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(Wolhynia, Shin Bone, or Quintan Fever)
Trench fever is a louse-borne disease caused by Bartonella quintana and observed originally in military populations during World Wars I and II. Symptoms are an acute, recurring febrile illness, occasionally with a rash. Diagnosis is by blood culture. Treatment is with a macrolide or doxycycline.
Humans are the only reservoir of this Bartonella infection (see also Overview of Bartonella Infections). B. quintana is transmitted to humans when feces from infected lice are rubbed into abraded skin or the conjunctiva. Trench fever is endemic in Mexico, Tunisia, Eritrea, Poland, and the former Soviet Union and is reappearing in the homeless population in the US.
After a 14- to 30-day incubation period, onset is sudden, with fever, weakness, dizziness, headache (with pain behind the eyes), conjunctival injection, and severe back and leg pains. Fever may reach 40.5° C and persist for 5 to 6 days. In about half the cases, fever recurs 1 to 8 times at 5- to 6-day intervals. A transient macular or papular rash and, occasionally, hepatomegaly and splenomegaly occur. Relapses are common and have occurred up to 10 yr after the initial attack.
Trench fever should be suspected in people living where louse infestation is heavy. Leptospirosis, typhus, relapsing fever, and malaria must be considered.
The organism is identified by blood culture, although growth may take 1 to 4 wk. The disease is marked by persistent bacteremia during the initial attack, during relapses, and throughout the asymptomatic periods between relapses.
Although recovery is usually complete in 1 to 2 mo and mortality is negligible, bacteremia may persist for months after clinical recovery, and prolonged (> 1 mo) doxycycline or macrolide treatment may be needed. Doxycycline 100 mg po bid for 28 days is given plus, if endocarditis is suspected, gentamicin 3 mg/kg/day IV for 2 wk. Body lice must be controlled (see Body lice). Patients with chronic bacteremia should be monitored for signs of endocarditis.
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