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Comparative Immunology, Microbiology and Infectious Diseases 35 (2012) 93– 102

Contents lists available at SciVerse ScienceDirect

Comparative Immunology, Microbiologyand Infectious Diseases

j o ur nal homep age : w ww.elsev ier .com/ locate /c imid

Presented at the 6th International Meeting on Rickettsia and Rickettsial Diseases at Heraklion, Crete, Greece on June 5-7, 2011

eview

artonella and Bartonella infections in China: From the clinic to theaboratory�

iyong Liua,∗, Marina E. Eremeevab,∗∗, Dongmei Lia

Department of Vector Biology and Control, State Key Laboratory for Infectious Diseases Prevention and Control, National Institute for Communicableisease Control and Prevention, Chinese Center for Disease Control and Prevention, P.O. Box 5, Changping, Beijing, ChinaRickettsial Zoonoses Branch, Division of Vector-borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Controlnd Prevention, Atlanta, GA 30333, United States

r t i c l e i n f o

rticle history:eceived 5 August 2011eceived in revised form6 December 2011ccepted 4 January 2012

eywords:artonellaleaatat scratch disease

a b s t r a c t

The current status of Bartonella studies in mainland China is reviewed including both labo-ratory and ecological data and limited clinical data. Detection and isolation of Bartonellaspecies from arthropods, pets and small wild animals is commonplace; this includes avariety of known and emerging Bartonella pathogens. In contrast, the medical literatureanalyzed from 1980 to 2010 consists of 31 reports of only of cat scratch disease (CSD). Mostcases are from the East and South-Eastern provinces, the most populated areas with bestaccess to medical care. Disease typically is described as febrile illness with symptoms tra-ditionally reported for CSD elsewhere in the world. Clinical observations and anamnesisare the primary bases for diagnosis, since specialized serologic and molecular diagnosis isnot widely available. Seroprevalence of healthy populations determined using Bartonella

hina henselae antigen varies from 9.6 to 19.6%. The apparent discordance postulated betweenpossible environmental exposure to diverse Bartonella agents and restricted B. henselaecase etiologies suggests a need to determine whether other Bartonella species may alsobe etiologic agents of human illness and emphasizes the importance of applying moderndiagnostic tools widely in clinical practice in mainland China.

© 2012 Elsevier Ltd. All rights reserved.

ontents

1. Bartonella agents associated with cats and dogs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 942. Characteristics of Bartonella associated with Chinese rodents and insectivores . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

3. Characteristics of Bartonella agents associated with Chinese arthr4. Clinical diagnosis of Bartonella infection . . . . . . . . . . . . . . . . . . . . . . . . . . .5. Surveillance of Bartonella infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

� The findings and conclusions described in this manuscripts are those of the aisease Control and Prevention and the Department of Health and Human Servic∗ Corresponding author. Tel.: +86 10 61731296/13910599152.

∗∗ Corresponding author. Current address: Jiann-Ping Hsu College of Public Heanited States.

E-mail addresses: liuqiyong@icdc.cn (Q. Liu), meremeeva@georgiasouthern.ed

147-9571/$ – see front matter © 2012 Elsevier Ltd. All rights reserved.oi:10.1016/j.cimid.2012.01.002

opods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

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uthors and do not necessarily represent the views of the Centers fores.

lth, Georgia Southern University, PO Box 8015, Statesboro, GA 30460,

u (M.E. Eremeeva).

94 Q. Liu et al. / Comparative Immunology, Microbiology and Infectious Diseases 35 (2012) 93– 102

6. Prospectus for future investigations of Bartonella infections in China . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100Conflict of interests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

. . . . . . . .

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Bacteria of the family Bartonellaceae include morethan 20 recognized species and subspecies and a grow-ing number of genotypically distinct zoonotic isolates withundefined taxonomic status. Several Bartonella species areconsidered to be human pathogens [1–7]. The best charac-terized infections due to Bartonella have a wide spectrumof epidemiologic features including acute epidemics withpersistent chronic manifestations (trench fever and Oroyafever) or sporadic cases with clearly identified animal hosts(cat scratch disease). Many Bartonella-associated illnessesare linked with arthropod or animal transmission; how-ever, animal reservoirs, maintenance mechanisms, andvectors have not been clearly identified for the major-ity of the Bartonella species. Diseases caused by Bartonellamanifest with a wide range of signs and symptoms; clin-ical presentation may vary from self-limiting cat scratchdisease (B. henselae) to persistent infections and endo-carditis (B. henselae and B. quintana) and potentially fatalOroya fever (B. bacilliformis). Infections caused by B. bacil-liformis are primarily found in the mountain valleys ofEcuador, Peru and Bolivia, while diseases caused by B. quin-tana and B. henselae are described from both the Old andNew World [3]. Similarly, B. clarridgeiae, B. elizabethae andseveral newly described genotypes of Bartonella exist indifferent parts of the world. Some of these new agentshave been linked to human diseases, while the pathogenicpotential of others is currently unknown.

To our knowledge this review provides the first compre-hensive summary of the ecological and laboratory researchthat has been conducted on Bartonella species in mainlandChina; we also evaluate the present evidence for novel Bar-tonella agents as causes of febrile illness in China and therelevance of these observations in the context of currentclinical practices for diagnosis of Bartonella infections.

1. Bartonella agents associated with cats and dogs

The first laboratory confirmed Chinese evidence of asso-ciation of Bartonella spp. with domestic and pet animalswas obtained in 2005 (Fig. 1 and Table 1) [8]. Twelve iso-lates of Bartonella were grown from blood of 64 cats fromShandong Province; multilocus sequence typing analysisconfirmed identification of all isolates as B. henselae. Laterstudy provided additional confirmation to these findingsby detecting the presence of B. henselae in the same regiontwo years later [9]. Culture and isolation detected circula-tion of another feline Bartonella sp., B. clarridgeiae in catsfrom Henan Province [10]. However, based on extrapola-tion from the reports of others [2], distribution of theseagents is likely well beyond the sites studied. Subsequently,

two isolates of B. vinsonii berkhoffii where obtained fromblood specimens of domestic dogs from urban areas ofShandong Province [11]. Preliminary identification indi-cated 100%, 99.75% and 97.2% sequence similarity with

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

homologous fragments of the 16S rRNA gene, gltA and 16S-23S rRNA intergenic regions, respectively, of the referenceisolate B. vinsonii berkhoffii. Recent reports indicate thatseveral genetic variants of B. vinsonii berkhoffii exist in theUSA and Canada [12]. Thus further studies will be needed toestablish the specific genotype of the Chinese isolates, andto understand their reservoir association, mode of trans-mission, spectrum of diseases, and pathological conditionsthey may cause in mammals.

The seroprevalence of B. henselae antibodies in cats fromShandong and Henan provinces was 29.6% including 19.3%in kittens that were younger than 6 months and these num-bers doubled in older cats (>2 years old) [9]. No informationis available about the seroprevalence to Bartonella of Chi-nese dogs.

2. Characteristics of Bartonella associated withChinese rodents and insectivores

A 1990 report first implicated a domestic rat bite as acause of CSD in Liaoning Province [13]; however, in theabsence of proper laboratory data, this may be incorrect.

The detailed characterization of Bartonella species inChinese rodents was first described in 2002 (Table 1 andFig. 1). Bartonella isolates were obtained from the gen-era Rattus (41.5%, n = 130), Apodemus (59%, n = 92) andEothenomys (19%, n = 32) trapped in three districts of Yun-nan Province [14] (Table 1 and Fig. 1). Bartonella in the bloodof the infected rodents was estimated to range from 8000 to320,000 colony forming units [15]. Diverse Bartonella iso-lates were obtained from the blood of the Chevrier’s fieldmouse, Apodemus chevrieri, from Jianchuan Municipalityand Rattus tanezumi flavipectus from Baoshan Municipalityin Yunnan Province (43%, n = 53) [14]. A. chevrieri is limitedto the northern part of Yunnan Province, Western ShishuanProvince and Southeast Tibet; therefore, the occurrence ofspecific Bartonella associated with these rodents may berestricted in distribution. The high level of the Bartonella inthe blood of R. tanezumi flavipectus has particular impor-tance since these rodents populate large regions of Chinaand they are often found in proximity to human householdsin both rural and urban areas.

Subsequent studies expanded further the list of rodentsinfected with Bartonella and extended the geography oftheir distribution. Bai et al. [16] reported isolation ofBartonella from Rattus nitidus (22%, n = 100), R. flavipec-tus (14.8%, n = 210) and Rattus norvegicus (1.2%, n = 87)trapped, respectively, in Jingdong, Yingjiang and Longling,and Nanhuan municipalities of Yunnan Province (Table 2).Another study described isolation of Bartonella from R.

tanezumi flavipectus (42%, n = 154), R. norvegicus (15.8%,n = 19) and from the red-backed vole, Eothenomys miletus(100%, n = 2) and the Gardner’s shrewmouse, Mus pahari(100%, n = 1) trapped in the peridomestic environment

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95Table 1Detection and identification of Bartonella in mammals and arthropods from China.

Bartonella speciesa Province Associated mammalianhost

Associatedarthropod

PCR detection(source)

Isolation (source) Reference Associated NCBIaccession numberb

Bartonella clarridgeiae Henan Cat NRc No Yes (blood) [10] EU770616

Bartonellacoopersplainsensis

Beijing Human NR Yes (blood) No [70] AY464941

Bartonellacoopersplainsensis-like

Yunnan Apodemus chevrieri NR No Yes (blood) [14] AF391276Rattus norvegicus NR No Yes (blood) [14] AF342938Rattus tanezumiflavipectus

NR No Yes (blood) [14] AY217216

Bartonella elizabethae Beijing Rattus norvegicus NR No Yes (blood) Li et al.,unpublished

DQ884390

Fujian Mus musculus, Rattusrattus, Rattusnorvegicus, Rattustanezumi flavipectus

NR Yes (blood) No [21] NR

Yunnan Rattus tanezumiflavipectus

NR No Yes (blood) [14] AF329679

Bartonellaelizabethae-like

Zhejiang NR Ixodes sinensis Yes (tick) No [37] EU167179

Bartonellagrahamii-like

Yunnan Apodemus draco NR No Yes (blood) [14] AF391278Apodemus penninsulae NR No Yes (blood) [14] AF391275Apodemus penninsulae NR No Yes (blood) [14] AF391280

Zhejiang Apodemus agrarius NR Yes (blood) No [29] EU179229

Bartonella henselae Shandong Cat NR No Yes (blood) [8] DQ345295, DQ222471

Bartonellaphoceensis-like

Yunnan Apodemus chevrieri NR No Yes (blood) [14] AF391272Apodemus latronum NR No Yes (blood) [14] AF391279

Bartonellaqueenslandensis

Fujian Rattus tanezumiflavipectus

NR Yes (blood) No [21] NR

Bartonellarattimassiliensis-like

Yunnan Cow Boophilus microplus Yes (tick) Yes (tick) [31] AY517722, AY518181,AY517723

Rattus tanezumiflavipectus

NR No Yes (blood) [14] AF342931

Bartonella tribocorum Fujian Suncus murinus NR No Yes (blood) [21] NRYunnan Rattus tanezumi

flavipectusNR No Yes (blood) [14] AF342929

Rattus tanezumiflavipectus

Xenopsylla cheopis Yes (flea) No [32] DQ884377

Bartonellatribocorum-like

Yunnan Rattus sp. NR No Yes (blood) [16] DQ983152

Bartonella vinsoniiberkhoffii

Shandong Dog NR No Yes (blood) [11] DQ192516, DQ192515

Bartonella washoensissubsp. cynomysii-like

Hebei Spermophilus dauricus NR No Yes (blood) Li et al.,unpublished

DQ645427

Bartonella washoensissubsp. cynomysii-like

Liaoning NR Haemaphysalislongicornis

Yes (tick) No [37] EU179228

Bartonellawashoensis-like

Yunnan Apodemus chevrieri NR No Yes (blood) [14] AF391237

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35 (2012) 93– 102

Table 1 (Continued)

Bartonella speciesa Province Associated mammalianhost

Associatedarthropod

PCR detection(source)

Isolation (source) Reference Associated NCBIaccession numberb

UncharacterizedBartonella sp.

Fujian Rattus norvegicus NR No Yes [18] Not sequencedSuncus murinus NR No Yes [18] Not sequenced

Yunan Cat Ctenocephalidesfelis

No No [17] Not sequenced

Apodemus chevrieri NR No Yes (blood) [14] AF391273Apodemus chevrieri NR No Yes (blood) [14] AF391277Dog Ctenocephalides

felisYes (fleas) Yes (flea) [30] AY566176, AY566177

Eothenomys miletus NR No Yes (blood) [14] AF391281Eothenomys miletus NR No Yes (blood) [14] AF391282Mus pahari NR No Yes [17] Not sequencedRattus nitidus NR No Yes (blood) [16] Not sequencedRattus tanezumiflavipectus

Ctenophthalmuslushuiensis

Yes (flea) No [30] DQ884380 andDQ884378

Rattus tanezumiflavipectus

Leptosylla segnis Yes (fleas) No [30] Not sequenced

Zhejiang Apodemus peninsulae NR No No [29] Not sequencedEothenomysmelanogaster

NR No No [29] Not sequenced

Microtus fortis NR No No [29] Not sequencedNiviventer confucianus NR No No [29] Not sequencedRattus losea NR Yes (blood) No [29] Not sequencedRattus norvegicus NR Yes (blood) No [29] Not sequencedRattus tanezumi NR Yes (blood) No [29] Not sequencedSuncus murinus NR Yes (blood) No [29] Not sequenced

a If the Bartonella sp. was not identified in the original manuscript, an isolate was classified based on ≥96% nucleotide sequence similarity to the gltA of the nearest Bartonella species available from the NCBIGenBank.

b Only one accession number is provided for the same gene; however multiple isolates of the same or similar genotypes may be described in the manuscript.c NR, data are not reported in the manuscript, sequencing was not done or accession number cannot be found.

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97

Table 2Summary of clinical reports on cat scratch disease in China.

Location Reporting period Cases [sex] Age range [median] Lymph node orinvolvement

Primary lesionnoted

Primary clinicaldiagnosis orother symptoms

Animal contactor exposure

Biopsy Reference

Bengbu, AnhuiProvince

1/1997–12/1999 38 [24♂, 14♀] 4–56 [20.8] Lymphadenitis None CSD Yes, 34/38 catcontact

Yes, 38/38 [43]

Beijing City 5/2001–10/2004 26 [8♂, 18♀] 12–61 [29.2] Lymphadenopathy Yes, 9/26 papule CSD Yes, 21/26 catcontact, 5/26 dogcontact

Yes, 26/26 [55]

Fuzhou, FujianProvince

2006 2♀ 13–35 Lymphadenopathy Yes, 2/2 papule;4-monthincubation period

CSD Yes, 1/2 catcontact, 1/2 catbite

None [49]

Xiamen city, FujianProvince

9/1998–9/2003 12 [8♂, 4♀] 12–54 [34] Lymphangitis,lymphadenopathy

Yes, 12/12 papule CSD Yes, 10/12 catscratches, 2/12dog bites

Yes, 12/12 [45]

Shantou city,Guandong Province

8/2000–5/2004 5 [3♂, 2♀] 5–67 Enlarged lymphnodes

None CSD Yes, 5/5 catcontact

Yes, 5/5 [50]

Guiyang, GuinzhouProvince

Not reported 25 [17♂, 8♀] 10–47 [24] Lymphadenopathy Yes, 25/25 Lymph nodetuberculosis[5/25], 1/25Hodgkin’sdisease

Yes, 25/25 catscratches or bites

Yes, 25/25 [46]

Hengshui, HeibeiProvince

1/2003–12/2004 20 [6♂, 12♀]a 7–60 [36] Lymphadenitis Not reported CSD Yes, 12/20 catscratches, 8/20cat contact

Yes, 20/20 [52]

Shiyan, HubeiProvince

1983–1998 38 [21♂, 17♀] 6–64 [28.6] Lymphadenitis Not reported CSD 12/38 catscratches, 14/38cat contact

Yes, 38/38 [56]

Nantong city, JiangsuProvince

1/1996–10/2003 30 [17♂, 13♀] 11–64 [41] Lymphadenopathy Yes, 10/30 Fever 37.5–40 ◦C[17/30]

30/30 cat contact Yes, 6/30 [47]

Jiangsu Province 1985–1994 16 [11♂, 5♀] 5–27 [14.7] Lymphadenopathy Yes, 6/16 papulaand erythema

Encephalopathy 9/16 catscratches

Yes, 6/16 [53]

Hangzhou city,Zhejiang Province

1998–2005 37 [not specified] 7–54 [32.6] Lymphadenopathy,granuloma withabscess likepathology

Not reported CSD 26/37 catscratches or bites

Yes, 21/37 [66]

Huzhou, ZhejiangProvince

1986–1999 15 [9♂, 6♀] 5–77 [26] Tumor-like regionallymphadenopathy

Yes, 11/15 CSD 13/15 catscratches or bites

Yes, 15/15 [51]

Zhaoqing,GuangdongProvince

1993–2004 19 [11♂, 8♀] 4–63 Lymphadenitis,lymphadenopathy

Yes, 19/19 CSD 19/19 cat contact Yes, 19/19 [42]

Huzhou, ZhejiangProvince

Not reported 21 [12♂, 9♀] 2–77 [19] Lymphadenitis Yes, 9/21 CSD, fever37.5–40 ◦C[10/21], cough[2/21]

15/21 catscratches, 6/21cat bites

Yes, 21/21 [48]

CSD, cat scratch disease.a Sex of 2 pediatric patients is not identified.

98 Q. Liu et al. / Comparative Immunology, Microbiology and Infectious Diseases 35 (2012) 93– 102

al sampderlinedong Kon

Fig. 1. Geography of Bartonella sp. detected in animal and environmenta map correspond to the numbers of the articles cited in this review: unbrackets are for clinical reports. Abbreviations: B, Beijing; T, Tianjian; H, H

and mountainous brush and forest areas in Jianchuan, Yun-long, Dali, Xiangyan and Yuanxian Municipalities of theYunnan Province [17] (Table 1). In total, 39.2% (n = 176)of rodents were positive by PCR assay targeting a frag-ment of gltA. Ye et al. reported isolation of uncharacterizedBartonella from the shrew, Suncus murinus, and R. norvegi-cus from Fujian Province, hence expanding further theregions where Bartonella were found in association withrodent and insectivore reservoirs (Table 1) [18]. Thedata on association of Bartonella with S. murinus areparticularly important since around 20% of small com-mensal mammals trapped in south-eastern China are S.murinus including coastal areas of Fujian and Guang-dong Provinces, Taiwan and Macao [19,20]. According tothe recent reports, S. murinus captured in mainland ofChina and in Taiwan is frequently found bacteremic forB. tribocorum [21,22].

Different rodent Bartonella genotypes have been iden-tified by sequencing a 325 bp gltA fragment [14,17]. Mostof the Yunnan isolates from R. flavipectus, R. norvegicus, A.chevrieri, Apodemus draco (South China field mouse), and

les, and reports of human clinical cases in mainland China. Numbers on numbers are for environmental and veterinary reports and numbers ing; M, Macau.

Apodemus latronum (Sichuan field mouse) have their high-est nucleotide sequence similarity to B. elizabethae andB. grahamii, rodent Bartonella species with known poten-tial for causing human infection [23–25]. Some of theYunnan isolates from the same species of rodents andBartonella from the vole E. miletus are more divergent.An A. draco isolate found in Yunnan Province is relatedto B. rattimassiliensis. Multiple Bartonella with disparatephenotypes were recovered from R. flavipectus, R. norvegi-cus, R. yunnanensis and R. nitidus in Yunnan province [26].Bartonella isolates from a ground squirrel, Spermophilusdauricus trapped in Shandong Province and from A. chevri-eri trapped in Yunnan exhibit a genotype like that of B.washoensis, an agent linked to endocarditis in a human andin a dog [27,28]. The list of small mammal species associ-ated with Bartonella infections was further extended duringthe studies conducted in Fujian coastal region [21] and Zhe-

jiang Province [29]; the former study reported findings ofanother new Bartonella genotype in China, B. queenslan-densis and confirmed the presence of B. elizabethae and B.tribocorum [21].

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. Characteristics of Bartonella agents associatedith Chinese arthropods

Several attempts were made to identify potential vec-ors responsible for transmission of Bartonella in areashere infected animals are present in high prevalence

30–32]. The fleas, Ctenocephalides felis (108), C. orien-alis (101) and Pulex irritans (17) were collected from 21ats and 34 dogs from Yunlong Municipality of Yunnanrovince [30]. Bartonella isolates were obtained from 7 C.elis found on a dog from Yunnan Province [31].

Leptosylla segnis was found on R. norvegicus and R.anezumi; these rats were also infested with Neopsylla spe-ialis specialis and Xenopsylla cheopis, respectively. Only C.uadrates were collected from E. miletus [30]. One poolf 8 C. felis tested positive by PCR for Bartonella gltA and6S-23S rRNA intergenic region fragment. Five of 10 L.egnis collected from R. tanezumi flavipectus were PCR pos-tive using the same set of primers. Unfortunately, furtherenetic identification of some of these Bartonella DNAs byequencing was not performed. In a follow up study, Bar-onella F47YN isolated from X. cheopis collected from R.avipectus in a residential area of the Lincang Municipal-ty of the Yunnan Province was identified as B. tribocorum32]. Ctenopthalmus lushuiensis collected from the nests ofhe E. miletus voles in Longling of Yunnan were infectedith Bartonella of two different genotypes. There were 4

solates (F12YN, F13YN, F14YN, and F16YN) with a simi-ar genotype that was almost identical to that previouslyescribed for Em1531yn and Em1712yn Bartonella isolatesrom Yunnan Province [14,32]. The flea isolate F15YN rep-esents a unique genotype closely related to B. clarridgeiaend B. rochalimae [32]; similar Bartonella are found in asso-iation with rodents in Greece and Sweden [33,34] and itas identified both in R. norvegicus and fleas from Taiwan

22,35].Isolates of Bartonella were made from 6 adult Rhipi-

ephalus (Boophilus) microplus collected from a cow fromunnan Province [31]. Tick isolates of Bartonella had a geno-ype identical to that of B. rattimassiliensis which may have

wide distribution compared to its original identificationn the Mediterranean area [36]. The detection of Bar-onella DNA in association with Haemaphysalis longicornis36.0%, 54 of 150 groups) from Liaoning Province and Ixodesinensis (16.28%, 14 of 86 groups) from Zhejiang Provinceas reported [37]; these Bartonella were identified as B.ashoensis subsp. cynomysii type and B. elizabethae, respec-

ively (Table 2). In other countries these ticks are alsoften infected with Anaplasmataceae and Borrelia burgdor-eri which may complicate differential diagnosis of illnessn human or veterinary patients associated with these ticksf this complex association is also true in China [38–40].

. Clinical diagnosis of Bartonella infection

Based on our review of 30 Chinese clinical articles pub-ished on Rochalimaea and Bartonella infections between

980 and 2006, cat scratch disease (CSD) is presentlyhe only clinically recognized Bartonella infection in ChinaTable 2). We identified 15 clinical reports from majorospitals of 9 provinces that describe multiple cases with

y and Infectious Diseases 35 (2012) 93– 102 99

similar clinical presentations of CSD [41–56] and severalpublications reporting individual cases [13,57–61]. Notsurprisingly, most Bartonella cases were reported from theEast and South-Eastern provinces of China, the most popu-lated areas with the best access to medical care. Typically,in each cohort of reported cases, male patients were preva-lent; young people and children were most often affectedalthough the oldest patient was 77 years old. Seasonality ofthe cases diagnosed was not emphasized as found in othercountries [62], and epidemiological deductions are limiteddue to the non-reportable status of CSD in the Chinesemainland.

Typical clinical manifestations include lymphadenopa-thy and/or lymphangitis (or lymphadenitis) with under-lying febrile illness, fatigue, nausea, malaise and myalgiathat develop following 7–60 days of incubation. Severalarticles described cases of suspected Bartonella infec-tions whose manifestations included pulmonary [49],neurologic [53,60] or exceptionally and possibly incor-rectly enteric disease [61,63]. Descriptions of papulescorresponding to the inoculation site were reported inseveral cohorts of patients with a prevalence of 16–100%[45–47,49,51,53,55]. Development of enlarged lymphnodes was the primary symptom used as inclusion cri-teria; lymphadenopathy of the pectoral, axillary, pelvic,inguinal and neck lymph nodes was reported with thegreatest frequency [42,48,52,53]; lymphadenopathy typ-ically developed near the site of an animal scratch or bite[42,48]. Most of the patients had reported animal contacts,were cat or dog owners, and had scratches and bites priorto the onset of disease.

When reported, the patients were usually treated withpenicillin and penicillin derivatives and sometime withciprofloxacin [53,60]; all patients recovered and becamewell. However, since Bartonella is only moderately suscep-tible to penicillin [64,65], the most likely cause of recoveryand good outcome is due to the self-limited nature of classicCSD in immunocompetent patients [65].

Since specific laboratory diagnostic tools, includingserology, culture, and PCR detection and identification ofamplicon sequences for routine clinical identification anddetection of individual Bartonella agents are not widelyavailable in China, these clinical reports mostly describepresumptive cases of CSD.

The pathological evaluation of the removed lymphnodes by hematoxylin and eosin staining [42,48,66,67]detected necrotizing granulomas and star-like micro-abscess zones [48,66] often seen in CSD patientselsewhere [68]. Infiltration of the granuloma zones with B-lymphocytes, neutrophils and macrophages was detected;proliferation of the epithelial cells and T-cell infiltrationwas also observed on the periphery of the area affected [42].Pleomorphic bacilli were detected in the vascular wallsand microabcess areas with Warthin-Starry stain [48,67].Furthermore, Bartonella bacilli were detected in 72.7%(n = 77) of paraffin-embedded lymph node tissues usingimmunochemical stain with monoclonal antibodies to B.

henselae [67]. Some groups used sonogram examinationof the lymph nodes as a non-invasive method for eval-uation of the lymphadenopathy sites [52]; however, thisdiagnostic approach is not specific for Bartonella infections.

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Therefore, more advanced radiological tools, includingcomputed tomography and magnetic resonance imagingmay be more suitable for interpreting the images of pseu-dotumors that have to be evaluated in the context ofepidemiological and clinical data [69].

One report employed a 16–23S rRNA intergenic regionand gltA PCR assays to retrospectively confirm bartonellosisin a patient from Beijing who presented with pulmonarysyndrome and lymphadenopathy [70]. Surprisingly, theBartonella DNA was subsequently identified as B. coop-ersplainsensis, the first report of a human illness due tothis Bartonella (Table 1). It was previously found onlyin association with rats (R. tanezumi) that are endemicin Yunnan Province [14]. Whether B. coopersplainsensisalso infects R. rattus and their fleas in China mainland,as has been previously reported from Australia, remainsunknown [71,72].

5. Surveillance of Bartonella infection

An experimental ELISA assay was used to determine theprevalence of antibodies to Bartonella in humans from Bei-jing [73]. B. henselae strain Houston-1 grown on blood agarplates and disrupted by sonication was used as a groupantigen. Screening of 357 sera from healthy blood donorsdetected the presence of IgG antibodies to B. henselae in34.5% of 357 of the serum samples tested; a similar sero-prevalence was established by microimmunofluorescence(indirect microimmunofluorescence assay, IFA) performedon the same set of sera. Recently, a 9.6% prevalencerate of B. henselae seroreactivity was determined usingIFA in 365 farm workers from Tianjin Province [74]; afollow up study from the same province indicated thatthere was a possible annual increase in Bartonella sero-prevalence in farmers surveyed during 2007–2009 [75].A similar Bartonella IFA seroprevalence of 10.9% (n = 579)was established for healthy humans from a rural area ofZhejiang Province [76]. Anti-Bartonella antibodies foundin 19.6% (2–32%, range) of people with dog bites fromindustrial areas of Zhejiang Province suggests that dogbites may be a risk factor for Bartonella infections [77].Since antibodies to B. henselae exhibit a significant degreeof cross-reactivity with other species of Bartonella due toshared outer membrane antigens [78,79] and heterolo-gous reactivity with other bacteria including Chlamydia,Coxiella and Rickettsia (mostly due to cross-reactivity ofconserved heat shock proteins) [78,80–82], such serolog-ical results are not necessarily specific to B. henselae orCSD.

A definitive role for rodent-borne Bartonella agents assignificant human pathogens has not been demonstrated inChina. A limited pilot seroprevalence study in humans wasconducted in 2004 in Yunnan Province [83]. A low antibodytiter (1:128 IgG) to antigens of B. elizabethae was detectedby IFA in 1 of 30 healthy 18–20-year-old male blood donorswith suspected exposure to rats. Four other donors had

low level titers to antigens of unnamed Bartonella isolates(specifically referred to as A1, B2, and Neotoma) obtainedin the US [84]; those isolates are genetically related to theB. vinsonii group.

y and Infectious Diseases 35 (2012) 93– 102

6. Prospectus for future investigations of Bartonellainfections in China

We have provided a summary of the contemporary Chi-nese information available on the ecological and laboratoryresearch on Bartonella and its application to the epidemiol-ogy and clinical diagnosis of Bartonella infections. Despitesignificant progress at research institutions, available dataand modern technology have not yet translated into rou-tine use in Bartonella clinical research in China. Althoughclassic CSD has been commonly recognized, diagnosisof other etiologies for human and veterinary Bartonellainfections remains limited because specific molecular labo-ratory confirmation is not routinely performed for unusualpresentations. Many cases may also remain undetected dueto insufficient awareness among physicians and laboratorypersonnel about these other agents. A primary limitation isthe scarcity of commercial serological reagents, UV micro-scopes and PCR testing and the atypical incubation timeand conditions required for blood culture of Bartonellaagents. An even more fundamental limitation is the lackof inexpensive commercial sources of Bartonella referencediagnostic reagents which are needed for IFA and PCRtesting and even for molecular-biological or antibody iden-tification methods for differentiating Bartonella species.While, some of the Bartonella agents detected in associationwith Chinese rodents and their ectoparasites have beenimplicated as causes of human illness in other countries,the real incidence of these infections remains unknownboth in China and worldwide and little is known aboutthe mechanism(s) by which they may be transmitted tohumans. However, taking into account that some knownhuman and veterinarian pathogens like B. henselae and B.vinsonii berkhoffii do circulate in domestic pets, and theincreasing numbers of pets in Chinese households, par-ticularly in urban and suburban environments, these twofactors may also result in future increases in the incidenceand diversity of Bartonella zoonoses in human populations.A recent article described the possibility of a long term cir-culation of B. quintana in a colony of captive monkeys inBeijing‘s Zoo [85]. This observation further illustrates thecomplexity of the problems faced by clinical and researchcommunities involved in Bartonella research in mainlandChina.

Conflict of interests

None.

Acknowledgments

We thank Gregory A. Dasch for helpful discussion andreview of the manuscript, Meng Fengxia, Xu Chuanbin, SunJimin, Huang Ruting and Chu Xianbin for their assistancewith bibliographical search and translation of Chinese pub-lications, Ruth E. Whitworth for assistance with Fig. 1. We

also thank Sonia Olsen and Robert Fountain of the USA CDCOffice of Global Health for their encouragement and sup-port of this collaboration between the China CDC and USACDC.

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