Medical history of venous insufficiency of the lower legs presented with pain in the right foot and both lower limbs.
A HIV-positive patient with a medical history of venous insufficiency of the lower legs presented with pain in the right foot and both lower limbs.
On clinical examination there were purplebrown nodules on the skin of both feet, legs and arms. These nodules were histologically proven to be Kaposi-sarcoma. Conventional radiographs and MR-images of the lower legs and feet were obtained at that time. The patient received medication for both skin and bone lesions. MR-imaging was performed during and after therapy.
Plain radiography (fig. 1), AP view, of the right lower leg (A) shows multiple oval, sharply demarcated lytic lesions in the cortex of the tibia and fibula. Radiograph of the left calcaneus and midfoot, lateral view (B) demonstrates extensive osteolysis in the calcaneus and the midfoot. MR of the right foot (fig. 2), sagittal T2-weighted image (A) shows hyperintense lesions in the calcaneus and also in the midfoot.
On coronal T1-weighted image of the tibia and fibula (B) before therapy there are multiple small nodular hypointense lesions in the bone marrow of both tibiae and proximal fibulae. On coronal T1-weighted image after therapy (C), the bone marrow lesions in the tibia have disappeared. Imaging findings in this HIV-positive man are caused by bacillary angiomatosis. The diagnosis was confirmed by a positive serology and good response to antibiotic therapy with erythromycin.
Bacillary angiomatosis is an infectious disease in immuno-compromized patients, caused by Bartonella henselae and Bartonella quintana. In immuno-competent patients, these microorganisms cause cat scratch disease. A few weeks after inoculation by a cat scratch or bite a regional lymphadenopathy develops usually in the elbow or axillary region.
Bacillary angiomatosis is characterized by a combination of highly vascular cutaneous and subcutaneous lesions, and osteolytic lesions. The cutaneous lesions are difficult to differentiate from Kaposi-sarcoma clinically and histopathologically. Histopathologically the Bartonella bactery can be found in the highly vascular cutaneous and subcutaneous nodules. The osseous lesions usually consist of well circumscribed lytic areas which occur in the medulla and/or cortex. The lesions have a high signal intensity on T2-weighted images and a low signal intensity on T1-weighted images. Less often there are ill defined regions of cortical destruction and medullary permeation with some periosteal reaction. Diagnosis is made with biopsy (Whartin-Starry stain or electromicroscopy) and serology. The presence of bone lesions can be detected on Tc-99m MPD-scintigraphy.
In case of involvement of the spleen and liver the disease is known as bacillary peliosis. The treatment consists of antibiotic therapy with erythromycin over a prolonged period resulting in regression and resolution of the osteolytic lesions.
Bacillary angiomatosis
Based on the provided images (including X-ray and MRI), local osteolytic lesions are noted in the right foot and both lower limbs. On the X-ray, there are relatively clear, slightly round or irregular low-density areas, suggesting possible bone destruction or bone resorption. MRI reveals high signal intensity in these lesion areas on T2-weighted images and relatively low signal on T1-weighted images, consistent with local soft tissue enhancement.
In the foot and around the tibial shaft, there may also be abnormal high-signal intensities in the subcutaneous and intermuscular spaces, indicating soft tissue involvement. As the patient complains of right foot and bilateral lower limb pain, the history of lower extremity venous insufficiency also needs to be taken into account.
This condition typically appears in immunocompromised patients, though it can occasionally be seen in immunocompetent individuals. Radiologically, there may be osteolysis and vascular proliferative lesions within soft tissues, which can be confused with Kaposi’s sarcoma on imaging and pathology. A history of exposure to cats (e.g., cat scratches) may be present.
Commonly seen in immunodeficient individuals, such as those with HIV/AIDS. Skin and soft tissue lesions can resemble those of Bacillary Angiomatosis, and in rare cases, the disease can involve bone. A definitive diagnosis requires histopathological examination and evaluation of the patient’s immune status.
If there is a history of chronic ulcers or trauma, osteomyelitis might present with bone destruction and periosteal reaction, typically accompanied by noticeable localized redness, swelling, heat, pain, and related inflammatory markers.
Certain malignant tumors or malignant lymphomas can cause bone destruction, often presenting with more extensive lesions and other systemic symptoms or oncological features.
Taking into account the patient’s history of venous insufficiency, lower limb and foot pain, imaging findings of osteolytic lesions, and the characteristic features of Bacillary Angiomatosis caused by Bartonella infection, it is highly likely that the diagnosis is:
Bacillary Angiomatosis
If further tests (e.g., tissue biopsy with Warthin-Starry staining, serologic tests) confirm this condition, prompt initiation of appropriate therapy is necessary.
First-line treatment consists of macrolide antibiotics (e.g., erythromycin) or tetracyclines (e.g., doxycycline) for a prolonged course (usually at least 6 to 8 weeks, and may be extended based on clinical and imaging improvement). The goal is to control the bacterial infection and promote bone regeneration as well as resolution of soft tissue lesions.
During treatment, attention should be paid to lower limb venous insufficiency. Measures to improve leg circulation—such as the use of compression stockings or leg elevation—can help reduce edema and venous stasis if needed.
In general, Bacillary Angiomatosis relies primarily on medical management. Surgical intervention is considered only if there is severe structural destruction or functional impairment in the lesions, or in cases of fractures or irreversible damage.
Disclaimer: This report provides a reference-based medical analysis and does not replace an in-person consultation with a professional physician. If you have any concerns or if symptoms worsen, please seek medical attention and follow your specialist’s treatment plan.
Bacillary angiomatosis
