History
Trench fever
During World War I, trench fever was recognized and precisely described as a distinct syndrome by several physicians. [9, 4, 5, 1, 2] The clinical incubation period was 3-48 days. [24] Associated lice infestation was common. Young soldiers with trench fever would experience headache, relapsing fevers, shin pain, truncal rash, and splenomegaly. Most patients could vividly remember the specific time of symptom onset.
The differential diagnoses of the initial symptoms associated with trench fever included typhoid fever, epidemic typhus, influenza, and meningitis. Although there was no recognized mortality, it caused serious and prolonged disability.
Headaches were sudden in onset and were described as frontal or retro-orbital. They were often associated with a stiff neck and photophobia, raising the possibility of meningitis. Other neuropsychiatric symptoms included weakness, depression, restlessness, and insomnia. Many patients with trench fever would experience severe prostration.
The dramatic onset of fever coincided with the onset of headaches. Temperatures were often as high as 104°F and were associated with malaise, chills, and sweats. Fever occurred in one of 3 distinct patterns, as follows:
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Abortive fever: Temperature elevation lasting several days, after which the fever abated and disappeared
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Relapsing/quintan fever: The most commonly observed pattern occurred at 5-day intervals (range, 4-8 days), giving rise to the names quintan fever and 5-day fever; the fever would progressively increase during the first episode and then progressively improve during subsequent paroxysms; recurrent fever months to years after the original defervescence have been reported
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Continuous fever: Lasted for the duration of the disease
Bone pain, particularly involving the shins, progressively worsened throughout the duration of illness. The pain became dramatically worse with exercise and could be so severe that it prevented patients from even changing position in bed. Another common site of pain was the loin with radiation to the lower extremities or into the upper back.
Gastrointestinal (GI) symptoms of trench fever would begin with diffuse abdominal pain, often associated with anorexia, nausea, vomiting, weight loss, diarrhea, and constipation.
Conjunctivitis was another common initial symptom. An erythematous truncal rash and tachycardia would develop during the febrile episodes. Dyspnea could also be present.
Urban trench fever
Urban trench fever has been characterized by one or more of the symptoms described above, but the presentation tends to be more variable. [10, 44, 37, 13, 15, 42] Urban trench fever occurs in homeless and alcoholic persons who exhibit poor personal hygiene. The presence of lice and other external parasites is less prevalent in these individuals. Headaches, conjunctivitis, relapsing fever, and shin pain have been documented, whereas abdominal and neurologic symptoms appear to be uncommon.
Associated syndromes
The descriptions of other syndromes associated with B quintana infection over the past 30 years were unknown to physicians during World War I. A large percentage of persons with B quintana infection may be asymptomatic, and those with syndromes consistent with infection may have negative blood culture results. Typical manifestations of these associated syndromes are as follows:
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Chronic lymphadenopathy - enlarged cervical lymph nodes, without fever or other associated symptoms [10]
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Bacillary angiomatosis - characteristic skin lesions, with or without regional lymphadenopathy, without systemic symptoms [15]
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B quintana endocarditis - fever, new murmur, and heart failure; 20% demonstrate embolic sequelae [43]
Chronic B quintana bacteremia is occasionally accompanied by all of the syndromes described above and may last for years. [20]
Physical Examination
Trench fever
The physical findings of trench fever during World War I were fairly consistent. Infected persons experienced an abrupt onset of fever (up to 104°F), associated with chills and diaphoresis. Patients would initially exhibit a toxic appearance associated with prostration. A furred or coated tongue was common. Some patients were able to continue with their daily activities and recover after a short fastigium, but most would develop a significant disability for months.
Patients with trench fever exhibited a characteristic nonpruritic, blanching, erythematous, macular rash that typically started on the trunk and extended as far as the abdomen, neck, and proximal extremities. The rash accompanied the fever, recurring with each febrile paroxysm. Although the rash was not pruritic, coexisting body louse and scabies infestations caused pruritus and excoriations.
The vast majority of patients with trench fever developed conjunctivitis at the onset of illness. Photophobia was common. Paroxysmal tachycardia generally paralleled the fever. Splenomegaly was common in those with more prolonged courses of illness. Bone and muscle tenderness accompanied the shin pain and became progressively more severe and debilitating as the disease progressed. Loss of the Achilles reflex, a manifestation of peripheral neuropathy, was common.
Urban trench fever
The physical findings of urban trench fever are more variable. Rash, fever, conjunctivitis, bone tenderness, splenomegaly, and neurologic signs (eg, absent Achilles reflexes) have been documented but are generally less prevalent than in the case descriptions from World War I. Nonspecific findings such as weight loss and weakness have been reported. Lastly, many patients with microbiologic or serologic evidence of B quintana infection are asymptomatic.
Associated syndromes
Patients with chronic lymphadenopathy usually have lymphatic involvement of the cervical and mediastinal lymph nodes. They do not experience fever and are otherwise asymptomatic.
Bacillary angiomatosis typically presents with one or more papules that progress to nodules and may be confined to one or more anatomic regions. In immunocompromised patients, however, lesions tend to be more widespread and are more likely to involve viscera such as the liver, spleen, and GI tract. The lesions are red, purple, or nonpigmented and can be superficial or subcutaneous. They may be mobile or fixed to underlying structures (eg, bone). Regardless of appearance, they bleed profusely when punctured or incised. Associated regional adenopathy is common.
Immunocompetent patients with bacillary angiomatosis are typically afebrile. The same lesions occurring in immunocompromised patients are generally more widespread and are more likely to involve visceral organs such as the liver, spleen, and GI tract.
Patients with B quintana endocarditis present with fever and murmur. Lesions typically involve the left-sided heart valves, resulting in mitral insufficiency, aortic insufficiency, or both. Right-sided cardiac involvement is unusual. Heart failure may occur, and embolic lesions develop in as many as 20% of patients. [43]
Interestingly, Koo et al implicated B Quintana in a culture-negative mycotic abdominal aortic aneurysm in a patient with chronic back pain but without other signs of infection. The diagnosis was made by polymerase chain reaction (PCR) and mass spectrometry of tissue sample. [45] Prosthetic endovascular ascending aortic graft infection diagnosed with a combination of serology and whole-body positron emission tomography (PET) has also been reported. [46]
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Dorsal view of female body louse, Pediculus humanus var corporis. This louse is a known vector responsible for transmission of epidemic typhus, trench fever, and Asiatic relapsing fever; it also causes dermatitic condition known as pediculosis. Image courtesy of Centers for Disease Control and Prevention.
