Bartonella and the Spleen

      A healthy 54-year-old woman was admitted with a 4-day history of high fever and left upper quadrant pain radiating to the back, associated with nausea. Her temperature was 39°C, but examination findings were normal except for left upper quadrant and left costovertebral tenderness. Chest radiograph and urinalysis were normal. Hemoglobin was 10 g/dL (normocytic), white blood cells 10 × 109/L, platelets 141 × 109/L, albumin 3.5 g/dL, and globulins 3.2 g/dL. Other tests were normal except for lactic dehydrogenase (LDH) 784 IU/L (normal 240-480 IU/L) despite normal liver and muscle enzymes. Computed tomography (CT) urography (left urolithiasis or renal abscess was first suspected) and abdominal CT demonstrated few splenic subcapsular wedge-shaped lesions and other hypodense scattered lesions (Figure 1). All cultures were negative. Echocardiography (including transesophageal) was normal. No antiphospholipid or other autoantibodies were found. Viral, ricketsial, and Q fever serology was negative. Serology for Bartonella henselae was positive for the presence of immunoglobulin G and immunoglobulin M antibodies, supported by the history: 2 cats lived in her apartment. She was treated with doxycycline 100 mg twice a day, with good clinical response. On the fourth hospital day, white blood cells decreased to 4.4 × 109/L, platelets increased to 234 × 109/L, and globulins to 4.4 g/L. LDH persisted (689 IU/L) but C-reactive protein, which peaked at 236 mg/dL (erythrocyte sedimentation rate 81 mm/h, ferritin 600 mg/dL) went down to 139.8 mg/dL, with parallel improvement in imaging. Chest CT showed only minor reactive axillary lymphadenopathy. At 1-month follow-up she was well, with utterly normal tests (eg, C-reactive protein 0.85 mg/dL, LDH 301 IU/mL) and imaging (Figure 2).
      Figure 1
      Figure 1Axial image from computed tomographic urography, nephrographic phase: several small, hypodense, ill-defined foci (arrowheads) and few subcapsular hypodense wedge-shaped lesions (arrow) are scattered throughout the spleen.
      Figure 2
      Figure 2In contrast-enhanced computed tomography of the abdomen (portal phase) 4 weeks later, all lesions have vanished and the spleen enhances homogeneously. The spleen has shrunk in size, down to 10 cm in transverse length from 12 cm on both previous scans.
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