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Bartonella henselae antibodies after cat bite.

To the Editor: Bartonella henselae is the causative agent of cat-scratch disease, which is the most common form of human bartonellosis (1). In immunocompromised patients, e.g., HIV-infected patients, B. henselae can give rise to longstanding fever, bacillary angiomatosis, and peliosis hepatitis (2). Domestic cats are the reservoir for B. henselae, and cat fleas transmit the organism between cats (3). The seroprevalence and culture findings of Bartonella spp. in cats have been shown to be low in Sweden (4,5) compared with warmer areas (6). Cat-scratch disease is most often spread from cats to humans by scratches, but other forms of transmission, including cat bites, have been suggested (7).

To determine seroprevalence of antibodies against B. henselae in Sweden, we used data from a recently published prospective study of patients with infected cat bites (8). In addition to the information about bites, information about cat scratches was collected by retrospective review of the patients' medical records. Serum samples were taken during the patient's first visit to a hospital and at a follow-up visit about 2 weeks later. The study was approved by the local ethics committee.

Immunoglobulin G against specific Bartonella spp. was detected by the immunofluorescence antibody test (1). Cell-cultivated antigens were prepared from the following strains: B. henselae Houston-1 (ATCC 49882), B. henselae Marseille (CIP 104756), B. henselae Berlin1 (M. Arvand), B. henselae K68 (E. Olsson-Engvall), B. elizabethae (ATCC 49927), and B. grahamii (ATCC 700132). The cutoff values for a positive immunofluorescence antibody test result were chosen as [greater than or equal to] 128 for B. henselae and B. grahamii and [greater than or equal to] 256 for B. elizabethae. The titers are expressed as the reciprocal of the end-point dilution. For controls, we also analyzed serum from 117 blood donors with these antigens. The [chi square] test was used for statistical analysis.

We analyzed antibodies to Bartonella spp. in serum from 71 patients (51 women and 20 men), median age 47 years (range 15-85 years). Only 11 patients had fever. Cat scratches were reported for 17 patients. A single serum sample was obtained from 37 of the 71 patients, and an additional convalescent-phase sample was obtained from 34 patients after a median of 16 days (range 6-54 days).

Antibodies against any B. henselae strain were found for 24/71 (34%) patients, against B. elizabethae for 9/71 (13%), and against B. grahamii for 12/71 (17%). A total of 13/71 (18%) patients showed reactivity to B. henselae only. Antibodies to any Bartonella spp. were found for 28/71 (39%) of the patients. As many as 13/24 (54%) serum samples with antibodies against B. henselae reacted to antigens of only that species. More patients (19/71; 27%) reacted to the antigen from the cat in Sweden, K68, than to other strains. The least common reactivity found in this study was against the B. henselae Marseille strain.

Of the 117 controls, 1 (0.8%) had antibodies against B. henselae K68 antigens, 3 (2.6%) against Berlin1, 2 (1.7%) against Marseille, 1 (0.8%) against Houston-1, and 4 (3.4%) against any Bartonella spp. The difference between patients and controls was significant (p<0.001).

Seroconversion was reported for 6 of the 34 patients (18%) from which 2 serum samples were analyzed (Table). Among those who seroconverted for B. henselae, 1 had fever and only 2 reported having been scratched. Two of the patients who seroconverted were treated with doxycycline, and 1 was treated with ciprofloxacin. In addition, 1 patient with Sjogren disease was initially treated with penicillin, and later a hemangioma-like exanthema developed. Because of severe acne, the patient was treated with doxycycline for 6 months. The other patients who seroconverted were treated with penicillin or amoxicillin.

Seroconversion for B. henselae occurred in 4 patients, of which only 2 had reported a scratch. Three of these patients reacted to B. henselae Berlin1, and 1 reacted to the Houston-1 strain. Because symptoms did not differ between the patients who did seroconvert and those who did not, these findings could indicate subclinical infection.

The prevalence of immunoglobulin G against B. henselae in particular was shown to be much higher than that previously reported in Sweden (9). Earlier studies used only 2 B. henselae antigens (Houston-1 and

Marseille) compared with the 4 different B. henselae antigens used in the present study. Most reactivity to B. henselae in the present study was directed against the Swedish isolate K68 (27%); only 0.8% of controls had antibodies against that antigen.

An increased prevalence of antibodies against B. henselae after exposure to cats has been reported from Spain (10). Because seroconversion against B. henselae occurred in 2 patients who had not been scratched, cat bites may contribute to transmission of B. henselae.


We thank Mardjan Arvand and Eva Olsson-Engvall for providing antigens of B. henselae Berlin1 and B. henselae K68, respectively.

The study was supported by local funds from the Academic Hospital, Uppsala Community.


(1.) Regnery RL, Olson JG, Perkins BA, Bibb W. Serological response to "Rochalimaea henselae" antigen in suspected cat-scratch disease. Lancet. 1992;339:1443-5. DOI: 10.1016/0140-6736(92)92032-B

(2.) Koehler JE. Bartonella-associated infections in HIV-infected patients. AIDS Clin Care. 1995;7:97-102.

(3.) Chomel BB, Boulouis HJ, Maruyama S, Breitschwerdt EB. Bartonella spp. in pets and effect on human health. Emerg Infect Dis. 2006;12:389-94.

(4.) Hjelm E, McGill S, Blomqvist G. Prevalence of antibodies to Bartonella henselae, B. elizabethae, and B. quintana in Swedish domestic cats. Scand J Infect Dis. 2002;34:192-6. DOI: 10.1080/00365540110080188

(5.) Engvall EO, Brandstrom B, Fermer C, Blomqvist G, Englund L. Prevalence of Bartonella henselae in young, healthy cats in Sweden. Vet Rec. 2003;152:366-9.

(6.) Jameson P, Greene C, Regnery R, Dryden M, Marks A, Brown J, et al. Prevalence of Bartonella henselae antibodies in pet cats throughout regions of North America. J Infect Dis. 1995;172:1145-9.

(7.) Chomel BB, Kasten RW, Henn JB, Molia S. Bartonella infection in domestic cats and wild felids. Ann N Y Acad Sci. 2006;1078:410-5. DOI: 10.1196/ annals.1374.080

(8.) Westling K, Farra A, Cars B, Ekblom AG, Sandstedt K, Settergren B, et al. Cat bite wound infections: a prospective clinical and microbiological study at three emergency wards in Stockholm, Sweden. J Infect. 2006;53:403-7. DOI: 10.1016/j. jinf.2006.01.001

(9.) McGill S, Wesslen L, Hjelm E, Holmberg M, Auvinen MK, Berggren K, et al. Bartonella spp. seroprevalence in healthy Swedish blood donors. Scand J Infect Dis. 2005;37:723-30. DOI: 10.1080/00365540510012152

(10.) Blanco Ramos JR, Oteo Revuelta JA, Martinez de Artola V, Ramalle Gomara E, Garcia Pineda A, Ibarra Cucalon V. Seroepidemiology of Bartonella henselae infection in a risk group [in Spanish]. Rev Clin Esp. 1998;198:805-9.

[1] Presented in part at the 4th International Conference on Bartonella as Emerging Pathogens, 2004 Aug 26-28, Uppsala, Sweden.

Katarina Westling, Anna Farra, Christina Jorup, Asa Nordenberg, Bo Settergren, [2] and Eva Hjelm

[2] Current affiliation: Central Hospital, Kristianstad, Sweden.

Author affiliations: Karolinska Institutet, Stockholm, Sweden (K. Westling, A. Farra, C. Jorup, B. Settergren); and University Hospital, Uppsala, Sweden (A. Nordenberg, E. Hjelm)

DOI: 10.3201/eid1412.080002

Address for correspondence: Katarina Westling, Division of Infectious Diseases, Department of Medicine, Karolinska University Hospital/ Huddinge I 73, SE 141 86 Stockholm, Sweden; email:
Table. Titers against Bartonella spp. antigens in 6 patients
who seroconverted

Patient sex/       Reciprocal titer
age, y               Acute-phase       Convalescent-       Interval, d
                         serum          phase serum

F/77                      32                128                 6
F/50                      32                256                17
M/74                      128               512                19
F/62                      32                128                44
M/56                      32                128                15
F/23                      32                128                10

Patient sex/                                High titer
age, y                  Antigen              to other

F/77              B. henselae Berlin1     B. henselae K68
F/50              B. henselae Berlin1            0
M/74                  B. grahamii         B. henselae K68
F/62                B. elizabethae        B. henselae K68
M/56             B. henselae Houston-1      B. grahamii
F/23              B. henselae Berlin1       B. grahamii
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Article Details
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Title Annotation:LETTERS
Author:Westling, Katarina; Farra, Anna; Jorup, Christina; Nordenberg, Asa; Settergren, Bo; Hjelm, Eva
Publication:Emerging Infectious Diseases
Article Type:Report
Geographic Code:4EUSW
Date:Dec 1, 2008
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