Clinical Manifestations

There are two stages in Carrion's disease: the "anemic stage," characterized by an acute febrile anemia with bartonellas in the red blood cells; and the "verrucose stage," characterized by a disseminated verrucous eruption in the skin and mucous membranes. The anemia is of the macrocytic and hypochromic types, and, in severe infection, erythrocyte levels plummet to less than a million in a few days. The parasitic index in these cells reaches 80 to 100 percent.

The onset is abrupt, with fever, chills, and generalized osteal pain. Bone marrow hyperplasia, reticulo-cytosis, and jaundice are observed, with an increase of bilirubin in the blood and urine. The blood culture is positive, even in the earliest days of the anemia. The verrucose stage is characterized by a diffuse generalized granulomatous eruption on the mucocutaneous integument. Usually this phase is separated from the anemic stage by an asymptomatic interval of several months to a year or more. There are several types of eruption. The first, called the "miliary form," is a profuse, homogeneous, small intradermic eruption, which resembles multiple disseminated hemangioma. In the second, the "nodular form," nodules appear primarily on the arms and the legs; they can be deep in the dermis or prominent on the surface of skin; some are ulcerated and bloody. The third type, the "mular form," has pseudotumoral lesions V2 to 1 inch in diameter which are seated in the deep tissue. The eruption become painful only when a secondary infection develops or with increased bleeding (Figure VIII.22.2A-C).

In the verrugiformis type, the clinical picture is that of a diffuse granulomatous eruption similar to the bacilliformis type, but less intense. One special feature of the verrugiformis type is that the eruption can recur two or more times during a lifetime; some of these patients of endemic areas become latently infected.

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