Table 2.

Peripheral nerve paresis associated with Bartonella species infection

Peripheral neuropathies: peripheral nerve paresis
Diagnosis	Patient age/sex	Initial symptoms/clinical findings	Elapsed time to neurological symptoms	Key diagnostic results	Bartonella serology/PCR	Treatment/ duration	Outcome	Refs.
Chronic inflammatory demyelinating polyneuropathy (CIPD)	3/M	Lymphadenitis	6 weeks Symmetric distal muscle weakness, sensory ataxia, ↓ to absent deep tendon reflexes	Infectious and autoimmune panels NSF1 CSF mild ↑ protein, oligoclonal bands and slight intrathecal IgG synthesis. Decreased motor neuron conduction	Bh IgG > 1:850 IgM > 1:250 Serum PCR neg CSF serology and PCR neg	Clarithromycin + prednisone taper over 4 months	Recovery of motor and sensory function, reflexes, repeat titers IgM < 1:250, no change to IgG. Nerve conduction normalized at 1 year	[37]
	2/M	Previous history of woodlouse hunter spider bites, intermittent rashes and sinusitis	2 years Ataxia, leg pain, dizziness, visual floaters and constipation	CSF: ↑ protein. MRI: enhancement of ventral nerve roots/pia from 11th thoracic vertebrae to sacrum	Not initially obtained	IVIG × 4 d. for suspected GBS	Rapid improvement then relapsing muscle weakness 2 months later	[38]
			Weakness and pain in legs, tingling around mouth	EMG: chronic sensory motor demyelinating polyneuropathy	Bh IgM/IgG not detected at 1:16	IVIG + prednisone + gabapentin × 4 w Azithromycin × 10 d	Antibiotic helpful, relapsing muscle weakness 1 year later
			Weakness in legs	None noted	Titer 1: + Bh, Bk, Titer 2: + Bvb I-III, BhSA2/H1 and Bk Titer 3: all decreasing	IVIG Azithromycin × 30 d	Improvement on antibiotics and IVIG
						Taper of IVIG Clarithromycin + rifampin × 6 months	Full recovery with minimal stiffness in legs after 2 months
Cranial nerve paralysis	29/F	Fever, night sweats, headache, left parotid enlargement and facial weakness	5 weeks OS ptosis, mydriasis and enlarged occipital LN	MRI: regional lymphadenopathy Histopathology: granulomatous inflammation	Bartonella sp. positive serology (not specified)	None	Complete recovery over 4 months	[51]
	28/M	Headache, fever, fatigue and myalgia × 3d, followed by right preauricular LN swelling 1 week later	16 days Blurred vision, right eyelid weakness	CBC, EBV, CMV NSF	No initial Bartonella diagnostics	Prednisone	Improvement with relapse upon treatment cessation	[49]
			1 week later Recurrent ocular, facial nerve symptoms, fever, chills and myalgia. New ↑ cervical LNs	CBC mild ↑WBC, viral and STI screening NSF3 CT: cortical necrosis right preauricular LN and parotid sialadentis	Bh IgG > 1:640 IgM neg Bq neg	Azithromycin × 5d	Resolution 2 weeks after treatment
	7/M	Transient fever, cat scratch left cheek	1 month Left facial palsy with recurrent fever and cervical lymphadenopathy	WBC and CRP normal	No initial Bartonella diagnostics	IV Acyclovir + prednisolone	Fever initially responded then relapsed	[47]
				Repeat WBC ↑, CRP normal CSF normal		Flomoxef + azithromycin	No clinical improvement, WBC returns to normal
				Ultrasound/MRI cervical/parotid swelling + facial nerve compression	Bh IgG > 1:1024 IgM neg	Minocycline + ceftriaxone	Improvement
						Amoxicillin + pred	Resolution over 6 months
	5/F	19-day history of fever, headache, fatigue, weight loss. Strep. pharyngitis	21 days Left sided facial palsy	↑CRP, ESR. Blood culture and cranium CT NSF. Infectious disease testing NSF4.Ultrasound: hypoechoic splenic and hepatic foci. Brain MRI NSF	Suspected disseminated CSD, no specific Bartonella diagnostics	Azithromycin + Rifampin × 14d	Resolution of all clinical signs	[48]

Subscripted numbers indicate additional laboratory findings associated with individual patients

¹Negative for adenovirus, respiratory syncytial virus, coronavirus, influenza, parainfluenza, Sendai virus, mumps, measles, herpes simplex, varicella zoster, Mycoplasma pneumoniae, Chlamydia psittici, Coxiella burnetti, Mycobacterium tuberculosis, atypical Mycobacterium. Enolase, myelin basic protein autoantibodies, glucose and lactate normal. ANA, ANCA and complement 3, 4 normal

²Blood draws for titers were obtained every other day for 3 samples. Titer 1: Bh SA2 and Bh H1 1:256, Bk 1:128. Titer 2: Bvb I 1:64, Bvb II 1:1024, Bvb III 1:128, Bh SA2 1:512, Bh H1 1:512, Bk 1:2048. Titer 3: Bvb I 1:32, Bvb II 1: 512, Bvb III 1: 128, Bh SA2 1:256, Bh H1 1:256, Bk 1:512. All negative by 2 months follow-up

³Gonorrhea, chlamydia PCR, HIV antigen/antibody, plasma reagin, hepatitis B and C, Epstein-Barr virus IgM, cytomegalovirus IgG, LDH all negative/normal

⁴Rickettsia, Lyme (Borrelia), West Nile virus, varicella, mumps, Epstein-Barr virus, cytomegalovirus and herpes simplex virus 1 and 2

NSF no significant findings, CSF cerebrospinal fluid, Bh Bartonella henselae, PCR polymerase chain reaction, LN lymph node OS-left eye, MRI magnetic resonance imaging, CBC complete blood count, EBV Epstein-Barr virus, CMV cytomegalovirus, WBC white blood cells, STI sexually transmitted infections, CT computerized tomography, Bq Bartonella quintana, CRP C reactive protein, IV intravenous, ESR erythrocyte sedimentation rate, CSD cat scratch disease. ANA antinuclear antibody, ANCA anti-neutrophil cytoplasmic antibody, LDH lactate dehydrogenase