You are in: eMedicine Specialties > Infectious Diseases > MEDICAL TOPICS Trench FeverArticle Last Updated: Jun 26, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital Eleftherios Mylonakis is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America Coauthor(s): Michael A Forgione Jr, MD, Chief of Infectious Diseases, Instructor, Department of Medicine, Keesler Medical Center Editors: Jeffrey M Zaks, MD, Clinical Associate Professor of Medicine, Wayne State University School of Medicine; Vice President, Medical Affairs, Chief Medical Officer, Department of Internal Medicine, Providence Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Thomas M Kerkering, MD, Professor of Medicine and Microbiology, Department of Internal Medicine, Division of Infectious Disease, Brody School of Medicine at East Carolina University; Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital; Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital Author and Editor Disclosure Synonyms and related keywords: trench fever, 5-day fever, quintan fever, shinbone fever, shank fever, His-Werner disease, Wolhynia fever, urban trench fever, bacteremia, perivascular lymphocytic infiltrates, valve replacement, endocarditis INTRODUCTIONSection 2 of 10
  BackgroundTrench fever is a blood-borne infection caused by a fastidious, pleomorphic, aerobic, gram-negative bacillus. The organism that causes trench fever previously was classified as Rochalimaea quintana and now is classified as Bartonella quintana. Historically, the infection was referred to as trench fever, 5-day fever, quintan fever, shinbone fever, shank fever, His-Werner disease, and Wolhynia fever. The first clinical description occurred during World War I (WWI), but the condition has probably caused human infection for centuries. Trench fever was considered the most prevalent disease among Allied troops serving in the trenches during WWI. After WWI, trench fever became dormant, until it reemerged as an epidemic on the eastern European front during World War II. Since WWII, classic trench fever has almost disappeared as a clinical entity. Over the past decade, a contemporary B quintana infection emerged in various US cities and abroad and was dubbed urban trench fever. This disease primarily affects inner-city dwellers, chronic alcohol abusers, and political refugees. Seroprevalence data on these populations suggest that exposure is common and many infections are subclinical. Endocarditis is prominent in recent urban trench fever cases among homeless, inner-city dwellers. PathophysiologyLittle is known about the pathophysiology of classic trench fever. Prolonged bacteremia is common, but where the organism resides in the body is uncertain. Biopsy of skin lesions does not show organisms, but it does show perivascular lymphocytic infiltrates with inflammatory cells. Excised valves show perforations and fibrinous vegetations. FrequencyUnited StatesTrue incidence is not known; however, incidence reportedly occurs in small clusters of homeless persons. In Seattle, 20% of the patients in a downtown clinic that serves an indigent and homeless population had a greater than 1:64 microimmunofluorescence titer to B quintana, although most of these patients did not have symptoms of B quintana infection. InternationalTrench fever is endemic to Eastern Europe, Russia, North Africa, and probably China, but the occurrence rate is unknown. Mortality/MorbidityTrench fever may cause significant morbidity and prolonged disability, but no fatalities are attributed. RaceNo race predilection exists. SexHistorically, trench fever was an infection of WWI and WWII veterans; therefore, most documented cases are in males. AgeNo particular age pattern exists. CLINICALSection 3 of 10
HistoryTrench fever can have diverse clinical presentations ranging from practically asymptomatic to a persistent fever lasting months. The incubation period is 5-20 days.
PhysicalThe physical examination findings can vary based on the level of patient symptoms during infection. The main features include the following:
CausesThe body louse, Pediculus humanus, transmits classic trench fever. No human-to-human transmission occurs. The disease is transmitted by inoculation of the organism in louse feces through a skin break or a louse bite. Humans are the only known reservoir for the louse, and the patient can remain asymptomatic and bacteremic with B quintana for up to several years. Epidemic and endemic infection can occur in conditions in which lice are prevalent (eg, homeless populations, refugee camps, war, natural disasters). DIFFERENTIALSSection 4 of 10
Babesiosis Bacillary Angiomatosis Cryptococcosis Lyme Disease Lymphoma, Non-Hodgkin Relapsing Fever Rocky Mountain Spotted Fever Tuberculosis
|
| Drug Name | Doxycycline (Vibramycin) |
|---|---|
| Description | Broad-spectrum, synthetically derived antibiotic in the tetracycline class. Almost completely absorbed, concentrates in bile, and is excreted in urine and feces as a biologically active metabolite in high concentrations. Bacteriostatic, and its mechanism of antimicrobial action is inhibition of protein synthesis by binding to the 50S subunit of the ribosome. Tetracyclines as a class cause a dramatic response with disappearance of the associated symptoms and defervescence, usually in 1-2 days. |
| Adult Dose | 100 mg PO/IV bid |
| Pediatric Dose | <8 years: Not recommended >8 years, <100 lb: 2 mg/lb/d PO/IV divided bid > 8 years, >100 lb: Administer as in adults Alternatively, 2-5 mg/kg/d PO/IV in 1-2 divided doses; not to exceed 200 mg/d |
| Contraindications | Documented hypersensitivity to same or similar drug; severe hepatic insufficiency |
| Interactions | Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy |
| Pregnancy | D - Unsafe in pregnancy |
| Precautions | Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconi-like syndrome may occur with outdated tetracyclines |
| Drug Name | Ceftriaxone (Rocephin) |
|---|---|
| Description | Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Bactericidal and works by arrests bacterial growth by binding to one or more of the penicillin binding proteins. |
| Adult Dose | 2.0 g IV qd |
| Pediatric Dose | 50-75 mg/kg/d IV qd or divided q12h; not to exceed 4 g/d |
| Contraindications | Documented hypersensitivity |
| Interactions | Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | More than 10% of the treated subjects, children in particular, develop hematological changes (eosinophilia, thrombocytosis, less frequently leucopenia); an increase of transaminases is not uncommon (5-7%); ceftriaxone causes reversible biliary pseudolithiasis mainly in young women and children (ie, "sludge" in the gallbladder), occasionally with colics; dose adjustment necessary in renal failure; other rare adverse effects include headaches, dizziness, nausea, vomiting, abdominal pains, reduction of the renal functions, vaginitis, etc; pain can occur at the site of injection; since ceftriaxone may suppress bilirubin from the protein binding, it could favor a bilirubin encephalopathy in neonates; avoid in predelivery/neonates |
| Drug Name | Gentamicin (Garamycin, Jenamicin) |
|---|---|
| Description | Aminoglycoside antibiotic for gram-negative coverage bacteria, including Pseudomonas species. Synergistic with beta-lactamse against enterococci. Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits. Dosing regimens are numerous and are adjusted based on CrCl and changes in volume of distribution, as well as body space into which agent needs to distribute. Dose of gentamicin may be given IV/IM. Each regimen must be followed by at least trough level drawn on third or fourth dose, 0.5 h before dosing; may draw peak level 0.5 h after 30-min infusion. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Consider if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms. |
| Adult Dose | Serious infections and normal renal function: 3 mg/kg/dose IV q8h Loading dose: 1-2.5 mg/kg IV Maintenance dose: 1-1.5 mg/kg IV q8h Extended dosing regimen for life-threatening infections: 5 mg/kg/d IV divided q6-8h Follow each regimen by at least a trough level drawn 0.5 h prior to the fourth dose; may draw a peak level 0.5 h after 30-min infusion |
| Pediatric Dose | <5 years: 2.5 mg/kg/dose IV q8h >5 years: 1.5-2.5 mg/kg/dose IV q8h or 6-7.5 mg/kg/d divided q8h; not to exceed 300 mg/d; monitor as in adults |
| Contraindications | Documented hypersensitivity; non-dialysis–dependent renal insufficiency |
| Interactions | Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; because aminoglycosides enhance effects of neuromuscular blocking agents, prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly) |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment |
Article Last Updated: Jun 26, 2006
