Immunocompromised people and pets: testing for Bartonella
I did a presentation at a conference last week with a physician on the topic of "Pets and Immunocompromised Owners". It led to some interesting discussion. People with suboptimal immune systems are becoming more common in households and they often own pets. These individuals are susceptible to infections caused by microorganisms that would not typically cause disease in healthy people, and they are also more susceptible to severe (including fatal) disease caused by microorganisms that would only otherwise cause mild disease. Therefore, there's a lot of concern about pets transmitting infection to immunocompromised people. Rarely is removal of pets from households of immunocompromised people necessary, but precautions should be taken to reduce the risks of disease transmission.
One topic that comes up periodically is testing for Bartonella henselae. This bacterium is the cause of cat scratch disease, which is spread by cats through scratches (obviously) but also through bites and by fleas. Cats that carry Bartonella henselae hardly ever have any signs of disease. In healthy people, cat scratch disease typically causes fever, local lymph node swelling, headache and fatigue. Immunocompromised people, particularly people with HIV/AIDS, are at higher risk for severe disease, which can be fatal if it is not identified and treated promptly. Similar disease can also be caused by other species of Bartonella that are not carried by cats.
Tests for Bartonella are not 100% accurate. Some tests just indicate exposure which does not tell you whether the cat is still carrying Bartonella or if it was previously exposed but already eliminated the bacterium from its body. False negative tests (e.g. the cat has been exposed but the test comes back negative anyway) can also occur. When considering screening tests, or any diagnostic tests in general, only do a test if there's a reasonable chance that the results will affect what you do.
- If a cat is positive, I wouldn't recommend removing it from the house. It may or may not be shedding Bartonella, so the key points for avoiding cat scratch disease are reducing the risk of bites and scratches, and controlling fleas.
- If a cat is negative, it's probably (but not guaranteed to be) free of Bartonella, but it could be infected later in life, and the key points for avoiding cat scratch disease are reducing the risk of bites and scratches, and controlling fleas.
So, if the recommendations are exactly the same in both cases, save your money and spare the cat the blood sample. I don't recommend testing for Bartonella henselae. The Infectious Disease Society of America also does not recommend testing (or treating) cats for Bartonella in their guidelines for HIV/AIDS patients.
Cat Scratch Disease - Bartonella henselae
Bartonella henselae is a small, Gram-negative bacterium that is host-adapted to cats. It may rarely cause mild illness in cats, but most felines, from tiny house cats to the king of the beasts, carry the bacteria with no clinical signs whatsoever. Unfortunately, when B. henselae infects a person it can cause any of several serious conditions (most of which have very long names!). These include bacillary angiomatosis (formation of masses of abnormal blood and lymph vessels), endocarditis (infection of the lining of the heart), chronic lymphadomegally (enlarged lymph nodes), and pyogranulomatous lymphadenitis, better known as cat scratch disease. There are at least four Bartonella species (among many, many other Bartonella species) that can infect cats, but B. henselae is the most common. There are at least nine Bartonella species that can infect humans, seven of which are zoonotic.
Between 5% and 40% of cats in the USA have B. henselae in their bloodstream. It is most common in cats from temperate areas, and is much less common in Canada. Bartonella spp. live in the red blood cells of their host – quite a clever strategy really, because it makes the bacteria readily available to be picked up by vectors like blood-sucking fleas, it protects the bacteria from the hosts immune system so it can live there for a long time, and it may even partially protect the bacteria from antibiotics. Cats can maintain a waxing and waning infection for months or even years. The bacterium is transmitted between animals by the cat flea (Ctenocephalides felis felis). Studies have shown that transmission does not occur between cats kept in a flea-free environment. Some ticks may also be able to transmit the disease. Diagnosis in cats is difficult – blood culture is the most reliable means, but it is not always sensitive. Antibody production only confirms exposure but not active infection. Polymerase chain reaction is often faster but no more sensitive than blood culture. An effective treatment regimen to eliminate B. henselae infection in cats has yet to be determined.
Transmission of B. henselae from cats to humans is thought to occur through contamination of scratches and bites (broken skin) with flea dirt (i.e. partially digested blood from the infected animal that is excreted by fleas = flea poop). Infection in individuals with weakened immune systems can be extremely serious or even fatal. In otherwise healthy people, the infection tends to remain localized, but can still cause massive swelling and abscessation of local lymph nodes. The type of disease that occurs may depend on the strain of Bartonella involved.
There are a few simple steps people can take to decrease the risk of cat scratch disease. These are particularly important for individuals with compromised immune systems, in which infection can be much more severe:
- Keep your pets flea- and tick-free. Effective treatment and prevention products are available from your veterinarian.
- Avoid or prevent situations that may result in bites and scratches from your pet. There is more information about this on the Worms & Germs Resources page and in our archives. If you do accidentally get scratched or bitten, be sure to clean the wound thoroughly. Consider seeking medical attention for bites in particular.
- Be aware of where cats come from. Stray or shelter cats less than one year old are most likely to be infected with B. henselae.
It is also important to note that there is NO evidence that declawing cats decreases the risk of transmission of B. henselae to humans!
As a point of interest, Bartonella quintana (a human-adapted Bartonella species) was the cause of trench fever in World War I, and was transmitted by lice.
Dog Bite Septicemia - Capnocytophaga canimorsus
Lots of people have heard of cat scratch fever (an infection caused by Bartonella henselae, which is often transmitted by cat scratches and bites), but dog bite septicemia is a much less familiar condition, although it is equally if not more serious when it occurs. As the name suggests, the infection (caused by the bacterium Capnocytophaga canimorsus) is typically transmitted by dog bites, and causes an infection of the bloodstream, resulting in very serious body-wide illness. The bacteria can also cause other types of infection including meningitis, endocarditis (infection of the heart valves) and rarely ocular infections.
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One study reported that 16% of dogs carried C. canimorsus as part of the normal bacteria in their mouths. Compared to the number of dog bites that occur, C. canimorsus infection is relatively uncommon. Most of the people affected by this bacteria have some kind of predisposing factor, particularly having had their spleen removed (splenectomy), having a weakened immune system, or being an alcoholic. The majority of cases occur in people who have regular close contact with dogs or who were bitten by a dog. Septicemia with C. canimorsus is fatal in approximately 1/3 of cases.
Prompt attention and treatment of dog bites is the best defence against bite-associated infections, including C. canimorsus. The bacteria are typically susceptible to many different antibiotics, but if treatment is delayed too long, the damage to the body may be too severe for the patient to survive.
ALL bite wounds should be taken seriously, and immediately washed thoroughly with lots of soap and water. Consult a physician for any bite on the hand, over a joint or tendon sheath (such as on the wrist or ankle), over any kind of implant or prosthesis, or in the groin area. It is also very important to consult a physician regarding treatment of any bite to a person with a compromised immune system, who has had their spleen removed, or who has any serious underlying chronic disease. Animal bites should also be reported to the local public health department.
More information on bites, much of which is also applicable to dog bites, is available on the Worms & Germs Resources page on the cat bites information sheet.
Picture: Trained attack dog Samo leaps forward toward a decoy's arm wrap as Tech. Sgt. David Adcox restrains him. (USAF Photo archives)
Cat bites - Why it's not "just a scratch"
Even the most well-natured, lovable cat has the potential to bite. Particularly if an animal is frightened or in pain, it may lash out with teeth and claws, even at its most trusted human companion. Many of us are used to sustaining small cuts and wounds in everyday life, and at times it hardly seems worthwhile to trouble a physician to look at a little cat bite. But 20-50% of cat bites become infected, compared to 4-20% of dog bites. The bacteria responsible are most often combinations of Pasteurella spp., Staphylococcus spp., Streptococcus spp. and others. In some cases, particularly when Pasteurella multocida is involved, the infection can develop very rapidly (within hours) and may become very serious, or even spread to the bloodstream. Cat scratch disease (Bartonella henselae infection), despite the name, can also be transmitted by cat bites. Cat bites can be very deep, even though they look very small at the level of the skin, which may lead to infection of things like joints and tendons under the skin, which are more serious.You should see a doctor about any cat bite on a hand, over a joint, over a tendon sheath (such as the wrist or ankle), over a prosthesis or implant, in the genital area, or that causes a deep tear. You should also see a doctor for any bite if you happen to have a weakened immune system for any reason (e.g. HIV/AIDS, cancer or transplant patients).
The best way to prevent infection is to prevent the cat from biting you in the first place!
- Use common sense – know how to handle a cat properly so that it is not frightened or uncomfortable. If a cat growls at you or tries to get away, let it go!
- Don’t let cats play with your hands, feet or hair. Use a nice cat toy instead.
- Don’t approach strange cats, especially strays. If you are bitten by a cat that may not have been vaccinated for rabies, it is very important to report the incident to you local public health department and your doctor, as you may need to receive rabies post-exposure prophylaxis (PEP).
