial origin of multiple sclerosis: the end of a myth [in French]. Presse Med. 1987;16:684.PubMedGoogle Scholar
- Breitschwerdt EB, Sontakke S, Cannedy A, Hancock SI, Bradley JM. Infection with Bartonella weissii and detection of Nanobacterium antigens in a North Carolina beef herd. J Clin Microbiol. 2001;39:879–82. DOIPubMedGoogle Scholar
- Seriburi V, Ndukwe N, Chang Z, Cox ME, Wormser GP. High frequency of false positive IgM immunoblots for Borrelia burgdorferi in clinical practice. Clin Microbiol Infect. 2012;18:105–204.PubMedGoogle Scholar
- Raoult D. Diagnostic biologique de la maladie de Lyme. Interet du Western blot. Med Mal Infect. 1990;20:163–4. DOIGoogle Scholar
Table of Contents – Volume 18, Number 11—November 2012
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Please use the form below to submit correspondence to the authors or contact them at the following address:
Christina A. Nelson, Centers for Disease Control and Prevention, 3150 Rampart Rd, Mailstop P02, Fort Collins, CO 80525, USA
Didier Raoult, Faculte de Medecine, Aix Marseille Université, URMITE, UMR CNRS 7278, IRD 198 Centre National de Référence, 27 Blvd Jean Moulin, Marseille 13005, France
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