CORRESPONDENCE

Treatment of Bartonellosis

To the Editor: A report in a recent publication described a traveler to Peru who developed acute febrile Bartonel- losis. The disease was eventually correctly diagnosed in the second stage of illness with the appearance of typi- cal papillary hemangiomatosis.’ Chloramphenicol was then prescribed.

Bartonellosis has two distinct phases. The first is acute onset of high fever and severe anemia.The diag- nosis is easily made by examining Wright- or Giemsa- stained peripheral blood smears.The case fatality rate is high, especially in foreign or nonnative patients. The mortality is related to anemia or other infections, par- ticularly intercurrent Salmonella species (including typhQ bacteremia.* Although Bartonella is susceptible to peni- cillin, tetracycline, and ampicillin, the drug of choice is chloramphenicol(3 g/day in adults or 50 mg/kg day in children, in divided doses), which significantly reduces m~r ta l i ty .~

The second phase of Bartonellosis is characterized by the appearance of skin lesions. Bacteremia is inkequent, and mortality is rare. Chloramphenicol is not useful. In our series, we used streptomycin (1 g, IM, daily for 10 days) and documented a significant decrease in the erup- tive phase.The use of rifampin (300 mg orally twice a day in adults or 10 mg/kg/day in children in divided doses) has resulted in exceUent clinical re~ponses.~

Hepatitis A Vaccine

To the Editor: In an abstract submitted to the Inter- national Society of Travel Medicine for the Fourth International Conference on Travel Medicine and pub- lished involume 2 of the Journal of Travel Medicine, P. Bovier et al express, for the first time, the HAV content of Epaxal in EL.U’s. Indeed, in all previous publications on Epaxal, the antigen content has been expressed in micrograms, or predominantly in RIA Units.

The RadioImmunoAssay Unit as well as the ELISA Unit are arbitrary and therefore only meaningful to those who developed the units.Therefore, the ELISA Unit used by one laboratory or company cannot be compared to the Elisa Unit of another laboratory or company.

Since the early development of HAVRIX, Smith- Kline Biologicals expressed the antigen content in the ELISA Unit. One can thus wonder why the Swiss Serum

In the recently published case,’ chloramphenicol was used with minimal success. Travelers to Peru might develop one of two distinct stages of Bartonella infec- tion. It must be remembered that treatment is different for each stage.We currently recommend chlorampheni- col for the treatment of the first stage of illness and rifampin for the second stage.

References

1. Matteelli A, Castelli F, Spinetti A, et al. Verruga Peruana in an Italian Traveler from Peru. Am J Trop Med Hyg 1994;

Cuadra M. Salmonellosis complication in human bartonel- losis.Tex Rep Biol Med 1956; 14:97. Maguina C. Bartonelosis humana en el Peru-experirncia epidemiologica, clinica y terapeutica. Doaoral thesis, UPCH, 1994. Maguina C, Gotuzzo E. La enfermedad e carrion. Enf Inf Microbiol Clin (Spain) 1988; 6:432-435.

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Ciro Maguina, MD, and Eduardo Gotuzzo, MD, FACC Instituto of Medicina Eopical, “Alexander Von Humboldt”, Universidad Peruana Cayetano Heredia, Lima, Peru

and Vaccine Institute (SSVI) has chosen to make use of an ELISA Unit for the antigen content of Epaxal when this product is already on the market.This initiative may give rise to a misleading impression, i.e., that the antigen content of Epaxal and HAVRIX can be compared.This is indeed a very nonscientific approach, and such infor- mation should not be published in a scientific journal.

I would suggest to the SSVI to participate in the World Health Organization’s initiative to develop an official standard to which any vaccines can be compared and calibrated.

In the meantime, I would recommend the SSVI stick to the RIA Unit.

Eric D’Hondt, PhD, SmithKline Beecham Biologicals s.a., Rixensart, Belgium

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