eMedicine Specialties > Infectious Diseases > Bacterial Infections

Trench Fever: Differential Diagnoses & Workup

Author: Alfred Scott Lea, MD, Associate Professor of Internal Medicine and Infectious Diseases, University of Texas Medical Branch School of Medicine
Contributor Information and Disclosures

Updated: Feb 20, 2009

Differential Diagnoses

Babesiosis
Lymphoma, Non-Hodgkin
Bacillary Angiomatosis
Q Fever
Brucellosis
Relapsing Fever
Catscratch Disease
Rocky Mountain Spotted Fever
Chronic Fatigue Syndrome
Tuberculosis
Cryptococcosis
Typhoid Fever
Histoplasmosis
Lyme Disease

Other Problems to Be Considered

Epstein-Barr virus infection
AIDS
Culture-negative endocarditis
Epidemic typhus

Workup

Laboratory Studies

B quintana infection is difficult to diagnose in the laboratory, especially with blood cultures, since results are frequently negative even in the presence of infection. Serologic testing frequently cross-reacts with other organisms and is hampered by inadequate immune responses. Polymerase chain reaction (PCR)–based genomic testing is sensitive and specific but is technically demanding. Therefore, the microbiology laboratory must be consulted to maximize the diagnostic effort, since special handling of the specimens is necessary.

Blood cultures obtained for the diagnosis of Bartonella infection are typically low-yield procedures in most laboratories. The Clinical Laboratory Standards Institute notes that lysis-centrifugation techniques in combination with inoculation of fresh enriched chocolate agar is optimal.41 The plates should be incubated at 35ºC in a humid, carbon dioxide–rich environment for 14-21 days. Newer broth lytic systems can be used for a 7-day incubation period, followed by subculture onto enriched chocolate media in a humid, carbon dioxide–rich environment at 35ºC for 21 days. An older protocol using Bactec blood culture bottles involves staining with acridine orange after 7 days of incubation.42 If organisms are seen, blood or chocolate subcultures are incubated at 37ºC in a humid, carbon dioxide–rich environment for up to 4 weeks.

Immunofluorescent assays (IFAs) for immunoglobulin M (IgM) and immunoglobulin G (IgG) antibody levels for both B quintana and B henselae are available in most reference laboratories and some tertiary care centers. These antibody tests may cross-react with each other and should be quantitated in tandem for comparison to establish a diagnosis.6 Serologic cross-reactivity between antibodies against B quintana and those against Chlamydia pneumoniae and Coxiella burnetii is common.6,43,28,26 Acute and convalescent IFA titers for each of these organisms can be diagnostic. Enzyme immunoassay (EIA) and enzyme-linked immunosorbent assay (ELISA) techniques have been described and are available in some laboratories.

Serological testing is positive for antibodies to B quintana in many patients with trench fever, urban trench fever, Bartonella bacteremia, and angioproliferative disease. They are helpful for diagnosis and seroprevalence studies.40 The highest levels of antibodies are found in patients with Bartonella endocarditis.21 Patients with chronic Bartonella bacteremia have low or absent antibody levels.

Several PCR-based genomic assays and histochemical stains that allow direct detection of Bartonella DNA in both tissue and blood have been developed and are very specific, when results are positive.6 Detection of B quintana DNA in vegetations from immunocompetent patients is essential in the diagnosis of endocarditis. Bartonella DNA testing via PCR is available at the Centers for Disease Control and Prevention (CDC) and at most reference laboratories.

Imaging Studies

  • Transthoracic and transesophageal echocardiography demonstrates the presence of valvular vegetations.

Procedures

See Surgical Care.

Histologic Findings

Biopsy of skin lesions in patients with Bartonella infection show perivascular lymphocytic infiltrates with some inflammatory cells. Bartonella organisms can be detected in the interstitial tissues. Lesions may also involve liver, spleen, bone marrow, and lymphatic tissues.6

The histology of enlarged lymph nodes reveals a noncaseating granulomatous reaction similar to that seen in catscratch disease.6 Bartonella organisms cannot be demonstrated using light microscopy.

The pathology of involved cardiac valvular tissue reveals a destructive mononuclear inflammatory reaction with focal calcifications.6 Bartonella organisms can be detected using PCR techniques.

More on Trench Fever

Overview: Trench Fever
Differential Diagnoses & Workup: Trench Fever
Treatment & Medication: Trench Fever
Follow-up: Trench Fever
Multimedia: Trench Fever
References
Further Reading
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References

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Further Reading

  • Maurin M, Raoult D. Bartonella (Rochalimaea) quintana infections. Clin Microbiol Rev. Jul 1996;9(3):273-92. [Medline].
  • Rolain JM, Brouqui P, Koehler JE, Maguina C, Dolan MJ, Raoult D. Recommendations for treatment of human infections caused by Bartonella species. Antimicrob Agents Chemother. Jun 2004;48(6):1921-33. [Medline].

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Keywords

trench fever, 5-day fever, five-day fever, quintan fever, shinbone fever, shin bone fever, shank fever, tibialgic fever, His-Werner disease, Russian intermittent fever, Meuse fever, Polish fever, Wolhynia fever, urban trench fever, Bartonella quintana bacteremia, perivascular lymphocytic infiltrates, valve replacement, Bartonella quintana endocarditis, bartonellosis, Bartonella quintana, B quintana, bacillary angiomatosis, peliosis

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Contributor Information and Disclosures

Author

Alfred Scott Lea, MD, Associate Professor of Internal Medicine and Infectious Diseases, University of Texas Medical Branch School of Medicine
Alfred Scott Lea, MD is a member of the following medical societies: American Academy of Wound Management, American College of Physicians, American Medical Association, Harris County Medical Society, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

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
Jeffrey M Zaks, MD is a member of the following medical societies: American College of Cardiology, American College of Healthcare Executives, American College of Physician Executives, and American Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Thomas M Kerkering, MD, Chief of Infectious Diseases, Virginia Tech, Carilion School of Medicine, Roanoke, Virginia
Thomas M Kerkering, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Public Health Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Medical Society of Virginia, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD 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
Disclosure: Nothing to disclose.

Chief Editor

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
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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