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From the Townsend Letter
July 2015

Unraveling the Mystery of Bartonellosis
by Scott Forsgren
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Some believe that devitalized teeth and jawbone cavitations may be associated with Bartonella infection. Mozayeni collaborates with an endodontist who indicated that Bartonella "is big in the endodontal scientific literature," as it is known to cause cysts around dental roots that may lead to chronic, hard-to-diagnose head and face pain. Additionally, Mozayeni has observed a very high incidence of root canals in his practice which may be related to a compromise of small blood vessels that feed the dental pulp, another manifestation of small vessel disease. Although a single case report, a veterinarian infected with Bartonella henselae and Bartonella vinsonii subsp. berkhoffii developed neurological symptoms and periodontal disease concurrently.21
Numerous symptoms that have been associated with human Bartonella infection are listed in Table 2. Although incompletely studied at this time, there may be variations in symptom presentation depending on the specific Bartonella species involved, the virulence of the infecting strain, the status of the host immune response, and, as noted, where in the body the microcirculation is most impaired.

Bartonella and Psychological Manifestations
Bartonella patients often describe a number of psychoemotional manifestations of the infection. These may include anxiety, depression, anger, obsessive-compulsive thoughts or behaviors, rage, and even suicidal thoughts.
Mozayeni shared that small vessel disease manifests in the central nervous system and the brain and affects executive function, often leading to mild or moderate cognitive impairment. As people become increasingly unable to process information, anxiety may develop. While there is generally no dementia or long-term memory impairment, short-term working memory and reaction time are often affected. "People become unable to think their way out of a negative thought, which leads to anxiety and fear," shared Mozayeni.
Mozayeni has said, "Many neuropsychiatric conditions can often be traced back to an infectious cause." A common pattern may be that a patient initially presents with anxiety, which goes hand in hand with depression if not treated. They are two sides of the same coin. Over time, as a result of overstimulation, neurotransmitter depletion may lead to depression.
In a recent post on his blog, "LymeMD," Daniel A. Jaller, MD, stated, "Bartonella, as I know it, is frequently associated with specific neuropsychiatric symptoms, which may include: irritability, anxiety, rage and many others."31
More and more clinicians are beginning to recognize the impact of Bartonella on psychological well-being. Further research is needed to validate what these experienced clinicians have observed and to highlight that Bartonella's impact extends far beyond its physical manifestations. Many of those that have personally experienced Bartonella can attest to having experienced a number of these distressing neuropsychiatric symp­toms.

Bartonella Testing
Bartonella presents a diagnostic challenge for clinicians. A number of different laboratory tests exist to support the confirmation of Bartonella infection. However, cases of Bartonella infection may exist even when available tests are negative. Although current diagnostic tests have limitations, it is of critical importance to attempt to confirm a diagnosis of bartonellosis before embarking on a long, costly, and complex treatment regimen. As has been stated in the medical literature for many decades, "The kindest form of therapy is an accurate diagnosis."
The first option is an antibody test looking for IgM and IgG antibodies in serum using an indirect fluorescent antibody (IFA). Many commercially available antibody tests focus primarily on Bartonella henselae and Bartonella quintana, a small subset of the Bartonella species that can cause human disease. Bartonella testing that relies on an antibody response is generally not very sensitive, as Bartonella has many properties that allow it to evade the immune system. Diagnostically relevant production of antibodies is not generally observed with Bartonella infection. As many as 85% of those chronically infected with Bartonella, confirmed through DNA amplification of blood or tissue, may have negative test results with IFA assays (for antibody detection).32 Further, there is a potential for cross-reactivity between Bartonella and other organisms such as Coxiella burnetii and Chlamydia, which further complicates interpretation of the results.33 Furthermore, antibodies indicate evidence of prior exposure and do not confirm active infection.
Traditional PCR testing for Bartonella is available, though these assays were designed to only detect Bartonella henselae and Bartonella quintana DNA in the patient's specimen, thus potentially missing many cases of Bartonella infection. Another challenge with traditional PCR testing is that Bartonella often infects humans at very low levels, making it difficult to detect with standard PCR techniques.
Three of the top specialty laboratories for Bartonella testing include Fry Laboratories, Galaxy Diagnostics, and IGeneX.
Fry Laboratories (Scottsdale, Arizona) offers IgM and IgG IFA testing for Bartonella as well as Bartonella PCR testing using molecular diagnostics. The Bartonella spp. by PCR testing screens for numerous clinically relevant species of Bartonella using a genuswide PCR method. Additionally, they offer assays using a modified May-Grünwald and other stains; however, these stains are not specific for Bartonella.
Galaxy Diagnostics (Research Triangle Park, North Carolina) has emerged as one of the more recent options for Bartonella testing. Its ePCR panel uses the BAPGM (Bartonella alpha-Proteobacteria growth medium) platform to optimize results. Bartonella are usually present in very low numbers. Therefore, an initial step to culture the blood and "enrich" the number of "copies" of Bartonella is usually necessary to enable PCR detection. Three of four positive tests are usually enabled by the enrichment culture step. All PCR-positive results are confirmed by DNA sequencing to confirm Bartonella and to identify the species. Galaxy specializes in Bartonella testing and has emerged as a leader in the field.
IGeneX Inc. (Palo Alto, California), a respected laboratory in vector-borne infections, offers IgM and IgG IFA testing, PCR testing, and a Bartonella FISH (fluorescent in situ hybridization) assay. The advantage of the FISH assay is that it looks for Bartonella RNA and thus does not rely on the response of the host immune system in order to identify the presence of the organism.
It has been suggested that vascular endothelial growth factor (VEGF) may be elevated in a subset of those infected with Bartonella.34 It is believed that Bartonella may produce VEGF to stimulate its growth in the endothelium or VEGF may result from endothelial inflammation and infection. There may be an association between Bartonella-induced VEGF and various skin lesions such as bacillary angiomatosis or even striae. Some have suggested that monitoring VEGF throughout treatment may serve as an indicator of treatment progress, but Mozayeni has not found this to be a consistently reliable marker.
Mozayeni has found that patients solely infected with Bartonella can have elevated C4a levels, an inflammatory marker commonly high in patients with Lyme disease or those with biotoxin illnesses such as mold illness.

Galaxy Diagnostics ePCR
With the Galaxy ePCR Panel, there has been a confirmed positive rate of 9.2% as compared with only 0.98% for traditional PCR testing Conventional IFA testing identifies exposure but cannot confirm presence of active infection In terms of sensitivity, the ePCR is reported to be 10 times more sensitive than PCR and is 100% specific; each positive ePCR test result is confirmed by DNA sequencing Conventional IFA testing is reportedly only 66% to 76% specific, which means that even when the result is positive, it may not be the result of Bartonella infection.
There is a cyclical nature of Bartonella bacteremia that may influence test results Bartonella generally resides in the tissues that line the blood vessels and is not consistently found in the bloodstream This makes testing more difficult and potentially leads to higher false negative test results This drawback is minimized by Galaxy's True Triple Draw which collects three blood samples over a 7 to 8-day period to maximize test performance The ePCR is believed to have a 90% reduction in false negatives as compared with conventional PCR testing
In order to optimize the sensitivity of the testing, it is recommended that patients be tested prior to starting antibiotics or be off all antimicrobial therapies, including antimicrobial herbs, for 2 to 4 weeks prior to the blood draws Bartonella exists in human blood in very low amounts and maximizing the numbers in the blood optimizes test results
For those with chronic Bartonellosis, the ePCR test panel is an ideal tool as compared with conventional IFA testing which generally has high false negative rates for chronically infected individuals IFA testing may be a better option for classical CSD.3
is a stealth infection The bacteria have a long division time of around 22 to 24 hours which makes diagnostic testing much more difficult as compared with testing of more rapidly dividing bacteria A special growth environment was needed for Bartonella species, and it was an innovation from Breitschwerdt's research team at North Carolina State University College of Veterinary Medicine that led to a new culture medium. Considering that Bartonella is often found in sand flies, fleas, lice, and other insect vectors, an insect biochemical composition was evaluated as opposed to a conventional mammalian growth medium. This became the "secret sauce" of the Galaxy Diagnostics ePCR platform and is known as BAPGM (Bartonellaalpha-Proteobacteria growth medium) With this enrichment medium, Bartonella is exponentially grown to levels that can be detected with a PCR assay, making false negative test results much less common, even in those with low levels of Bartonella
The Galaxy Bartonella ePCR is designed to detect all known pathogenic Bartonella species Although blood is the most readily available diagnostic specimen, BAPGM enrichment prior to PCR has facilitated the detection of various Bartonella species in cerebrospinal fluid, joint fluid, aqueous fluid, and pathological effusions such as pleural, pericardial, and abdominal effusions.

Bartonella Prevalence in Humans
Mozayeni began working with patients with small vessel disease (SVD), relying on a careful subcortical neurological examination to find evidence of the disease in the nervous system Once he had a group of patients who met the criteria for SVD, he started testing this group for evidence of Bartonella infection.
Studies were done comparing 296 of Mozayeni's patients (some with a prior diagnosis of Lyme disease); 192 high-risk patients with animal exposures or veterinarians with fatigue, joint pain, and arthritis; and 32 healthy medical school volunteers serving as controls.
Of the 32 controls, only 1 had positive Bartonella antibodies and none of the 32 had a positive test using the BAPGM platform The high risk patients had a seropositivity rate of 49%; whereas Mozayeni's patients had a positive rate of 63% Using ePCR testing, 24% of the high risk group were positive; whereas 41% of Mozayeni's patients had a positive test result which means that one or more Bartonella species were isolated or DNA of the bacteria was PCR amplified.3
Based on serological testing, blood donors have a Bartonella positivity rate of around 3.6%, veterinarians between 6% and-9%, and forestry workers between 10% and 40%. The Mozayeni patient population was higher than any of these groups. Importantly, serology may underestimate active infection with Bartonella in 50% and 75% of bacteremic individuals; therefore, serology has diagnostic limitations and the true prevalence of infection may be even higher than what is noted in these studies.

Bartonella and Lyme Disease
Bartonella has been described as a common c-infection found in people with Lyme disease Mozayeni hypothesizes that the reason some patients with Lyme disease do not improve with treatment is because the emphasis may often be put on the wrong infections. Practitioners may focus on Borrelia burgdorferi, the causative agent of Lyme disease, rather than Bartonella, Babesia, and various protozoa such as Protomyxzoa rheumatica.3 It may be these other microbial burdens that create the majority of the symptoms in what many refer to as "Lyme disease" rather than Borrelia itself.
"The paradigm in Lyme disease has been that one of the reasons the disease persists is because Borrelia has a complicated genome, is a smart organism that is very stealthy, has different forms, and evades the immune system," said Mozayeni. He continued, "We are now entering a second way of thinking about it, a 'Lyme 2.0.' We are trying to understand the ecosystem and the microbiome of the different organisms that are involved."
As common as Bartonella may be in those with Lyme disease, it can certainly exist on its own Many people with Bartonella alone may not express symptoms severe enough to be recognized and may be asymptomatic carriers. Over the long term, Mozayeni hypothesizes that carrying Bartonella chronically may cause a variety of common human diseases including arthritis, arteriosclerosis, and a host of other conditions. Bartonella is known to cause immune suppression in dogs and is immunosuppressive in humans, which may make people more prone to harbor other opportunistic microbial burdens and may fail to make antibodies to germs which might enable their serological detection.

Conventional Treatment Approaches
The most frequently used antimicrobial drugs for Bartonella are those that can enter the cell as the microbe is most commonly found intracellularly. While treatment is often successful in reducing symptoms, there are those where persistent infection has been identified "There is increasing evidence of treatment failures in people with normal immune systems, and it is not uncommon to see relapses in immunocompromised patients who were treated for six weeks or longer."3

According to the Infectious Disease Society of America, erythromycin and doxycycline are drugs of choice with clarithromycin or azithromycin as alternatives For those with central nervous system disease, they suggest that the combination of doxycycline and rifampin may be the preferred treatment. They note that in immunocompromised patients with repeated relapses such as in those with HIV, treatment may need to be indefinite.3

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