Trench fever causes headache, tender shins, splenomegaly, macular rash, and fever that may be relapsing. Humans are the reservoir and body lice the intermediate hosts and vectors. Infection is transmitted by organisms in lice feces entering through breaks in the skin.
CASES/YEAR
45,000 (US); 900,000 (Global)
OTHER NAMES
Quitana fever; Bartonella quintana infection; Bacillary angiomatosis;
INCUBATION
3-30 days; [CCDM]
INITIAL SYMPTOMS
Headache, tender shins, splenomegaly, macular rash, and fever that may be relapsing; [CCDM]
PRECAUTIONS
Standard (after delousing); "A history of trench fever is a permanent contraindication to blood donation." [CCDM, p. 622]
COMMENTS
The two main patterns are: 1.) an opportunistic infection of AIDS patients; 2.) a louse-borne disease of the homeless. Documented complications of trench fever in AIDS patients include bacteremia, osteomyelitis, lymphadenopathy, and bacillary angiomatosis (BA). Endocarditis is a complication reported in patients who are alcoholics or homeless. Humans are the reservoir and body lice the intermediate hosts and vectors. Infection is transmitted by organisms in lice feces entering through breaks in the skin. [CCDM, p. 621-3] "PCR testing of blood or tissue samples can be done." [Merck Manual, p. 1580] Several fever patterns have been observed: a single bout of fever lasting 4-5 days; 3-8 bouts of fever each lasting about 5 days; and continuous fever lasting for up to 6 weeks. Many patients with active infections are afebrile. Nonspecific findings may include hepatosplenomegaly, myalgias, leukocytosis, albuminuria, dizziness, and fatigue. Differential diagnoses for BA include verruga peruana, Kaposi's sarcoma, and pyogenic granuloma. [PPID, p. 2828-9] Bartonella quintana, the organism that causes trench fever, is associated with the following: lymphadenopathy uveitis-retinitis, chronic bacteremia, infective endocarditis, and BA. BA is also caused by Bartonella henselae, the organism responsible for cat-scratch disease. [Cecil, p. 1968t]
DIAGNOSTIC
Blood culture; Serological testing; [Merck Manual, p. 1580] Culture on blood or chocolate agar under 5% CO2: microcolonies visible in 8-21 days; Serology (IFA) tests may cross react with other organisms; PCR of resected heart valves; [CCDM, p. 621]
SCOPE
Epidemics occurred in Europe during the two world wars; People living in crowded, unhygienic conditions are at risk. [CCDM]
SIGNS & SYMPTOMS
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>arthralgia
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>fatigue, weakness
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>fever
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>fever, biphasic or relapsing
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>myalgia
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G hepatomegaly
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H anemia
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H leukocytosis
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H lymphadenopathy
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H splenomegaly
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H thrombocytopenia
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N headache
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N stiff neck
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S papules or plaques
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S rash (exanthem)
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S skin or subcutaneous nodule
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S ulcer of skin
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S warty growth of the skin
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*endocarditis
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*osteomyelitis
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*sepsis
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*uveitis
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*weight loss
ENTRY
Skin or Mucous Membranes (Includes Conjunctiva)
RISK FACTORS
- AIDS patients
- Travel to endemic area
TREATMENT
Treat with doxycycline 200 mg PO daily for 4 weeks and gentamycin 3 mg/kg IV daily for 2 weeks. [5MCC 2020]
REFERENCES FOR CASES/YEAR
1. (US) 1/20 of global cases/yr;
2. (Global) Epidemics occurred during World Wars I and II; 2 main forms of disease currently: opportunistic infection of AIDS patients and louse-borne disease in homeless people or alcoholics; [CCDM, p. 621] In 1999, the incidence of pediculosis in Russia was as high as 300/100,000. About 11% of the homeless were infested with lice. A study at a delousing center in Moscow found 12% of the lice samples contained B. quintana. Guesstimate: Assume that 1/2 the world population has the 1999 Russian rate of 300/100,000, then 3 billion/100,000 = 30,000; 300 X 30,000 = 9 million infested with lice; If assume 10% of these get infected with B. quintana, then the rate is 900,000 worldwide.