NCCID Disease Debriefs provide Canadian public health practitioners and clinicians with up-to-date reviews of essential information on prominent infectious diseases for Canadian public health practice. While not a formal literature review, information is gathered from key sources including the Public Health Agency of Canada (PHAC), the USA Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO) and peer reviewed literature.
This disease debrief was prepared by Meghana Aithal. Questions, comments, and suggestions regarding this disease brief are most welcome and can be sent to nccid@manitoba.ca.
What are Disease Debriefs? To find out more about how information is collected, see our page dedicated to the Disease Debriefs.
Questions Addressed in this debrief:
- What are important characteristics of Bartonella quintana?
- What is happening with the current outbreak of Bartonella quintana?
- What is the current risk for Canadians for B.quintana?
- What measures should be taken for a suspected B.quintana case or contact?
What are important characteristics of Bartonella quintana?
Characteristics and Causes
Bartonellosis is a group of infectious diseases caused by bacteria within the Bartonella genus. The bacteria are fastidious, aerobic, gram-negative cocci/small rods, and are hemotropic. The bacteria invade erythrocytes and the lining of blood vessels where they then proliferate. There are at least 22 known species that are transmitted by vectors, 14 of which are known to be zoonotic. The 3 primary vectors are sandflies, fleas, and body lice. This disease debrief is specific to the species Bartonella quintana – also known as “Trench fever” because of the high levels of recorded cases among soldiers in the trenches during World War I – an emerging disease in Canada.
Pathogen Safety Data Sheets: Infectious Substances – Bartonella Quintana – Health Canada
Bartonella quintana Characteristics and Clinical Management – Emerging Infectious Diseases
Signs and Symptoms
Characteristic symptoms of Bartonella quintana are headaches, maculopapular rashes on the abdomen, papular lesions, and a sudden onset of chills and relapsing fever. Bone pain (mainly occurring on the neck, shins, and back) as well as enlargement of spleen or liver may also occur. Culture negative endocarditis can also occur with B.quintana, typically involving the mitral and aortic valves; it carries a high risk of embolization. In a person with a healthy immune system, the disease is self-limiting, although there have been some cases of relapsing and chronic bacteremia. In immunocompetent persons, febrile symptoms occur around 15-25 days after infection. Fevers will occur in multiple bouts, each episode lasting 4-5 days and recurring around 3-5 times.
In immunocompromised patients, less common symptoms such as endocarditis and bacillary angiomatosis can occur. Known risk factors for these complications are homelessness, alcoholism, and infestation with body lice. Endocarditis caused by B.quintana is associated with those with no previous valvular injuries. Bacillary angiomatosis results in neovascular skin proliferation, most often seen in persons living with HIV. It is identifiable by elevated, blood-filled lesions that bleed easily and have a scaly, ring-like appearance surrounding them. A small number of cases of B.quintana causing endocarditis and bacillary angiomatosis in immunocompetent persons have also been reported.
Pathogen Safety Data Sheets: Infectious Substances – Bartonella Quintana – Health Canada
Bartonellosis – National Organization for Rare Disorders
Bartonella quintana Characteristics and Clinical Management – Emerging Infectious Diseases
Facts about Bartonella quintana infection (‘trench fever’) – European Centre for Disease Prevention and Control
Bartonella, a common cause of endocarditis: a report on 106 cases and review – Journal of Clinical Microbiology
Case series of Bartonella quintana blood culture-negative endocarditis in Washington, DC – Journal of Medical Microbiology
Severity and Complications
While no known deaths have been associated with the fever aspect of the disease, there is an 11.9% mortality rate associated with endocarditis infection globally. In immunocompromised patients, bacillary angiomatosis takes a more severe form, and if left untreated, can lead to death.
Endocarditis associated with Bartonella infection is frequently diagnosed in tissue obtained during heart valve replacement.
Pathogen Safety Data Sheets: Infectious Substances – Bartonella Quintana – Health Canada
Epidemiology
Cases of Bartonella quintana have been recorded worldwide, with peaks during both the First and Second World War. Since the 1990s, the disease has been re-emergent among the homeless population in both Europe and the United States.
Eight cases have been reported in Canada since the 1990s, five of which were detected since 2019. It is likely the disease is significantly underdiagnosed. An epidemiologic survey in a French hospital showed that 30% of 71 tested homeless persons had antibody titers against B. quintana and that 14% were bacteremic. An American study conducted between 2000 and 2003 found that 5.4% of 930 non-hospitalized, homeless persons tested were bacteremic. After 4 cases were detected in Denver in 2019, a study found that 15% of Denverites experiencing homelessness who presented for Covid-19 testing were also seroreactive for Bartonella.
Key risk factors are homelessness, body lice infestation, alcoholism, crowded and unhygienic communal living situations, and poor sanitation.
Pathogen Safety Data Sheets: Infectious Substances – Bartonella Quintana – Health Canada
Bartonella quintana Characteristics and Clinical Management – Emerging Infectious Diseases
Trench fever, rare disease that afflicted WWI soldiers, detected in homeless Winnipeggers – CBC News
Bartonella Seroactivity Among Persons Experiencing Homelessness During an Outbreak of Bartonella quintana in Denver, Colorado, 2020 – Oxford Academic
Reservoir and Transmission:
The bacteria is most commonly transmitted by a vector – the body louse Pediculus humanus. Once the body louse ingests B.quintana, typically from feeding on an infected human, the louse is infected for life. The bacterium proliferates and goes through the intestinal tracts of the louse, and is then excreted in the feces. The infected feces can remain infectious for as long as a year, so cases can still arise even after elimination of a louse population. The bacterium is transferred to humans via itching or scratching, when the infected feces is rubbed into damaged skin or the eyes.
Humans are reservoirs for B.quintana; it is likely that cats and other primates are also reservoirs for the disease.
Pathogen Safety Data Sheets: Infectious Substances – Bartonella Quintana – Health Canada
Facts about Bartonella quintana infection (‘trench fever’) – European Centre for Disease Prevention and Control
Incubation period:
The incubation period of Bartonella quintana ranges from 15 to 25 days.
Pathogen Safety Data Sheets: Infectious Substances – Bartonella Quintana – Health Canada
Diagnosis
Other than monitoring for symptoms, B. quintana can be diagnosed using serological testing to identify antibodies in blood serum, with indirect immunofluorescence as the reference method. Observation of IgG antibodies titers > 1:50 indicate possible Bartonella infection, however, it should be noted that cross reactions can be possible. The disease can also be cultured by growing the bacteria by direct plating on blood agar media, cocultivation in cell culture, and blood culture broth. However, diagnosis with blood culture is challenging for detection of B.quintana, as growth takes several days or weeks, and tests may come back negative even when infection is present. PCR done on blood and tissue, as well as immunohistochemistry done on tissues can also be used to detect the bacteria.
Pathogen Safety Data Sheets: Infectious Substances – Bartonella Quintana – Health Canada
Bartonella quintana Characteristics and Clinical Management – Emerging Infectious Diseases
Bartonellosis – National Organization for Rare Disorders
Prevention and Control
The disease can be controlled through enhanced sanitary measures in homeless shelters and other high-traffic, congregate environments. These measures include:
- Prompt detection and treatment of body lice.
- Frequent sanitization of living quarters
- Washing shared items like bedding or towels at temperatures above 60°C.
- Quickly treating and covering skin wounds
- Encouraging people in these environments to frequently wash hands with soap and water, and avoid touching or rubbing the face
Healthcare practitioners can control the disease by performing serologic and blood culture testing, even in the absence of clinical signs and symptoms, for those who are homeless or who live in crowded/unsanitary conditions.
Bartonella quintana Characteristics and Clinical Management – Emerging Infectious Diseases
Bartonella Infection (Cat Scratch Disease, Trench Fever, and Carrion’s Disease) – Centers for Disease Control and Prevention
Vaccination
There is currently no vaccination against B.quintana or for the Bartonella genus. There are also no vaccines available for animals.
Pathogen Safety Data Sheets: Infectious Substances – Bartonella Quintana – Health Canada
Treatment
While full recovery from B.quintana usually occurs within 1-2 months of infection, chronic bacteremia has been known to occur in some cases. Antibiotics can be used in such cases. Doxycycline in combination with gentamicin can treat chronic bacteremia and has also been known to help in treatment of endocarditis. For bacillary angiomatosis, prolonged treatment using erythromycin should be the first line of treatment, with doxycycline as a secondary option.
Penicillin, cephalosporins, chloramphenicol, tetracyclines, rifampin, fluoroquinolones, cotrimoxazole, and macrolides are also known to limit bacterial growth of the Bartonella genus, but are not recommended as a first line of treatment. Bacterial resistance to fluoroquinolones has been shown to occur.
Prompt treatment of body lice infestation is also essential. Oral ivermectin has been shown to be effective at delousing persons in homeless shelters. Body lice live in clothing and only visit human skin to feed: for this reason, they can also be removed by boiling or treating all clothing with 10% DDT, 1% malathion, or 1% permethrin dust.
Pathogen Safety Data Sheets: Infectious Substances – Bartonella Quintana – Health Canada
Bartonella quintana Characteristics and Clinical Management – Emerging Infectious Diseases
Facts about Bartonella quintana infection (‘trench fever’) – European Centre for Disease Prevention and Control
What is happening with the current outbreak of Bartonella quintana?
Bartonellosis caused by B.quintana has been considered a “re-emerging disease” in North America since the 1990’s. The most recent outbreak occurred in Denver, Colorado, among people experiencing homelessness: 4 cases were identified as of July 20, 2020, and 15% of people experiencing homelessness who presented for Covid-19 testing were found to be seroreactive for Bartonella.
Rare trench fever found among Denver’s homeless population – The Denver Post
Bartonella Seroactivity Among Persons Experiencing Homelessness During an Outbreak of Bartonella quintana in Denver, Colorado, 2020 – Oxford Academic
Canada
Bartonellosis caused by B.quintana is quite rare in Canada, with 8 cases detected since the mid 1990s. The majority of diagnosed cases have been found in recent years, suggesting that the disease is re-emerging: Manitoba (1 case, 2015); Alberta (1 case, 2019); and Manitoba (4 cases, 2020). Based on serological findings from homeless populations in the United States of American and Europe, it is highly likely that it is underdiagnosed.
Trench fever, rare disease that afflicted WWI soldiers, detected in homeless Winnipeggers – CBC News
Bartonella quintana Characteristics and Clinical Management – Emerging Infectious Diseases
Endocarditis due to Bartonella quintana, the etiological agent of trench fever – Canadian Medical Association Journal
Quintessential Culture-Negative Endocarditis – Canadian Journal of Cardiology
What is the current risk for Canadians for B.quintana?
B.quintana is rare in Canada and general risk is low. Homeless populations, and those living in unsanitary or congregate environments, are at a higher risk.
What measures should be taken for a suspected B.quintana case or contact?
Case and Contact Management
If B.quintana is suspected due to a patient’s living situation, serologic and blood culture testing should be performed, even in the absence of clinical signs and symptoms. If endocarditis or bacillary angiomatosis is suspected, culture, immunohistochemical, and PCR tests (on the cardiac valve and skin biopsy respectively) should be performed. Chronic bacteremia and endocarditis should be treated with doxycycline in combination with gentamicin. For bacillary angiomatosis, prolonged treatment with erythromycin is recommended.
B.quintana is not reportable in Canada. Guidelines developed by the Government of Canada are available for management of infection.
Pathogen Safety Data Sheets: Infectious Substances – Bartonella Quintana – Health Canada
Bartonella quintana Characteristics and Clinical Management – Emerging Infectious Diseases