Bacteria from the genus Bartonella are emerging blood-borne bacteria, capable of causing long-lasting infection in marine and terrestrial mammals, including humans. Bartonella are generally well adapted to their main host, causing persistent infection without clinical manifestation. However, these organisms may cause severe disease in natural or accidental hosts. In humans, Bartonella species have been detected from sick patients presented with diverse disease manifestations, including cat scratch disease, trench fever, bacillary angiomatosis, endocarditis, polyarthritis, or granulomatous inflammatory disease. However, with the advances in diagnostic methods, subclinical bloodstream infection in humans has been reported, with the potential for transmission through blood transfusion been recently investigated by our group. The objective of this study was to determine the risk factors associated with Bartonella species infection in asymptomatic blood donors presented at a major blood bank in Southeastern Brazil. Five hundred blood donors were randomly enrolled and tested for Bartonella species infection by specialized blood cultured coupled with high-sensitive PCR assays. Epidemiological questionnaires were designed to cover major potential risk factors, such as age, gender, ethnicity, contact with companion animals, livestock, or wild animals, bites from insects or animal, economical status, among other factors. Based on multivariate logistic regression, bloodstream infection with B. henselae or B. clarridgeiae was associated with cat contact (adjusted OR: 3.4, 95% CI: 1.1–9.6) or history of tick bite (adjusted OR: 3.7, 95% CI: 1.3–13.4). These risk factors should be considered during donor screening, as bacteremia by these Bartonella species may not be detected by traditional laboratory screening methods, and it may be transmitted by blood transfusion.
Bacteria from the genus Bartonella are capable of causing long-lasting infection. Despite the fact that these bacteria may cause several diseases such as cat scratch disease, trench fever, and infection of cardiac valves, which can be fatal, they may also cause asymptomatic infection in humans. Several blood-sucking arthropods have been suggested or confirmed as responsible for transmitting these bacteria, including sandflies, body lice, fleas, ticks, and keds. In this study, 500 asymptomatic human blood donors from Brazil were screened for infection with species of Bartonella by blood culture coupled with molecular detection and genetic sequencing, and risk factors associated with such infection were identified. In this population, contact with cats and history of tick bite were significantly associated with human infection by Bartonella species. Since laboratory screening of donated blood for the presence of Bartonella species is not generally performed by blood banks, these risk factors should be should be considered during donor screening in order to avoid transmission of Bartonella species by blood transfusion.
Citation: Diniz PPVdP, Velho PENF, Pitassi LHU, Drummond MR, Lania BG, Barjas-Castro ML, et al. (2016) Risk Factors for Bartonella species Infection in Blood Donors from Southeast Brazil. PLoS Negl Trop Dis 10(3): e0004509. doi:10.1371/journal.pntd.0004509
Editor: Christine M. Budke, Texas A&M University, UNITED STATES
Received: September 29, 2015; Accepted: February 12, 2016; Published: March 21, 2016
Copyright: © 2016 Pedro Paulo Vissotto de Paiva Diniz. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: This work was partially supported and funded by the Faculty Grant in Global Health to Diana Scorpio (Johns Hopkins Center for Global Health); a grant from FAEPEX - UNICAMP (Fundo de Apoio ao Ensino, à Pesquisa e à Extensão - UNICAMP); and a summer research scholarship to Stanley Sowy from the Office of the Vice President for Research and Biotechnology, Western University, Western University of Health Sciences, Pomona, CA. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: Dr. Breitschwerdt has a patent U.S.A. #7,115,385 for media and methods for cultivation of microorganisms issued to Dr. Breitschwerdt, Dr. Sontakke and North Carolina State University. Dr. Breitschwerdt is the chief scientific officer for Galaxy Diagnostics, a company that provides diagnostic testing for the detection of Bartonella sp. infection in animals and human patient samples. All other authors have no conflict of interest to declare. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed. This does not alter our adherence to all PLOS policies on sharing data and materials.
Bartonella species are fastidious alpha-proteobacteria with worldwide distribution. To date, at least 15 species have been associated with human infections, with at least eight species also capable of infecting dogs and cats. Several blood-sucking arthropods have been suggested or confirmed as vectors for this genus, including sandflies, body lice, fleas, ticks, and keds . In humans, select species of Bartonella were confirmed as etiologic agents of cat scratch disease (CSD), trench fever, bacillary angiomatosis and Oroya fever . Moreover, Bartonella infections have also been documented by culture or molecular methods in human cases of endocarditis, myocarditis, polyarthritis and granulomatous inflammatory disease [1, 2]. In countries throughout the world, most diseases associated with Bartonella species infection are not reportable; therefore, incidence data is scarce. One study performed at the end of the 20th century estimated that 22,000 new cases of cat scratch disease appear every year in the United States, and roughly 10% of these infections were thought to require hospitalization .
Bartonella species cause chronic and intermittent intra-erythrocytic bacteremia and infect endothelial cells of both incidental and natural reservoir hosts. The establishment of chronic, stealth infection is achieved by evasion of innate immune responses. These include resistance to complement activation, antigenic variation of surface proteins, and inhibition of host cell apoptosis . Consequently, subclinical bloodstream infection in humans has been reported , supporting the fact that these bacteria will not follow Koch’s postulates for disease causation .
Asymptomatic Bartonella species infection poses a hazard for blood recipients because fast, sensitive and specific diagnostic tests are not currently available for donor screening. To the authors’ knowledge, no prophylactic measures are currently in place to prevent collection and transfusion of blood and blood products contaminated with species of Bartonella worldwide. Recently, using a combination of culture methods and PCR assays, we documented Bartonella henselae and Bartonella clarridgeiae infection of blood samples from 16 asymptomatic blood donors at a large blood bank center in Southeast Brazil . Risk factors for Bartonella species exposure in blood donors were initially evaluated in one study from Sweden using serology methods . However, antibody detection has limited predictive value in confirming or excluding Bartonella species bacteremia in humans and animals [6, 8–10]. Furthermore, higher vector activity is expected in tropical and sub-tropical regions of the world. Therefore, this study objective was to determine which risk factors are associated with Bartonella species infection in asymptomatic blood donors from a population in Campinas, Sao Paulo State, Brazil.
The Institutional Review Board of the State University of Campinas, Brazil approved this study under protocol number CEP 122/2005. The voluntary blood donors presented at the Blood Bank (HEMOCENTRO) of the State University of Campinas (UNICAMP), Brazil, and were enrolled after inform written consent was obtained.
Sample collection and diagnostic techniques
We collected blood from five hundred apparently healthy voluntary blood donors in this cross sectional study. Sample size was determined with an alpha of 0.05, power of 0.8, and estimated prevalence of 5%, as previously reported in a serology-based study . Donors were selected through convenience sampling, with inclusion and exclusion criteria following the current international standards for blood bank donor selection .
Bartonella species infection from the bloodstream was detected based on enrichment blood culture in a liquid growth medium (Bartonella alpha-Proteobacteria growth medium-BAPGM), coupled with isolation in solid medium and Bartonella-specific DNA amplification by PCR, followed by DNA sequencing to confirm species identification .
Epidemiological data collection
A standardized epidemiological questionnaire was delivered to each blood donor participant. The interviewer had no knowledge of the diagnostic test results, as Bartonella species testing was performed subsequent to interviews. The following information was captured: gender; self-reported ethnicity as African-American, native Indian, Caucasian, Asian or multi-racial; average monthly income represented by multiples of Brazilian monthly minimal wage; occupational animal exposure (veterinary professionals and others with direct animal exposure such as veterinary assistants, ranchers, biologists, and volunteers at shelters); contact with cats, dogs, other companion animals, livestock or wildlife (including handling animals, bedding, waste or sharing the same environment); bites from dogs, cats, and other animals; arthropod bites caused by ticks, fleas, or other insects; previous blood transfusion; previous history of blood donation; and presence of tattoos. Past history of contact with animals, animal bites, and/or arthropod bites (defined as more than one year after contact) were also recorded.
Potential risk factors were first compared in a univariate analysis using Fisher’s exact test or the Fisher-Freeman-Halton test. All risk factors significant at the p< 0.25 level were entered into a stepwise logistic regression model, and variables significant to p< 0.05 were retained. Univariate odds ratios (OR), adjusted odds ratios (aOR), and 95% confidence intervals (CI) were calculated. Variables with collinearity were removed from the multivariate analysis. Statistical analyses were performed using JMP Pro 10 for Windows (SAS Institute Inc., Cary, NC).
Bartonella species bloodstream infection was detected in 16/500 blood donors (3.2%). DNA amplification and sequencing identified B. henselae in 15 blood donors (3%) and B. clarridgeiae in one donor (0.2%), which was previously reported [5, 13]. B. henselae bacteremia was also confirmed in six donors by bacterial isolation. The univariate and multivariate analyses of risk factors between blood donors infected with Bartonella species and uninfected subjects are provided in Tables 1 and 2. With univariate analysis, a professional with animal exposure was seven times more likely to be infected with Bartonella species than blood donors working in all other professions. When significant variables were entered into the multivariate logistic regression model, collinearity between animal-related professions and cat contact was documented; therefore, profession was not maintained in the final model. Adjusted odds ratio indicated that subjects with cat contact, or past history of tick bite, were approximately 3 to 4 times more likely to have a Bartonella species infection than donors without cat contact or lack of history of tick bite (Table 2).
This study identified two risk factors associated with subclinical Bartonella species bloodstream infections in blood donors. Bartonella species infection was three times more likely to be diagnosed in blood donors who had contact with cats compared to blood donors with no contact. Similarly, blood donors working in animal-related professions were seven times more likely to be infected with these pathogenic bacteria, although this variable was not included in the multivariate model due to collinearity. In Swedish blood donors, contact with cats was also a risk factor for B. elizabethae seropositivity . Our findings indicate that cat contact also increases the risk of subclinical bloodstream infections with B. henselae or B. clarridgeiae. Previously, 24% of 192 non-immunocompromised Americans with frequent exposure to cats, cat scratches or fleas had detectable Bartonella species DNA in blood specimens using the same diagnostic approach as used in our study . Cats are natural reservoir hosts for B. henselae, B. clarridgeiae, and Bartonella koehlerae, all of which are important zoonotic species . After flea-transmitted infection with most Bartonella species strains, cats rarely develop clinical manifestations but remain persistently infected with high levels of intravascular bacteria, which facilitates pathogen acquisition by blood-sucking vectors . Recently, artificial feeding of Ctenocephalides felis with B. henselae- or B. clarridgeiae- infected blood demonstrated that these pathogens can persist in C. felis and be excreted in flea feces . Cat nails can be contaminated with infected flea feces, where B. henselae can survive for several days . Needle stick transmission of Bartonella species has also been reported . Bacterial transmission is less likely to occur by cat bite, since shedding of Bartonella species in cat saliva has not been clearly documented . Interestingly, a history of cat bite, cat scratches, or flea bite was not significantly associated with Bartonella species infection in our study. Possible explanations include donors avoiding cat bites and scratches during “rough play”, lack of identifying fleas as the source of an insect bite, cat confinement to the house, and routine use of parasiticides.
In Southeast Brazil, the combined Bartonella prevalence reported in domestic and stray cats by five reports was 38.5% (112/291), but ranged from 4.3% to 97% among feline populations tested [18, 19, 20, 21, 22]. Such wide variation may be associated with level of flea infestation or analytical sensitivity of PCR assays used. B. henselae and B. clarridgeiae were the only two species detected by molecular methods from cats in these studies. Furthermore, we have tested 112 cats from the same county of the blood donors (Campinas, Brazil) for Bartonella bacteremia, using the same diagnostic approach used in the present report (BAPGM culture and PCR), where we detected bacteremia in 90% (101/112) of cats and B. henselae was confirmed by DNA sequencing and BLAST analysis from three culture isolates . Therefore, similar to reports from other countries, cats may be the main reservoirs of B. henselae and B. clarridgeiae in Southeast Brazil, and pose as a risk factor for subclinical infection in humans in this region.
A previous history of tick bite was also determined to be a risk factor for Bartonella species infection in this human population. While cat fleas are a well-established vector, the capability of ticks to transmit these organisms has been the subject of substantial debate. It has been demonstrated that seven Bartonella species are capable of growing in an Amblyomma americanum tick cell line . Recently, the vector competency of Ixodes ricinus for transmission of Bartonella birtlesii was confirmed using a mouse model . Although. Ixodes ricinus and Amblyomma americanum are not present in Brazil, other ticks such as Ixodes loricatus, Ixodes didelphidis, Amblyomma cajennense, Amblyomma aureolatum, Amblyomma ovale, and Rhipicephalus sanguineus have been isolated from marsupials and rodents living in a locality where other tick-borne organisms had been previously identified . Therefore, while the mode of transmission of any Bartonella species to humans is still unclear, the potential role of tick transmission should not be ignored.
Cat-scratch disease, bacillary angiomatosis and endocarditis are the most frequently reported manifestation of Bartonella infection in both immunocompetent or immunocompromised Brazilian populations [27–29], although ocular, neurologic and dermatologic abnormalities were also reported . In addition, Correa et al. reported that the risk of Bartonella DNA bloodstream infection was 45 times higher in arrhythmic patients from Brazil or Argentina when compared to controls . Our results expand the current understanding about Bartonella species infection in humans in Brazil by reinforcing the ecological role of cats and ectoparasites in the transmission of Bartonella. Risk of human infection can be minimized by implementing year-round ectoparasite control in domestic animals, by avoiding cat bites and scratches, and by keeping cats indoors to minimize exposure to vectors . The medical impact of Bartonella species occurrence in the blood supply is still unknown and should be carefully investigated.
S1 Dataset. Complete data set of Brazilian blood donors who participated in the study.
Donors are identified by a unique numerical ID, and significantly associated variables (Tables 1 and 2) are provided with responses for occupational animal exposure, contact with cats, and recall of a past tick bite. Column labeled “status” refers to presence or absence of Bartonella infection following blood sample analysis described in Materials and Methods.
We thank the study blood donors, Dr. Steven Henriksen and Dr. Dominique Griffon for providing research infrastructure and support at Western University of Health Sciences, and Dr. Hannah Mirrashed, John Greenwood, and Marizete Salvadego for technical assistance.
Conceived and designed the experiments: PPVdPD DGS PENFV. Performed the experiments: LHUP MRD BGL MLBC. Analyzed the data: PPVdPD SS. Contributed reagents/materials/analysis tools: EBB. Wrote the paper: PPVdPD PENFV DGS LHUP.
- 1. Breitschwerdt EB, Maggi RG, Chomel BB, Lappin MR. Bartonellosis: an emerging infectious disease of zoonotic importance to animals and human beings. J Vet Emerg Crit Care. 2010;20(1):8–30. Epub 2010/03/17. doi: 10.1111/j.1476-4431.2009.00496.x pmid:20230432.
- 2. Chomel BB, Boulouis HJ, Breitschwerdt EB. Cat scratch disease and other zoonotic Bartonella infections. J Am Vet Med Assoc. 2004;224(8):1270–9. pmid:15112775.
- 3. Jackson LA, Perkins BA, Wenger JD. Cat scratch disease in the United States: an analysis of three national databases. Am J Public Health. 1993;83(12):1707–11. pmid:8259799; PubMed Central PMCID: PMC1694941.
- 4. Pulliainen AT, Dehio C. Persistence of Bartonella spp. stealth pathogens: from subclinical infections to vasoproliferative tumor formation. FEMS Microbiol Rev. 2012;36(3):563–99. Epub 2012/01/11. doi: 10.1111/j.1574-6976.2012.00324.x pmid:22229763.
- 5. Pitassi LH, de Paiva Diniz PP, Scorpio DG, Drummond MR, Lania BG, Barjas-Castro ML, et al. Bartonella spp. bacteremia in blood donors from Campinas, Brazil. PLoS Negl Trop Dis. 2015;9(1):e0003467. doi: 10.1371/journal.pntd.0003467 pmid:25590435; PubMed Central PMCID: PMC4295888.
- 6. Jacomo V, Kelly PJ, Raoult D. Natural history of Bartonella infections (an exception to Koch's postulate). Clin Diagn Lab Immunol. 2002;9(1):8–18. pmid:11777823; PubMed Central PMCID: PMC119901.
- 7. 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(10):723–30. doi: 10.1080/00365540510012152 pmid:16191889.
- 8. Maggi RG, Mozayeni BR, Pultorak EL, Hegarty BC, Bradley JM, Correa M, et al. Bartonella spp. bacteremia and rheumatic symptoms in patients from Lyme disease-endemic region. Emerg Infect Dis. 2012;18(5):783–91. Epub 2012/04/21. doi: 10.3201/eid1805.111366 pmid:22516098; PubMed Central PMCID: PMC3358077.
- 9. Maggi RG, Mascarelli PE, Pultorak EL, Hegarty BC, Bradley JM, Mozayeni BR, et al. Bartonella spp. bacteremia in high-risk immunocompetent patients. Diagn Microbiol Infect Dis. 2011;71(4):430–7. Epub 2011/10/15. doi: 10.1016/j.diagmicrobio.2011.09.001 pmid:21996096.
- 10. Kordick DL, Brown TT, Shin K, Breitschwerdt EB. Clinical and pathologic evaluation of chronic Bartonella henselae or Bartonella clarridgeiae infection in cats. J Clin Microbiol. 1999;37(5):1536–47. Epub 1999/04/16. pmid:10203518; PubMed Central PMCID: PMC84823.
- 11. Zarkovic A, McMurray C, Deva N, Ghosh S, Whitley D, Guest S. Seropositivity rates for Bartonella henselae, Toxocara canis and Toxoplasma gondii in New Zealand blood donors. Clin Experiment Ophthalmol. 2007;35(2):131–4. doi: 10.1111/j.1442-9071.2006.01406.x pmid:17362453.
- 12. AABB. Standards for blood banks and transfusion services. Bethesda, MD: American Association of Blood Bank; 2012.
- 13. Vieira-Damiani G, Diniz PP, Pitassi LH, Sowy S, Scorpio DG, Lania BG, et al. Bartonella clarridgeiae bacteremia detected in an asymptomatic blood donor. J Clin Microbiol. 2015;53(1):352–6. doi: 10.1128/JCM.00934-14 pmid:25392353; PubMed Central PMCID: PMCPMC4290971.
- 14. Bouhsira E, Ferrandez Y, Liu MF, Franc M, Boulouis HJ, Biville F. Ctenocephalides felis an in vitro potential vector for five Bartonella species. Comp Immunol Microbiol Infect Dis. 2013;36(2):105–11. doi: 10.1016/j.cimid.2012.10.004 pmid:WOS:000316775300001.
- 15. Finkelstein JL, Brown TP, O'Reilly KL, Wedincamp J Jr., Foil LD. Studies on the growth of Bartonella henselae in the cat flea (Siphonaptera: Pulicidae). J Med Entomol. 2002;39(6):915–9. pmid:12495192.
- 16. Oliveira AM, Maggi RG, Woods CW, Breitschwerdt EB. Suspected needle stick transmission of Bartonella vinsonii subspecies berkhoffii to a veterinarian. J Vet Intern Med. 2010;24(5):1229–32. Epub 2010/08/11. doi: 10.1111/j.1939-1676.2010.0563.x pmid:20695992.
- 17. Chomel BB, Boulouis HJ, Maruyama S, Breitschwerdt EB. Bartonella spp. in pets and effect on human health. Emerg Infect Dis. 2006;12(3):389–94. doi: 10.3201/eid1205.050931 pmid:16704774; PubMed Central PMCID: PMC3291446.
- 18. Crissiuma A, Favacho A, Gershony L, Mendes-de-Almeida F, Gomes R, Mares-Guia A, et al. Prevalence of Bartonella species DNA and antibodies in cats (Felis catus) submitted to a spay/neuter program in Rio de Janeiro, Brazil. J Feline Med Surg. 2011;13(2):149–51. doi: 10.1016/j.jfms.2010.08.010 pmid:21071251.
- 19. Andre MR, Baccarim Denardi NC, Marques de Sousa KC, Goncalves LR, Henrique PC, Grosse Rossi Ontivero CR, et al. Arthropod-borne pathogens circulating in free-roaming domestic cats in a zoo environment in Brazil. Ticks Tick Borne Dis. 2014;5(5):545–51. doi: 10.1016/j.ttbdis.2014.03.011 pmid:24889035.
- 20. de Souza AM, de Almeida DNP, Guterres A, Gomes R, de Mendonça Favacho AR, dos Santos Moreira N, et al. Bartonelose: análise molecular e sorológica em gatos do Rio de Janeiro–Brasil. Revista Brasileira de Ciência Veterinária. 2010;17(1).
- 21. de Bortoli CP, Andre MR, Seki MC, Pinto AA, Machado Sde T, Machado RZ. Detection of hemoplasma and Bartonella species and co-infection with retroviruses in cats subjected to a spaying/neutering program in Jaboticabal, SP, Brazil. Rev Bras Parasitol Vet. 2012;21(3):219–23. pmid:23070430.
- 22. Andre MR, Dumler JS, Herrera HM, Goncalves LR, de Sousa KC, Scorpio DG, et al. Assessment of a quantitative 5' nuclease real-time polymerase chain reaction using the nicotinamide adenine dinucleotide dehydrogenase gamma subunit (nuoG) for Bartonella species in domiciled and stray cats in Brazil. J Feline Med Surg. 2015. doi: 10.1177/1098612X15593787 pmid:26138812.
- 23. Drummond MR, Diniz PPVP, Lania BG, Demolin DMR, Gilioli R, Breithschwerdt EB, et al., editors. Molecular and microbiological detection of Bartonella spp. bacteremia in cats. International Meeting on Emerging Diseases and Surveillance; 2014; Vienna, Austria: International Society for Infectious Diseases.
- 24. Billeter SA, Diniz PP, Battisti JM, Munderloh UG, Breitschwerdt EB, Levy MG. Infection and replication of Bartonella species within a tick cell line. Exp Appl Acarol. 2009;49(3):193–208. doi: 10.1007/s10493-009-9255-1 pmid:19242658.
- 25. Reis C, Cote M, Le Rhun D, Lecuelle B, Levin ML, Vayssier-Taussat M, et al. Vector competence of the tick Ixodes ricinus for transmission of Bartonella birtlesii. PLoS Negl Trop Dis. 2011;5(5):e1186. doi: 10.1371/journal.pntd.0001186 pmid:21655306; PubMed Central PMCID: PMC3104967.
- 26. Silva N, Eremeeva ME, Rozental T, Ribeiro GS, Paddock CD, Ramos EA, et al. Eschar-associated spotted fever rickettsiosis, Bahia, Brazil. Emerg Infect Dis. 2011;17(2):275–8. doi: 10.3201/eid1702.100859 pmid:21291605; PubMed Central PMCID: PMC3204763.
- 27. Pinto VL Jr, Curi AL, Pinto Ada S, Nunes EP, Teixeira Mde L, Rozental T, et al. Cat scratch disease complicated with aseptic meningitis and neuroretinitis. Braz J Infect Dis. 2008;12(2):158–60. Epub 2008/07/22. pmid:18641856.
- 28. Velho PE, Ericson ME. Cryptogenic hepatitis and bartonellosis. Dig Dis Sci. 2012;57(4):1107–8. Epub 2012/02/07. doi: 10.1007/s10620-012-2065-z pmid:22307338.
- 29. Siciliano RF, Castelli JB, Mansur AJ, Pereira Dos Santos F, Colombo S, do Nascimento EM, et al. Bartonella spp. and Coxiella burnetii Associated with Community-Acquired, Culture-Negative Endocarditis, Brazil. Emerg Infect Dis. 2015;21(8):1429–32. Epub 2015/07/22. doi: 10.3201/eid2108.140343 pmid:26197233; PubMed Central PMCID: PMCPmc4517744.
- 30. Lamas C, Curi A, Boia M, Lemos E. Human bartonellosis: seroepidemiological and clinical features with an emphasis on data from Brazil—a review. Mem Inst Oswaldo Cruz. 2008;103(3):221–35. pmid:18592096.
- 31. Corrêa FG, Pontes CL, Verzola RM, Mateos JC, Velho PE, Schijman AG, et al. Association of Bartonella spp bacteremia with Chagas cardiomyopathy, endocarditis and arrhythmias in patients from South America. Braz J Med Biol Res. 2012;45(7):644–51. pmid:22584639; PubMed Central PMCID: PMCPMC3854270.
- 32. Brunt J, Guptill L, Kordick DL, Kudrak S, Lappin MR, American Association of Feline P, et al. American Association of Feline Practitioners 2006 Panel report on diagnosis, treatment, and prevention of Bartonella spp. infections. J Feline Med Surg. 2006;8(4):213–26. doi: 10.1016/j.jfms.2006.05.006 pmid:16846781.