Annals of Emergency Medicine
Volume 55, Issue 3 , Pages 280-282, March 2010

Update on Emerging Infections: News From the Centers for Disease Control and Prevention

Article Outline

 

Bartonella quintana in Body Lice and Head Lice From Homeless Persons, San Francisco, California, USA

[Bonilla DL, Kabeya H, Henn J, et al. Bartonella quintana in body lice and head lice from homeless persons, San Francisco, California, USA. Emerg Infect Dis. 2009;15:912-915.]

The human body louse and human head louse are generally recognized as 2 subspecies of Pediculus humanus (P humanus humanus and P humanus capitis, respectively) that have distinct ecologic preferences.1 However, a recent genetic analysis was not able to show any differences between these 2 subspecies.2 The human body louse is a small, parasitic insect that lives on the body and in the clothing or bedding of its human host. Body lice feed only on human blood. In the United States, body lice infestations usually are found only on persons who do not have access to clean changes of clothes or bathing facilities (eg, the homeless population).

Head lice also feed only on human blood and are found on the head. Head lice infestations occur most often in school children and may also occur in the homeless population, where they may be transferred by pillowcases, hats, and combs. Body and head lice are morphologically indistinguishable by the unaided human eye. Body lice are most reliably differentiated from head lice by their presence on clothing or on parts of the body other than the head or neck. These lice spend most of their time on the clothing of an infested person, visiting the body up to 5 times a day to feed. The eggs (called nits) of body lice are cemented to clothing fibers and seams or, occasionally, to body hairs.3, 4

In addition to causing discomfort and irritation, body lice can transmit disease-causing pathogens. Bartonella quintana is a bacterium transmitted through body lice feces that are scratched into the skin by the host. This organism can cause trench fever, endocarditis, bacillary angiomatosis, peliosis, and chronic bacteremia in infected humans.3 Since 1992, B quintana has been recognized as a reemerging infection in homeless populations in the United States and Europe, as well as an opportunistic pathogen in patients with AIDS.5 Infection with B quintana can cause prolonged disability in immunocompetent persons and can be life threatening in immunodeficient patients.

Studies of homeless persons seeking medical care in clinics and hospitals in the United States and France have found that 2% to 20% of persons tested had antibodies against B quintana.6, 7, 8, 9 In Tokyo, Japan, 57% of homeless patients had immunoglobulin G titers greater than 128 for B quintana.10 A study in Marseille, France, found that 14% (10/71) of homeless patients who came to a hospital emergency department had blood cultures positive for B quintana.11 In 1990, physicians in the San Francisco, CA, Bay area recognized the link between Bartonella spp. infections and bacillary angiomatosis12, 13 and bacillary peliosis hepatis.14 A subsequent study by Koehler et al15 documented the occurrence of bacillary angiomatosis in 49 patients treated during 8 years. All patients in this study were infected with either B quintana or B henselae (the agent of cat-scratch disease), most case patients were immunocompromised (92% had HIV infection), and B quintana infection was associated with homelessness and body lice infestation. In a subsequent study of HIV-positive patients with fever in San Francisco, Koehler et al16 found that 18% of 382 patients had positive test results for Bartonella spp.

The human body louse is currently thought to play a role in the transmission of B quintana among homeless persons, much as it did during the epidemics of trench fever that occurred during World Wars I and II.3 In the aforementioned study in Marseille, France, in 1999, body lice from 3 (20%) of 15 homeless patients were positive for B quintana by polymerase chain reaction.11 In Tokyo, Sasaki et al17 examined clothing from 12 homeless persons for body lice. These authors found that lice from 2 (16.7%) of 12 homeless persons were positive for B quintana by PCR.17 Furthermore, evidence now indicates that head lice may be involved in the transmission cycle of B quintana.18 Homeless populations in urban areas in northern California are vulnerable to body lice infestation and may be at risk for B quintana infection. We studied whether body and head lice from homeless populations in a northern California city are carrying B quintana or other pathogenic Bartonella spp.

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Materials and Methods 

In 2007 and 2008, staff from the Vector-borne Diseases Section of the California Department of Public Health (CDPH) participated in San Francisco's Project Homeless Connect. Under the auspices of San Francisco's Project Homeless Connect medical services, hair, body, and clothing of homeless persons were inspected for lice. Any lice found on the head with the presence of nits were considered to be head lice. Any lice on the body or clothing were considered to be body lice. Most infested persons self-referred directly to the CDPH booth at this event, with the exception of 1 physician referral. Lice were collected by using forceps, identified, sorted by subspecies, and placed in screw-top vials filled with 95% ethanol. Only a portion of the total lice infesting a person were collected for testing. The lice were shipped to the Centers for Disease Control and Prevention (Fort Collins, CO) for detection and identification of Bartonella spp.

Lice were pooled by host and then subspecies. Samples from hosts with greater than 20 lice were further tested individually to obtain an estimate of Bartonella spp. prevalence in the lice. We tested 36 pools of body lice, 7 pools of head lice, 108 individual body lice, and 4 individual head lice. Individual or pooled (2 to 20 lice/pool) samples were suspended in 250 μL of sterile phosphate-buffered saline solution and homogenized in an MM300 mixer (Retsch, Newtown, PA) for 8 minutes. DNA was extracted from the homogenates by using a Mini Kit (Qiagen, Valencia, CA) and the Blood and Body Fluid Spin Protocol according to the manufacturer's protocol, with a few minor changes. A PCR was performed in 20 μL of the mixtures containing 4 to 20 ng of the extracted DNA, 20 μL of 2× Ampdirect Plus, 0.5 U of Ex Taq Hot Start Version (Takara Bio, Otsu, Japan), and 1 pmol of each primer. Bartonella DNA was amplified by using gltA (citrate synthase gene) and ftsZ (cell division protein gene) primers as reported19, 20 in a thermocycler (iCycler; BioRad, Hercules, CA). A strain of B washoensis was used as a positive control, and sterile deionized water was used as a negative control. Using gel electrophoresis on a 2% agarose gel, we examined the PCR products for 900-base-pair (ftsZ) and 380- to 400-base-pair (gltA) fragments.

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Results 

In 2007 and 2008, 138 homeless persons had consultations at the CDPH booth at the San Francisco's Project Homeless Connect event. Of these persons, CDPH staff observed 33 persons with body lice infestations (23.9%), and 624 lice were collected (mean 18.9 lice/infested host). Head lice infestations were detected in 12 (8.7%) persons and 70 lice were collected (mean 5.8 lice/infested host). Six persons (4.3%) had body lice and head lice infestations.

Bartonella DNA was detected in body lice collected from 11 (33.3%) persons and in head lice collected from 3 (25.0%) persons. Nine pools of body lice (n=2 to 20; mean infection rate 5%) from 9 infested persons and 2 pools of head lice (n=7 to 12; mean infection rate 8.3%) from 1 infested person showed evidence of Bartonella DNA. Additional lice from persons with positive pooled samples of body lice (SFB6 and SFB24) were tested individually. Sample SFB6 had 13 (87%) of 15 lice positive for Bartonella DNA. Sample SFB24 had 27 (64%) of 42 lice positive for Bartonella DNA. One of the 4 individual head louse samples (SFH2) showed amplification of Bartonella DNA.

Host sample SFB16 showed no amplification of Bartonella DNA in its original test, but when an additional 3 pools of 20 lice and 11 individual lice were tested, 1 pool of 20 lice was positive. This host had a massive body louse infestation; 91 lice were collected from his clothing. Host sample SFB27 was also negative in its first test of a pool of 20 lice; 7 additional lice tested afterward produced a single detection of B quintana DNA in a body louse (14%).

Samples from 1 person who was coinfested with body lice and head lice were positive for Bartonella DNA by the gltA gene PCR (SFB17; 1 pool of 20 lice) in body lice, but not in the head lice pool (SFH7; n=4). Samples from another coinfested person were negative for Bartonella DNA in 1 pool of 5 body lice (SFB10). Bartonella DNA was detected in a pool of 12 head lice (SFH3; mean infection rate 8.3%).

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Discussion 

Our study has shown that homeless persons in the San Francisco Bay area have body and head lice that harbor B quintana type strain Fuller. Prevalence of B quintana in body lice from homeless persons (33.3%) in our study was slightly higher than the prevalence reported by Sasaki et al17 in Tokyo, where body lice in 2 (16.7%) of 12 homeless persons were infected with B quintana. Furthermore, similar prevalence of B quintana infection in body lice has been reported from Russia (12.3%)21 and Marseille, France (20%).11

Although Sasaki et al18 detected B quintana DNA in head lice by using molecular detection methods, their samples came from children in Nepal who also had body lice. However, there is no strong evidence that head lice are vectors of this organism between human hosts. Moreover, Fournier et al22 tested 143 head lice from schoolchildren from 8 countries and found no B quintana. We have detected B quintana in head lice from persons without a known concurrent body louse infestation. Further work is needed to examine how homeless persons acquire lice and which groups may be predisposed to louse infestation and B quintana infection.

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References 

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 Editor's note: This article is part of a regular series on emerging infection from the Centers for Disease Control and Prevention (CDC) and the EMERGEncy ID NET, an emergency department–based and CDC-collaborative surveillance network. Important infectious disease public health information with relevance to emergency physicians is reported. The goal of this series is to advance knowledge about communicable diseases in emergency medicine and foster cooperation between the front line of clinical medicine and public health agencies.

PII: S0196-0644(09)01901-5

doi:10.1016/j.annemergmed.2009.12.029

Annals of Emergency Medicine
Volume 55, Issue 3 , Pages 280-282, March 2010

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