Oroya fever and autoimmune hemolytic anemia, coexistence or complication?

Patrón-Ordóñez, Gino; Cano-Cárdenas, Luis Alberto

doi:10.1016/j.medcle.2019.10.024

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"tieneTextoCompleto" => true "saludo" => "Dear Editor:" "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "147" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Gino Patrón-Ordóñez, Luis Alberto Cano-Cárdenas" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Gino" "apellidos" => "Patrón-Ordóñez" "email" => array:1 [ 0 => "g.patron@urp.edu.pe" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Luis Alberto" "apellidos" => "Cano-Cárdenas" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Facultad de Medicina Humana, Universidad Ricardo Palma, Lima, Peru" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Nacional Dos de Mayo-Sala de Medicina Julián Arce, Lima, Peru" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fiebre de la Oroya y anemia hemolítica autoinmune: ¿coexistencia o complicación?" ] ] "textoCompleto" => "Oroya fever is the acute phase of bartonellosis or Carrión's disease, an endemic disease of the highlands of Peru, Ecuador and Colombia caused by Bartonella bacilliformis, a facultative intracellular, aerobic, pleomorphic gram-negative bacillus transmitted by the bite of a female mosquito Lutzomyia verrucarum, with man being the only host. The acute phase of the disease develops a rapidly anaemic feverish condition, accompanied by a series of complications, followed by a chronic phase known as the Peruvian wart, characterised by the occurrence of angiomatous lesions on the face and limbs as a result of pathogen-induced endothelial proliferation.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Due to the still scarce description of some complications of the acute phase, we report a case of Oroya fever associated with autoimmune haemolytic anaemia.We report the case of a 55-year-old man, with a 45-day history of fever reaching 38 °C, headache, asthenia, weight loss and, in the last 15 days, palpitations. He constantly travels to Caraz, Ancash, a village in the highlands of Peru. On examination, paleness and slight jaundice of the sclera were observed; arrhythmic heart sounds with the presence of a deficient pulse, findings compatible with atrial fibrillation; palpation of the abdomen revealed hepatosplenomegaly. The findings were confirmed by an electrocardiogram and an abdominal ultrasound.A complete blood count showed severe anaemia with haemoglobin 5.0 g/dl, 24% reticulocytes, leukocytes and platelets were normal, serum lactic dehydrogenase was elevated, and there was a slight increase in indirect bilirubin, direct Coombs was positive (3+) and mono-specific Coombs yielded positive IgG2 and C3d, abnormalities compatible with autoimmune haemolytic anaemia (AIHA) due to warm antibodies.However, the trip to Caraz, an endemic area for bartonellosis, plus the finding of fever and anaemia led to suspicion of an acute phase of bartonellosis, which is why a peripheral blood smear was performed which was negative, pending a blood culture. With these results, treatment for AIHA was started with prednisone 1 mg/kg/day in addition to ceftriaxone and ciprofloxacin due to clinical-epidemiological suspicion of severe acute bartonellosis, despite the negative result of the peripheral blood smear. Digitalis for the control of atrial fibrillation and blood transfusion were also indicated.Two days after the treatment, fever started to drop and there was an improvement in the condition, with sinus rhythm and haemoglobin controls showing an increase; 14 days of antibiotic treatment were completed, and steroids were continued, in addition to echocardiogram and Holter studies, which were normal. After 23 days and with the patient already discharged, the blood culture results arrived, which were positive for Bartonella bacilliformis.The acute phase of Carrión's disease is characterized by complications such as pericarditis, ascites, encephalopathy, and systemic vasculitis. In addition, opportunistic infections such as salmonellosis, histoplasmosis, pneumocystosis, tuberculosis and leptospirosis are known to occur.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Descriptive studies carried out in Peru have found cases of positive Coombs bartonellosis,<a class="elsevierStyleCrossRef" href="#bib0010">2</a> however, they do not describe the immunological profile or determine the association of AIHA with this acute phase. Let us remember that approximately 50% of the cases of this anaemia are secondary to an underlying disease, finding an association with autoimmune diseases, haematological neoplasms, use of drugs and viral and bacterial infections, such as those produced by cytomegalovirus, Mycoplasma, Brucella, Bartonella henselae and malaria, among others.<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a>Let us remember that the complications of Oroya fever have not yet been fully studied and since the association of AIHA with infectious diseases is known, we are able to identify it as a complication of the acute phase of bartonellosis. As a proposed mechanism of autoimmunity, antigen overlap, and stimulation of B lymphocytes have been described in other infections.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>Treatment should be based on clinical-epidemiological criteria, since the blood smear has a low sensitivity (36%) and the culture takes around 30 days, this becomes important in patients with AIHA from endemic bartonellosis areas.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>The patient's progression was favourable, with Coombs being negative within 2 months of treatment with steroids, and no further haemolysis. A separate mention is made for paroxysmal atrial fibrillation, where although cardiovascular complications have been described in patients with bartonellosis, complicated cases with this arrhythmia have not been reported so far.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>FundingThe authors declare that they have not received funding to carry out this study." 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Maguiña" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:6 [ "editores" => "E.T.Ryan, D.R.Hill, T.Solomon, N.E.Aronson, T.P.Endy" "titulo" => "Hunter’s Tropical Medicine and Emerging Infectious Diseases" "paginaInicial" => "604" "paginaFinal" => "607" "edicion" => "10th ed." "serieFecha" => "2020" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Manifestaciones clínicas y complicaciones de la fase aguda de bartonelosis o Fiebre de la Oroya en pacientes atendidos en el Hospital Nacional Cayetano Heredia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C.P. Maguiña Vargas" 1 => "R.B. Peña Collantes" 2 => "M.C. Ponce Alvarez" 3 => "T.F. Quispe-Chullo" 4 => "P.R. Ventosilla López" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Medica Hered" "fecha" => "2008" "volumen" => "19" "numero" => "3" "paginaInicial" => "87" "paginaFinal" => "95" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Autoimmune Hemolytic Anemia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Michel" 1 => "U. Jäger" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:6 [ "editores" => "R.Hoffman, E.J.Benz, L.E.Silberstein, H.E.Heslop, J.I.Weitz, J.Anastasi" "titulo" => "Hematology" "paginaInicial" => "648" "paginaFinal" => "662" "edicion" => "7th ed." "serieFecha" => "2018" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Warm autoimmune hemolytic anemia secondary to Plasmodium ovale infection: A case report and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.S. Johnson" 1 => "G. Delisca" 2 => "G.S. Booth" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.transci.2013.09.006" "Revista" => array:7 [ "tituloSerie" => "Transfus Apher Sci" "fecha" => "2013" "volumen" => "49" "numero" => "3" "paginaInicial" => "571" "paginaFinal" => "573" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24148713" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Compromiso cardiovascular en la fase aguda de la enfermedad de Carrión o bartonelosis humana: 20 años de experiencia en Hospital Nacional Cayetano Heredia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Maguiña Vargas" 1 => "E. Ordaya Espinoza" 2 => "C. Ugarte-Gil" 3 => "V. Franco Reusche" 4 => "P. Ventosilla Lopez" 5 => "L. Huayanay Falconí" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Acta Médica Peru" "fecha" => "2008" "volumen" => "25" "numero" => "1" "paginaInicial" => "30" "paginaFinal" => "38" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015600000003/v1_202102051000/S2387020620306434/v1_202102051000/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015600000003/v1_202102051000/S2387020620306434/v1_202102051000/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020620306434?idApp=UINPBA00004N"]

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Vol. 156. Issue 3.

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