Table 9.

Select cases of cerebral aneurysms secondary to occult Bartonella infections with neurological symptoms as primary presentation

Cerebral aneurysm related to Bartonella-associated endocarditis presenting with primary neurological signs
Age/ sex	Clinical history	Neurological signs	Pertinent diagnostics	Bartonella serology/PCR	Treatment/duration	Outcome	Ref.
48/M	Syncope	Altered sensorium	CT: large intracranial hemorrhage. CCA: fusiform aneurysm TTE: mod MR with thickened MV, no vegetative growth. Blood cultures neg	Not initially indicated	Craniotomy + endovascular embolization	Headaches developed after 2 years	[146]
		New onset headaches	CT: Intraventricular hemorrhage. CCA: new left distal P3 aneurysm. TTE: myxomatous change to mitral valve. Immune-mediated necrotizing GN Blood cultures and infectious disease screening neg1	Bh IgG 1:2560	Repeat endovascular embolization Doxycycline + rifampin	Readmission 2 months after discharge for CHF
		No new signs	CCA: new right middle cerebral aneurysm	Bh + PCR2	+ gentamicin, aneurysm surgery, valve replacement	Improvement on 3 months of doxycycline
39/M	↑BP Intermittent fever	Tonic-clonic seizure	CT: left parietal intraparenchymal hemorrhage, subdural hematoma, transtentorial + uncal herniation suspected. CTA: hyperattenuated focus consistent with aneurysm, also secondary unruptured aneurysm. Clot culture neg	Not initially indicated	Hemicraniotomy and clot evacuation Vancomycin + meropenem	Developed fever with negative blood and urine cultures, responded to cefazolin	[147]
			ESR and CRP ↑ TTE: 2 small mobile MV vegetations		Vancomycin, cefepime + gentamycin	Intermittent fevers developed post-op
			Blood culture neg Immune panel neg Coxiella burnettii neg	Bh 1:1024	Gentamycin × 2 weeks doxycycline × 6 weeks	Aneurysm stabilization Non-verbal, limited movement, feeding tube dependent at 6 months
42/M	↑BP, lipid DM	Acute onset aphasia, weakness in extremities	MRI: non-hemorrhagic infarct left middle cerebral artery. MRA confirmed absence of blood flow. TTE: suspected vegetations aortic valve Blood culture neg.2	Submitted	Empiric vancomycin + ceftriaxone	Continued doxycycline × 12 months Improvement and stabilization lead to outpatient rehabilitation	[148]
				Bh IgG > 1:2560	Gentamicin + doxycycline × 2 weeks
60/M	Flu-like illness 1 months prior	Acute headache, right upper extremity tingling and numbness	CT: left basilar subarachnoid hemorrhage, CTA left middle cerebral artery aneurysm TTE: MR, valvular vegetations Blood cultures neg3	Bh IgG > 1:1024	Endovascular embolization Vancomycin + ampicillin/sulbactam	Discharged on IV gentamicin + oral doxycycline × 2 weeks, repeat CTA in 2 weeks	[149]
			Repeat CTA: new left middle cranial artery aneurysm Repeat TTE: MR worse, MVP with increased size vegetations	Bh PCR + (valves)	Endovascular embolization Mitral valve replacement	Repeat 2 weeks gentamicin + 6 weeks doxycycline

¹Brucella, Coxiella and Bartonella quintana neg

²PCR positive and genetic sequence obtained from aneurysm: PCR positive from valve

³Slightly low hemoglobin, HCT, MCV, MCH. Mild ↑ immature granulocytes. ↑ d-dimer. Mild ↓ sodium. Mild ↑ creatinine. Mild ↓ TP and albumin. ↓ LDL and HDL. ↑ B12. Bq, Coxiella, Treponema pallidum and SARS-CoV2 neg

CT computed tomography, CCA coronary angiogram, TTE transthoracic echocardiogram, MR mitral regurgitation, MV mitral valve, GN glomerulonephritis, Bh Bartonella henselae, CHF congestive heart failure, PCR polymerase chain reaction, BP blood pressure, CTA CT angiography, ESR erythrocyte sedimentation rate, CRP C-reactive protein, DM diabetes mellitus, MRA magnetic resonance angiography, MVP mitral valve prolapse