Angiogenic process in bacillary angiomatosis

Eight cases of cutaneous bacillary angiomatosis related to acquired immunodeficiency syndrome were studied by light and electron microscopy and by immunohistochemistry with a panel of antibodies specific for endothelial and histiocytic markers. Light microscopy showed an inflammatory reaction with florid neovascularization and clusters of Warthin-Starry-positive bacilli. In addition, solid areas of spindle cells were also present that in some cases mimicked Kaposi's sarcoma or other sarcomas. The investigation focused primarily on the spindle cell areas and the angiogenic process present in bacillary angiomatosis. By immunohistochemistry the lesions, including the spindle cell areas, expressed all endothelial markers used; CD34, factor VIII-related antigen, and Ulex europaeus 1 were the most consistent in intensity, however. In those areas the other endothelial markers, BNH9 and Psophocarpus tetragonolobus, were weak and not always uniform. The macrophage/monocyte markers used were alpha 1-antitrypsin, lysosome, kp1 (CD68), and polyclonal factor XIIIa; these revealed a sprinkle of positive cells ranging from 10% to 20% of the cell population. By electron microscopy primitive capillaries were present lined by plump endothelial cells containing frequent abluminal microprocesses forming intercellular lumina. Mitoses and intracytoplasmic lumen formation were infrequent. The study illustrates that bacillary angiomatosis is composed of active endothelial neoformation with the spindle cells representing immature endothelial cells. Furthermore, the features of this angiogenic process recapitulate the morphologic events described in experimental models.