Trench fever is a bacterial infection caused by Bartonella quintana and carried by the human head and body louse. It is marked by fever, body aches, and a rash. It has historical significance as a common disease of the world war trenches.

What is the Trench Fever?

Trench fever is an infectious disease caused by the bacterium Bartonella quintana. It is spread by body lice (Pediculus humanus humans) and sometimes by head lice (P. h. capitis) ¹. It affected over a million soldiers who lived in dirty, overcrowded trenches during the world wars. This fever was first identified during World War I in 1915 by Hunt and Rankin. They noticed it was a different disease from the other fevers soldiers were experiencing. The disease was so prevalent that even famous writers like J.R.R Tolkien and C.S. Lewis contracted it during their drafts. This fever is also known by:

Five-day fever
Quintan fever
Wolhynia fever
Shin bone fever
Meuse fever
His disease
His–Werner disease²

Does Trench Fever still exist?

This fever is usually considered a disease of war. In recent years, outbreaks of this fever have been reported across North America. In 2020, Denver, Colorado, saw several cases among its homeless. Health Canada reported five cases of trench fever in Alberta in 2023. These infections came from organ donors who had been homeless. In November 2024, the CDC also warned that though rare, trench fever is still spreading, putting the unhoused and transplant recipients at the most significant risk.³

How common is Trench Fever?

Estimates show that up to 30% of the homeless are infected with this fever in certain areas of the United States. In addition to that, it is considered endemic in regions like Mexico, Tunisia, Eritrea, Poland, and the former Soviet Union. The disease was much more common during the world wars — a million soldiers contracted the bacteria in World War I alone. ⁴

Causes of Trench Fever

Trench fever results from the bacterium Bartonella quintana, a gram-negative, aerobic organism in the Bartonella genus. It is carried by the human body. Trench fever is primarily spread through three types of lice: the body louse (Pediculus humanus corporis), the head louse (Pediculus humanus capitis), and the pubic louse (Pediculus humanus pubis), with the body louse being the main vector responsible for transmission. The lice feed on someone who carries the bacterium and then carries it in their gut. Bartonella quintana colonizes the louse’s gut without harming the insect. It multiplies so much and so fast that lice feces remain infectious for weeks.

How is Trench Fever transmitted?

This fever is completely dependent on lice for transmission. Unlike many vector-borne diseases, it does not pass through direct human contact. It also does not spread through through respiratory droplets, water, or food.
When these lice bite another person, they excrete feces containing the bacteria. When you scratch the bite, the bacteria enter your body through breaks in your skin or through mucous membranes. Lice becomes infected after feeding on an infected person, and the transmission cycle continues.

Risk Factors

Any risk factor for lice infestation is a risk factor for trench fever. Many living conditions make lice spread fast, such as:

Poor Hygiene:

Lice spread fast without showers, clean clothes, and soap. They settle into dirty clothes, lay eggs, and spread bacteria. The longer you go without washing, the worse it gets. Even if you manage to remove the lice, they come back fast if your hygiene conditions don’t improve.

Lice on scalp — Trench fever is completely dependent on lice for transmission

Overcrowding:

Lice don’t just spread because of poor hygiene — they spread because people are packed too close together. When you live in an overcrowded residence, lice move easily from one person to another and crawl into everyone’s personal belongings. Even if you keep yourself clean, it only takes a few lice from someone nearby to start the infestation all over again.

War:

Historically, these fever outbreaks have been driven by war and conflict. Soldiers in World War I were particularly marred by widespread infestations. Today, people in war-torn areas and those forced to flee their homes face the same risks. With no shelter, clean clothes, and sanitation, lice and trench fever can spread easily.

Malnutrition:

A weak immune system makes infections harder to fight. Poor nutrition also slows recovery from illness. This makes people who live in famine-stricken areas more prone to contracting trench fever.

Homelessness:

Homelessness is often associated with poor living conditions and lack of access to sanitation. This creates ideal conditions for lice to thrive. Research shows that lice infestations affect between 19% and 68% of homeless individuals, which increases the risk of this fever manifold.

Substance Use:

Intravenous drug users face a high risk due to poor hygiene and crowded living conditions. Heavy drinkers who are in shared living spaces with limited sanitation face also face high risks of trench fever. In addition, substance use also weakens your immune system and makes you more susceptible to a more severe infection.

Symptoms of Trench Fever

This fever comes on suddenly, usually after 3 to 35 days of being infected. It follows a cycle where symptoms seem to improve, only to return days or even years later. The hallmark of trench fever is a relapsing fever that occurs in cycles, often every five days (hence the nickname “five-day fever“. Some people also develop serious complications like heart infections or organ swelling. Symptoms that you should watch out for include:

High fever up to 40.5°C or 105°F which lasts for 5 to 6 days.
Deep, aching pain in your lower back and shins
A throbbing headache often felt behind the eyes
Extreme fatigue
Dizziness
Skin rash
Enlarged liver and spleen⁵

Image of a woman suffering from trench fever — High fever, body aches, and dizziness are characteristic features of trench fever

How is a Trench Fever diagnosis established?

When you come in with symptoms that might suggest trench fever, your doctor will start by asking about your history and performing a careful physical exam. Then, they will run some important tests to confirm whether you have the disease or not.

History & Physical Exam

Your healthcare provider will get a detailed medical history and ask if you’ve been exposed to environments where body lice are common. They will ask where you live and what your hygiene is usually like. You’ll also be asked to describe your symptoms, such as sudden high fevers, severe leg pain, weakness, and headaches.
During the physical exam, they will check your temperature and palpate you for any tenderness in your shins and lower back. They may also look for a rash. If you have a relevant history and have had recurring episodes of these problems, your doctor will keep trench fever high on the list of possibilities even if you don’t have any active signs of trench fever.

Lab Investigations

Laboratory tests are important for piecing together your overall clinical picture of trench fever. They confirm the diagnosis and help your doctors select the appropriate antibiotic for your treatment. The first tests are usually a panel of baselines, such as:

Complete blood count
Liver function tests
Renal function tests
Serum electrolytes
Coagulation profile
Infectious diseases panel

Alongside these tests, the doctor will order some tests to confirm whether you have trench fiver or not:

You’ll have a blood sample taken to look for antibodies against Bartonella quintana. Tests like immunofluorescence assays or ELISA help determine if your immune system is actively fighting the infection. The lab may also check for a rising antibody titer over time, which confirms that the infection is active.
A polymerase chain reaction or PCR test picks up the DNA of Bartonella quintana in your blood. This test is particularly useful because the bacterium is difficult to grow in a lab and makes direct detection challenging.
Blood cultures are an important tool for diagnosing bacterial infections. They attempt to grow the bacteria from your blood sample. However, Bartonella quintana is slow-growing, and the culture might take several weeks. Sometimes, the results can be negative, even if you are infected.

Imaging

Imaging modalities are usually only reserved for finding out if trench fever has spread to any organs in your chest or abdomen.

You’ll undergo echocardiography, which is an ultrasound of your heart. This helps your doctor see if your heart valves are damaged or if there are signs of endocarditis.
CT or MRI scans are used if your doctor suspects the involvement of your abdominal organs.

What is the treatment for Trench Fever?

Some cases of trench fever are mild and can resolve on their own. However, they still cause considerable distress, and you are still a carrier for the disease. In order to completely cure yourself of trench fever, it is important to seek treatment.

Antibiotics

Antibiotics are the mainstay of trench fever treatment. A variety of antibiotics are available for trench fever, such as:

For uncomplicated trench fever, you will typically treated with oral doxycycline at 100 mg or 200 mg once a day for four weeks. This regimen is often combined with gentamicin, given at 3 mg/kg intravenously once daily for the first 14 days.
If gentamicin isn’t an option, rifampin at 300 mg twice a day for the first two weeks can be used instead.
In situations where you cannot take tetracycline derivatives, chloramphenicol is recommended instead. It is usually administered for 7 to 10 days. Other antibiotic options, such as erythromycin or azithromycin, may also be considered based on your specific condition.

Supportive Care

In addition to antibiotics, supportive care is also important for recovering from trench fever. However, since trench fever usually affects the most vulnerable populations, a number of patients don’t have access to these measures. Supportive care for trench fever includes:

Getting plenty of rest
Drinking enough fluids
Eating a well-balanced, nutritious diet rich in vitamins
Maintaining good personal hygiene
Living in a clean environment
Going for regular follow-up appointments with your healthcare provider
Managing general symptoms with over-the-counter painkillers and antipyretics such as ibuprofen and acetaminophen.⁶

What to do for Trench Fever Prevention?

The only way to prevent this fever is to avoid getting infected by lice. The best way to do it is to maintain hygiene and avoid contact with infected individuals. You can take several steps to do this, such as:

Take regular showers and baths to keep your skin clean and lower the risk of lice infestation.
Wash clothing and bedding frequently in hot water. Then, use a high-heat dryer to kill lice and their eggs.
Keep a clean living environment. Avoid sharing your personal items such as your clothes, towels, or bedding, even if you live in a crowded setting.
Even if you are at risk for trench fever, you can find community programs in your area that offer delousing treatments and hygiene facilities.

Complications

Sometimes, this fever spreads to vital organs and results in complications that are difficult to treat. Some of these complications are:

Trench fever can lead to endocarditis, an infection of the heart valves that may progress to heart failure if not promptly treated.
The bacteria can persist in your bloodstream, a condition known as “chronic bacteremia”.This can cause recurrent symptoms over time.
In individuals with weakened immune systems, trench fever may cause bacillary angiomatosis. This results in abnormal blood vessel growth on the skin and in other organs.⁷
Sometimes, the infection can lead to peliosis hepatis, a condition where blood-filled cavities develop in the liver.⁸

Mortality Rate of Trench Fever

Trench fever is usually not fatal. With prompt antibiotic treatment, most patients can recover. If complications develop, the disease becomes harder to treat. The bacteria can linger in your blood for weeks and sometimes months. A study estimates a 9.6% fatality rate among individuals who suffered from endocarditis as a complication of Bartonella quintana.⁹

What can be mistaken for Trench Fever?

This fever starts with generalized symptoms and has a commonplace vector. This can make it hard to differentiate from several other conditions, such as:

Other Diseases	Similarities to Trench Fever	Differences from Trench Fever
Typhoid	Fever is continuously high. Rash has a trunk-to-extremity spread, Higher mortality rate	Marked abdominal pain, Rose spots, Food and waterborne
Dengue	Fever, Headache, Muscle pain (Breakbone Fever)	Caused by a mosquito-borne virus, often includes rash, bleeding, and low platelet count. No lice involvement.
Relapsing fever	Recurrent fever, transmitted by lice or ticks	Caused by Borrelia species, relapses tend to be more abrupt and severe. Often associated with spirochetemia.
Leptospirosis	Fever, Headache, Body aches	Often has jaundice, conjunctival suffusion, and renal involvement. Transmitted via contaminated water.
Typhus	Fever, Rash, and Human lice are the vectors	The rash typically spreads from trunk to extremities; fever is sustained, not relapsing; higher mortality. Caused by Rickettsia prowazekii.

Trench fever vs Typhus

While both diseases are transmitted by lice and cause fever and a rash, trench fever and typhus have several differences. Typhus is spread by Rickettsia prowazekii. It usually brings a continuous, high fever. Its associated rash starts on the trunk and then spreads outward. In addition, typhus is more severe and far more fatal than trench fever.

Conclusion

Trench fever is caused by Bartonella quintana and spread by lice. Originally a disease of war, this fever now mainly affects the homeless and other vulnerable populations. It starts with fever, body aches, and a rash. However, it can sometimes complicate endocarditis. Treatments mainly consist of antibiotics and supportive care. It can be prevented with good hygiene and living in a clean environment.

Refrences

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Anstead, G. M. (2016). The centenary of the discovery of trench fever, an emerging infectious disease of World War 1. The Lancet Infectious Diseases, 16(8), e164–e172. https://doi.org/10.1016/s1473-3099(16)30003-2
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CDC. (2025, January 6). About Bartonella quintana. Bartonella Infection. https://www.cdc.gov/bartonella/about/about-bartonella-quintana.html
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Marshall, K. E., Martinez, H. E., Woodall, T., Guerrero, A., Mechtenberg, J., Herlihy, R., & House, J. (2022). Body Lice among People Experiencing Homelessness and Access to Hygiene Services during the COVID-19 Pandemic—Preventing Trench Fever in Denver, Colorado, 2020. The American Journal of Tropical Medicine and Hygiene, 107(2), 427–432. https://doi.org/10.4269/ajtmh.22-0118
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Bush, L. M., & Vazquez-Pertejo, M. T. (2024, June 2). Trench Fever. MSD Manual Professional Edition; MSD Manuals. https://www.msdmanuals.com/professional/infectious-diseases/gram-negative-bacilli/trench-fever
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Kassem. (2024, August 16). Bartonellosis (Bartonella Infection) Treatment & Management: Medical Care, Surgical Care, Consultations. Medscape.com; Medscape. https://emedicine.medscape.com/article/213169-treatment
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Akram SM, Anwar MY, Thandra KC, Rawla P. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jul 4, 2023. Bacillary Angiomatosis.
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Boodman, C., Gupta, N., Nelson, C. A., & Johan van Griensven. (2023). Bartonella quintana Endocarditis: A Systematic Review of Individual Cases. Clinical Infectious Diseases, 78(3), 554–561. https://doi.org/10.1093/cid/ciad706‌

Trench Fever: Causes, Symptoms, and Prevention

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