Trench Fever - Causes, Symptoms, Diagnosis, and Treatment

What Is Trench Fever?

Trench fever, also known as "five-day fever", is a disease caused by the gram-negative bacterium Bartonella quintana that is louse-borne and was observed originally in military populations during World War I and II. Humans are the only reservoir of the Bartonella quintana infection. Trench fever caused an epidemic during World War I by being a significant source of morbidity and mortality, and it affected more than 1 million soldiers. Soldiers were reported with relapsing fever, headache, dizziness, and shin pain. Symptoms are acute, with an occasional rash.

Diagnosis is made via blood culture. The patient is treated with macrolide or Doxycycline. Trench fever rarely causes death, but severe cases can be debilitating. Trench fever is endemic in Mexico, Eritrea, Tunisia, Poland, and the former Soviet Union. It is currently reappearing in the homeless population in the United States. On average, a mature body louse lives in the body for 20 to 30 days. Humans are considered to be the main host for this organism, but several researchers have reported the identification of the bacteria in mammals (macaques, cats, and dogs).

What Causes Trench Fever?

Bartonella quintana is predominantly carried by a vector, the body louse. The louse reproduces in the intestinal lumen and transmits the disease via inoculation of contaminated feces into exposed skin or conjunctivae. This route was documented by the medical research committee, set up by the American Red Cross in 1918. Bacteria remain infective in dried feces of body louse for months, and they can be inhaled as well. The transmission can be detected in crowded living conditions and among people with poor hygiene, such as the homeless and alcohol abusers. Body lice are primarily transmitted through direct contact with an infected person; transmission of the body lice also occurs through fomites, clothes, or bedding.

Who Are the Population at Risk?

Trench fever is now seen around the world, usually among populations that live close together and or with bad sanitary conditions.

This usually includes:

• Homeless people, either those in shelters or people with no access to clean clothes.

• Homeless people who are also alcohol abusers are at a higher risk.

• Inmates in prisons.

• Refugees in camps.

• Health care workers.

What Are the Symptoms of Trench Fever?

An incubation period of 14 to 30 days is noted, after which the following symptoms are manifested:

• A fever that comes and goes for about one to eight times in a 5-day cycle may reach 40.5 °C and last for about five to six days.

• Severe headache.

• Pain behind the eyes.

• Pain in the shin area.

• General body aches.

• Classic rash, which is pink to red patches and small bumps that appear and disappear along with the fever, is seen on the chest as the fever comes and goes.

• Occasionally, hepatomegaly and splenomegaly are associated.

• Endocarditis is seen in some complex cases.

Relapses are common, and they can occur up to 10 years after the initial attack.

How Is Trench Fever Diagnosed?

Trench fever is diagnosed through:

• Blood cultures can identify the organism but may take one to four weeks.

• Serologic tests can provide support for the diagnosis.

• Polymerase chain reaction (PCR) testing of blood or tissue samples can be done.

What Is the Treatment of Trench Fever?

• Usually, Doxycycline, a macrolide, or Ceftriaxone is prescribed.

• Recovery from trench fever is usually completed in a month or two. However, mortality is negligible, but bacteremia may persist for months after clinical recovery. Therefore, prolonged (of more than a month) Doxycycline or macrolide treatment may be needed.

• Patients with chronic bacteremia should be monitored for signs of endocarditis.

Antibiotic treatment protocols differ based on the disease presentation:

• Trench Fever and Chronic Bacteremia: Doxycycline (oral) 200 mg for 28 days, along with Gentamicin (IV) 3 mg/kg/day for 14 days.

• Endocarditis: Doxycycline (oral) 100 mg twice a day for six weeks, along with Gentamicin (IV) 3 mg/kg/day for 14 days.

• Bacillary Angiomatosis: First-line therapy- Erythromycin 500 mg (oral) four times daily for three months; alternative therapy- Doxycycline (oral) 100 mg twice daily for three months; refractory cases- Gentamicin (IV) 3 mg/kg/day for 14 days.

• If Gentamicin is unavailable, noted allergies, or if it is contraindicated, then Rifampicin 300 mg twice a day is recommended for the first 14 days.

• Combination therapy is given for serious or complicated infections.

• Measures are taken to control the body louse.

What Are the Self-Care Methods That Can Be Undertaken?

Importance should be given to getting rid of the body lice completely to prevent reinfection. If infected with trench fever:

• Bathe regularly.

• Change clothes frequently and wash them regularly. Body lice are highly vulnerable to cold and dryness. They are found on clothes that come in contact with the human skin. The infection can be controlled to an extent by discarding the infested clothes. They can also be washed and dried at temperatures above 60ºC. Oral Ivermectin has been proposed for delousing among populations with low compliance but does not protect from re-infestation.

• In case of fever, Acetaminophen, Aspirin (to be avoided for children under 18 years), or Ibuprofen can be taken twice daily after food.

• If an itchy rash is present, scratching must be avoided, as this may lead to further infection with other bacteria.

• Rest and stay well hydrated.

What Is the Differential Diagnosis of Trench Fever?

• Malaria (a mosquito-borne disease caused by a parasite resulting in fever, chills, and flu-like symptoms).

• Typhus (a bacterial infection causing fever, headache, and rash).

• Fever flare-ups.

• Leptospirosis (bacterial infection caused by Leptospira results in high fever, red eyes, chills, headache, and bleeding).

• Rocky Mountain Spotted Fever (RMSF is a bacterial infection caused by a tick bite).

What Are the Complications of Trench Fever?

There is evidence that chronically infected patients, especially those who were immunocompromised, developed endocarditis. Patients with endocarditis showed associated symptoms of chest pain, weight loss, shortness of breath, night sweats, malaise, cough, and fatigue. The clinical examination usually resembles classic endocarditis. This includes Janeway lesions, new cardiac murmurs, Osler nodes, and vascular and immunologic phenomena.

Conclusion:

Most of the time, trench fever is a self-limited illness. Therefore, some patients do not require treatment. However, it is recommended to treat the disease because of the increasing evidence of bacteremia. The prognosis is highly dependent on the patient's immune status. The disease often manifests in a more severe form, leading to critical complications and worse prognosis in patients with alcoholism, human immunodeficiency viruses (HIV), and those on immunosuppressants for transplantation.