ZSFG ID report -Palpable purpura and bartonella endocarditis!

ZSFG Morning report was bumpin this morning –  there were majestic volumes of learning. Thanks to Nick Iverson for presenting the case, Kat Christopoulos for acting as our wise ID consultant, and the room full of enthusiastic participants.
Top takeaways
  • The palpable purpura ddx below (in image form)
  • Consider Bartonella endocarditis in a patient with
    • symptoms of subacute endocarditis
    • risk factors for either bartonella henselae (kitten exposure) or bartonella Quintana (body lice, HIV, homelessness)
Palpable purpura
  • We’ve posted pearls on palpable purpura previously, which focused on ddx and first pass workup. Emma Bainbridge presented a framework for palpable purpura that is SO GOOD. See below (attached in evernote version). Sarah Goglin devised it.

palpable purpura.JPG

  • First pass workup (pulled directly from prior pearls)
    • CBC w platelets
    • ESR/CRP
    • Metabolic panel
    •  ANA
    •  ANCAs
    • Complements
    • UA
    • Infectious w/u including HIV, HCV, HBV, +/- ASo or strep throat culture and cryos
Bartonella endocarditis
  • Rare! We see 1-2 cases/year at ZSFG
  • Usually presents like sub-acute bacterial endocarditis with fevers, constitutional symptoms, and dyspnea
  • MANY subspecies of bartonella. Most common endocarditis culprits are Quintana and henselae
  • When to consider
    • subacute bacterial endocarditis sx
    • risk factors for either bartonella henselae (kitten exposure) or bartonella Quintana (body lice, HIV, homelessness)
  • Testing is complicated! Phone a friendly ID doctor for help. Usually a combination of serology and PCR. It is very antibiotic sensitive and fastidious so rarely grows in culture.
  • For the ID bound, feel empowered to nerd out about this paper from the French Reference laboratory for all Bartonella cases. Discusses bartonella endocarditis epidemiology, testing and trends: https://www.ncbi.nlm.nih.gov/pubmed/25540398
Other Sources:
Cahill TJ1, Prendergast BD2. Infective endocarditis Lancet. 2016 Feb 27;387(10021):882-93.

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