Carrion's disease
Synonyms and keywords: Oroya fever

# Overview
Carrion's Disease is an infectious disease produced by Bartonella bacilliformis infection.

# Historical Perspective
It is named for Daniel Alcides Carrion.
Carrion's disease has been known since Pre-Inca times. Numerous artistic representations in clay (called "huacos") of the chronic phase have been found in endemic areas. The Spanish chronist, Garcilazo De La Vega described a disease with warts in Spanish troops during the conquest of Inca Empire, in Coaque-Ecuador. For a long time it was thought that the disease was endemic only in Peru and that it had only one phase, the "Peruvian wart" or "verruga peruana"
In 1875 an outbreak, characterized by fever and anemia occurred in the region of construction of the railroad line between Lima and Oroya. This is the source of the name "oroya fever" sometimes used to describe acute bartonellosis.
In August 1885, Daniel Alcides Carrion, a Peruvian medical student, inoculated himself with material taken from a verruga lesion of a chronic patient (Carmen Paredes), with the help of a local physician (Evaristo Chavez). After 3 weeks he developed classic symptoms of the acute phase of the disease, thus establishing a common etiology (cause) for these two diseases.  He died from bartonellosis on October 5th, 1885 and was recognized as a martyr of Peruvian medicine and the term Carrion's Disease was used until our times (Peruvian Medicine Day is October 5 in honor to him).
Alberto Barton, a Peruvian microbiologist, identified Bartonella bacilliformis within erythrocytes in 1905, an announced the discovery of the etiologic agent (Barton bacillus) in 1909, which was called Bartonella bacilliformis.

# Causes
It is caused by Bartonella bacilliformis.

# Epidemiology and Demographics
Carrion's disease is found only in Peru, Ecuador, and Colombia. It is endemic in some areas of Peru and is caused by infection with the bacterium Bartonella bacilliformis and transmitted by sandflies of genus Lutzomyia.

# Diagnosis

## Symptoms
The clinical symptoms of Carrion's disease are pleomorphic and some patients from endemic areas may be asymptomatic.
The two classical clinical presentations are the acute phase and the chronic phase, corresponding to the two different host cell types invaded by the bacterium (red blood cells and endothelial cells).
- Acute phase: (Carrion's disease) the most common findings are fever (usually sustained, but with temperature no greater than 102F (39C)), malaise. This phase is characterized by severe hemolytic anemia and transient immunosuppression. The case fatality ratios of untreated patients exceeded 40% but reach around 90% when opportunistic infection with Salmonella species occurs. In a recent study the attack rate was 13.8% (123 cases) and the case-fatality rate was 0.7%.
- Chronic phase: (Verruga Peruana or Peruvian Wart) it is characterized by an eruptive phase, in which the patients develop a cutaneous rash produced by a proliferation of endothelial cells and is known as "Peruvian warts" or "verruga peruana".
The most common findings are bleeding of verrugas, fever, malaise, arthralgias, anorexia, myalgias.

## Physical Examination

### Skin
- Pallor
- Jaundice
- Rash - depending of the size and characteristics of the lesions, there are three types: miliary (1-4 mm), nodular or subdermic and mular (>5mm). Miliary lesions are the most common.

### Eyes
- Pallor
- Jaundice

### Neck
- Lymphadenopathy

### Abdomen
- Hepatomegaly
- Splenomegaly

## Laboratory Findings
- Acute phase can be diagnosed by obtaining a peripheral blood smear with Giemsa stain, Columbia-blood agar cultures, immunoblot, IFI, and PCR.
- Chronic phase can be diagnosed using a Warthin-Starry stain of wart biopsy, PCR, and immunoblot.

# Treatment

## Medical Therapy

### Acute Pharmacotherapy
- The drug of choice during the acute phase is Quinolones (such as ciprofloxacin) or Chloramphenicol in adults and Chloramphenicol plus beta lactams in children.
- For the chronic phase, Rifampin or macrolides are used to treat both adults and children.
- Preferred treatment regimen includes Ciprofloxacin 500 mg PO bid for 10 days.

# Antimicrobial therapy
- Oroya fever
- Preferred regimen: Ciprofloxacin 500 mg PO bid for 14 days
- Note: If severe disease, add Ceftriaxone 1 g IV qd for 14 days