Trench fever is an acute bacterial vector–borne infection. Pathognomonic signs of pathology are severe joint, muscle pain and abundant rash on the body. The disease is accompanied by paroxysmal fever, pronounced symptoms of general intoxication. Diagnosis of the disease consists in the isolation of the pathogen by sowing on nutrient media and molecular genetic methods; detection of antibodies to it. Etiotropic treatment involves course administration of antibacterial agents, analgesics, antipyretics, detoxification and other drugs are used as symptomatic therapy.
A79.0 Trench fever
Trench fever (Gis-Werner’s disease, five-day fever) is an infectious pathology with a transmissible transmission pathway. It was especially relevant in the practical infectology of the First World War, similar symptoms were mentioned by Hippocrates in his works. The German scientists Gis and Werner were among the first to describe the disease, the pathogen was discovered in 1917, the rickettsious nature was confirmed by the works of the Soviet researcher Mossing (1948). Nosology is spread all over the globe except Australia and Antarctica. The seasonality is winter-spring, sex and age differences are not described.
The causative agent of trench fever is the bacterium Bartonella quintana, previously classified as rickettsia, but because of its ability to grow on artificial nutrient media, it has been defined as a separate genus of Bartonella since 1993. The source of infection is a sick person who secretes a microorganism for more than a year after recovery, patients with chronic forms. The main method of infection is transmissible, the possibility of infection with hemotransfusions, intravenous use of narcotic drugs, ingestion of patients’ blood on damaged skin, mucous membranes and conjunctiva has been proven.
It is believed that the natural natural reservoirs for bartonella can be cats, rodents and possibly pets. The carrier is a human dress louse, in the digestive tract of which bacteria multiply for 5-9 days. After the bite, the infectious insect, having pumped blood, massively defecates into a wound on the skin. Bartonella are secreted by lice for about 60 days, remain viable inside the excrement for about 4 months. Itching makes a person comb the place of contact with a louse, mechanically rub the contents of the insect’s intestines into the blood.
The main risk factors for trench fever include unsatisfactory sanitary and hygienic living conditions, chronic malnutrition. Such circumstances accompany wars, natural disasters, cataclysms, provoke the mass spread of lice, therefore, increase the risk of the disease. Conditions such as HIV infection, alcoholism and drug addiction are becoming relevant, which contribute to a decrease in the immune resistance of the body, allow bartonella to cause a disease with a severe course and a likely fatal outcome.
Due to the benign course, the pathogenesis has not been sufficiently studied. There is no primary affect at the site of the lice bite. Pathological processes are triggered from the moment bartonella enters the bloodstream, from where the bacteria penetrate into the muscles and parenchymal organs. Pathogens have a tropicity to the bone marrow and heart valves, somewhat less – vascular endothelium, erythrocytes. Multiplying extracellularly, the microbe, along with its waste products and toxins, periodically enters the bloodstream, affecting new organs and causing feverish reactions.
Bartonella inhibit apoptosis, enhance the production of anti-inflammatory cytokines, which reduces the effectiveness of the immune response, contributes to the long-term persistence of bacteria in the body, the chronization of infection. Nosology is characterized by persistent bacteremia, maximum during the first attack of the disease. During the intercostal period, bartonella can also be in the bloodstream, although they multiply mainly inside the bone marrow. Pathohistological changes in blood vessels are caused by the appearance of nonspecific perivascular infiltrates.
The incubation period is approximately 7-17 days. The disease begins acutely, suddenly, against the background of full health, with a sharp terrific chill, pain when moving the eyeballs and pronounced weakness. Body temperature rises above 39 ° C, patients report drowsiness, severe headache, muscle and joint pain, especially in the sacrum and lower extremities. Often there is jaundice of the sclera, nausea, repeated vomiting, episodes of copious, frequent liquid stools. There is a decrease in blood pressure, palpitations, shortness of breath.
The deterioration of the condition occurs in the evening and at night, sometimes patients cannot move, make arbitrary movements, get up on their own, sit down on the bed. Especially often, patients with trench fever complain of pain inside the tibia. The infection proceeds paroxysmally, but mainly with one episode of an attack. After 3-5 days of fever, a period of normalization of temperature or subfebrility to 38.5 ° C occurs for about a week, then hyperpyrexia is noted again.
The face becomes puffy, the conjunctiva of the eyes turn red. On the skin of the back, abdomen and extremities in the first two days of the disease, an abundant rash appears in the form of spots from pale pink to red, less often tubercles. The rash does not itch, does not peel off, less often the spots merge to a large lesion (erythematous fields). Rashes disappear without a trace. With a chronic course and in immunosuppressive patients, lymph nodes increase, signs of endocarditis appear: shortness of breath, weight loss, spot hemorrhages on the body.
Among the complications of trench fever, purulent processes are most common against the background of the addition of secondary bacterial flora. Long-term bacteremia associated with the tropism of bartonella to erythrocytes in individuals with normal immune status lasts less than in patients with immunodeficiency. The danger of such a condition lies in the growing likelihood of cardiac infestations of the pathogen, directly proportional to the time and duration of bacteremia. Due to the tropicity of bartonella to the tissue of the heart valves, especially the aortic, endocarditis may occur.
It was found that 3/4 of all bartonella endocarditis are lesions of the causative agent of five-day fever. Among the European population, this cardiac pathology accounts for up to 3% of endocarditis, in Africa – up to 15.6%. The children examined in Ethiopia had afebrile endocardial lesions with congestive heart failure. Isolated cases of detection of aortitis in HIV-infected patients are described. Some researchers associate the invasion of B. quintana with the development of myocarditis, acute heart failure and sudden death.
Verification of trench fever requires consultation of an infectious disease specialist and often a dermatovenerologist. Other specialists are involved if there are indications. It is important to collect an epidemiological history in order to obtain information about cases of pediculosis in the family, an organized team. To confirm the disease, the following laboratory and instrumental methods are prescribed:
- Objective inspection. Physical data include a forced position of the body, difficulty in movement during seizures, rashes on the trunk, legs and arms, spotty-papular, roseolous, rarely erythematous fields without itching and peeling, moderate hepatosplenomegaly. In immunodeficient patients, lymphadenopathy, heart murmurs, changes in the phalanges of the fingers in the form of drumsticks, nail-watch glasses, weight loss can be detected.
- Laboratory tests. The blood test determines leukocytosis, lymphocytosis, monocytosis, moderate thrombocytopenia, acceleration of ESR, less often normochromic anemia. Biochemical studies show an increase in total bilirubin due to the direct fraction, a slight increase in ALT and AST activity, hypoalbuminemia, and a decrease in total protein. In the general clinical analysis of urine during a febrile attack, albuminuria, erythrocyturia, and cylindruria are detected.
- Identification of infectious agents. The isolation of bartonella is carried out by sowing blood on agar media, however, this method is characterized by duration and high cost. A more modern method is PCR. Serological diagnostics (ELISA, RSC) is recommended no earlier than 15-20 days of the disease, diagnostic titers for RSC are values greater than 1:32, while cross-reactions between the genera of Chlamydia, Cocciella and other types of bartonella are possible.
- Instrumental techniques. Chest radiography is necessary for the purpose of differential diagnosis. Ultrasound examination of the abdominal cavity visualizes an increase in the size of the liver, spleen. If bone neoplasms are suspected, ultrasound, scintigraphy, radiography, CT, MRI of bones are used. ECHO-CS and ECG are recommended to be performed in patients at risk for the development of endocarditis (immunosuppressive patients).
Differential diagnosis is carried out with influenza, in which respiratory tract lesions and catarrhal phenomena occur, typhoid fever, characterized by typhoid status, gradual onset and bradycardia. Malaria is characterized by progressive anemia, CNS lesions, hepatosplenomegaly, jaundice; typhus is clinically manifested by roseolus-petechial rashes, enanthema, changes in consciousness. Measles rashes appear on the 3-4 day of the disease, have a gradual spread, with measles, the phenomena of tracheobronchitis are observed.
Treatment is recommended to be carried out in a hospital setting. Patients are treated with body, hair and clothing with anti-lice products. Bed rest is indicated during periods of feverish attacks, severe pain. With stable normal values of body temperature for 4-5 days, it is possible to weaken the regime. The diet has not been developed, high-calorie food is recommended, sufficient water load.
Therapeutic measures for trench fever should be primarily aimed at eliminating the causative agent of infection. It is also important to understand the features of pathogenesis and drug relief of the main links of the pathological process. Symptomatic treatment of bartonella fever is aimed at alleviating the patient’s condition, especially during seizures.
- Etiotropic therapy. Preference is given to tetracycline and aminoglycoside preparations, macrolides, cephalosporins. Both monotherapy and treatment with a combination of drugs are possible. The greatest effectiveness is observed in the combination of doxycycline with gentamicin. The duration of the antibacterial course is usually about 30 days, when the heart valves are affected, it is extended to 3-4 months.
- Pathogenetic therapy. Detoxification measures are carried out both by enhancing oral fluid intake and by intravenous infusions of solutions (glucose-salt, chlosol, etc.). Vitamins P and C with angioprotective properties are used. For the relief of arterial hypotension, midodrine-containing agents are recommended.
- Symptomatic therapy. Medications are prescribed when symptoms occur. The most commonly used anti–inflammatory drugs are NSAIDs, preferably selective COX-2 inhibitors (celecoxib). Painkillers are indicated for severe pain syndrome, both conventional and narcotic analgesics can be used. Antipyretics are prescribed a short course during a fever attack.
Prognosis and prevention
The prognosis is favorable, no fatal cases have been recorded. Complicated course is more often observed among patients with immunodeficiency. Recovery is accompanied by prolonged asthenization, but two months after the onset of the disease, more than 85% of patients recover. The chronic course of trench fever is proven in less than 5% of cases. Repeated episodes of infection due to unstable immunity to bartonella, as well as relapses of the disease within 3-10 years from the moment of recovery, have been recorded.
Specific prevention (vaccines) have not been developed. Non-specific measures to prevent infection are the identification and treatment of persons with pediculosis, the fight against lice in organized groups, and the improvement of sanitary and hygienic living conditions. Patients with trench disease must be isolated. People who have suffered from Volyn disease are not recommended to be a blood donor for 1-2 years after recovery; the same precautionary measure should be observed by those who have recovered from lice.