Trench fever

Medical quality assurance by Dr. Albrecht Nonnenmacher, MD at June 28, 2016
StartDiseasesTrench fever

Trench fever, so called because of its prevalence in the trenches during World War I, is a serious though rarely lethal bacterial infection transmitted via body lice. It was so common during WWI that as many as one-third of all British troops and one-fifth of German and Austrian troops reported some symptoms of the disease. Trench fever is also sometimes called five-day fever, His disease, or shin bone fever.


Definition & Facts

There have been outbreaks documented in the developed world more recently, but they are rare. In contemporary times it is a condition associated with homelessness, poverty, and drug abuse. This may be due to the fact that body lice are more common among these populations.

Trench fever causes extremely unpleasant symptoms but it is rarely deadly in those with normally functioning immune systems. In the few known cases in which trench fever has been lethal, death has occurred due to heart failure caused by severe complications.

Symptoms & Complaints

The incubation period of trench fever can be anywhere between three and 48 days depending on the health of the infected individual. When symptoms do appear, they typically manifest rapidly and include a fever which is most frequently characterized by a relapsing rather than a continuous course.

Individuals who have this infection may find that they experience periods of reduced fever or even complete cessation of symptoms several times before making a full recovery. This fever is often accompanied by severe headaches, muscle soreness particularly in the legs and back, and acute pain accompanying any eyeball motion.

Its nickname, shine bone fever originated as a description of the most constant and consistent symptom: increased sensitivity and pain in the shins. Unlike the fever, this symptom remains constant as trench fever runs its course and presents itself in almost all cases.

This disease is often accompanied by conjunctivitis or other irritation of the eyes in the early stages as well as neurological symptoms that occur with the onset of fever. These include depression, weakness, a feeling of restlessness, and being unable to sleep. Upset stomach, diarrhea, and abdominal pain are less common symptoms. 


Shin bone fever is caused by infection with Bartonella quintana. The only way to contract it is by coming into contact with the feces of infected body lice. This can be via a louse bite or abrasion of the skin. The manner by which this infection is transmitted makes it quite rare in developed countries because of predominating hygiene standards.

Diagnosis & Tests

Laboratory diagnosis of trench fever can pose a challenge. Diagnosing physicians will often take blood cultures and perform tissue biopsies of the skin, one or more lymph nodes, or the cardiac valve. However, the disease also manifests itself in other tissues.

Antibody levels for Bartonella can be performed via immunofluorescent assays. These are blood tests performed by mixing a sample of the antibody with a fluorescent compound and a patient's blood sample. If the antibody is present in the blood, the sample will become fluorescent when exposed to ultraviolet light.

The presence of Bartonella antibodies can also be detected using enzyme immunoassay, in which an enzyme is linked to an antibody and used as a label. If this label is detected in the patient's blood, it indicates presence of the disease. A third test is often done on either blood or tissue samples to detect the responsible bacterial agents directly.

Treatment & Therapy

In most cases trench fever does not require medical intervention for complete recovery. Patients with compromised immune systems may have a harder time fighting off the disease. The most common treatment for five-day fever when it is necessary is to prescribe a course of antibiotics.

For those who do not have a compromised immune system, effective antibiotic treatments for acute cases include the use of doxyclycline taken twice daily for 28 days combined with gentamicin administered by IV for 14 days. Macrolides and ceftriaxone are also sometimes prescribed for acute manifestations.

In cases where the patient has a chronic condition, this treatment is often significantly prolonged. It can take up to four years of treatment before chronic trench fever patients are tested to be free of the bacteria. This must be proven via cultures to determine when treatment can safely be stopped.

The need for more extensive treatment is decided by which body parts the disease has spread to. When detected in the lymph nodes, erythromycin is used as a first line therapy. Treatment requires three months of taking oral doses four times daily to be effective. Doxycycline is sometimes prescribed as an alternative, taken only twice daily for the same duration. If these are not proving effective, IV gentamicin is typically added.

If this ordinarily comparatively short-lived disease has spread to the heart valve, the same antibiotic treatment is required and valve replacement surgery may be necessary to eradicate the disease. Those with severe liver disease or kidney disease, children under nine years of age, and pregnancy woman cannot be prescribed most of the common medications for His disease, as they are part of the tetracycline group of antibiotics. These can be dangerous for the above noted groups.

Prevention & Prophylaxis

Prevention of trench fever involves avoiding contact with body lice. This can be accomplished through regularly practicing proper personal hygiene. Getting rid of body lice involves taking a hot shower and using soap.

Clothes and bedding can be washed in hot water and dried on the hottest setting or pressed with an iron. Body lice cannot withstand temperatures of more than 122 degrees Fahrenheit (50 degrees Celsius).

Washing regularly with soap and water for the duration of the infestation and paying special attention to any affected areas will help to decrease the risk of trench fever. People who have contracted body lice should avoid contact with family members and others until they are able to eradicate them as they are extremely contagious