How Trench Warfare Lead to the Discovery of Bartonella Quintana – Among Other Things

(While I do not anticipate this to alter the post, I should note that one name that has published several articles into B. quintana is Didier Raoult. If that name sounds familiar, he was the guy who published a large case series of patients with COVID-19 who were treated with HCQ and kickstarted the HCQ craze worldwide). 

Infectious disease has an interesting link with other aspects of life as we have no doubt seen in the past year. Indeed, with the arrival of the new coronavirus, the role that infections have in global health, policy decisions, epidemiology, and political discourse cannot be denied. The most interesting link that infectious disease has is with history. Indeed, diseases such as leprosy, tuberculosis, yersinia pestis, HIV, and syphilis have shaped the current state of the world. I find these historical takes on infectious diseases fascinating, mostly because I am thankful I live in a time where antibiotics, antivirals, and vaccines are widely available.

One of the most interesting (and perhaps, most important) time periods in modern culture is world war I. Indeed, I think this is one of the biggest clusters that led to the fall of several empires, an entire genocide, a revolution that brought in a new political and economic ideology, and planted the seeds of a much bigger conflict to come. Fought in 2 fronts, this war was quite unlike anything that was seen before (just ask the brightly colored French army how different this was from previous wars). In an attempt to outflank each other, a series of trenches stretching 4000 miles from the English Channel to Switzerland were developed, leading to one of the worst conditions of war that have ever been endured:

A Tiny Bit of History (1, 2)

Trench fever was initially reported among the British forces in Flanders during the summer of 1915. By June 1915, a report by medical officer Major JHP Graham described a patient with what was described by the soldiers as Trench fever: 

‘ A private belonging to an infantry regiment was admitted to a casualty clearing station from a field ambulance where he had been detained suffering from a febrile illness of three days’ duration and of sudden onset…the patient’s condition on admission was marked by frontal headache, dizziness, severe lumbago, a feeling of stiffness down the front of the thighs, and severe pains in the legs referred chiefly to the shins.’ 

Major JHP Graham

The private’s fever resolved for several days, and then he had another bout of fever an the aforementioned symptoms. After the second round of fever, he recovered except for fatigue. Following this report, a Commanding officer of No 5 Canadian Mobile Laboratory alerted both the advisor in pathology to the British Expeditionary Force (sir William Leishman, yes that Leishman) and Sir Walter Herringham about 30 patients with headaches, back and limb pain, high fever, lack of rash, splenic enlargement in the absence of catarrh or GI symptoms. Both officers felt this was likely an unrecognized disease. In the summer of 1916, the condition was officially recognized and the search for the etiology was undertaken. One of the characteristics initially described for trench fever was the relapsing fever, which was a feature shared with malaria. In February 1916, one of the first experimental investigations was undergone and found that serological tests for typhoid, paratyphoid, and brucellosis in trench fever cases were negative. John McNee and Arnold Renshaw also reported the maladoy typically occurred in frontline soldiers and medical personnel and transmission occurred via inoculation of blood from a case of trench fever. Several individuals felt that the etiology was likely carried by a fly or a parasite found in the trenches and the body louse was the likely culprit, as the disease was prevalent during the winer when mosquitoes and flies were absent in the trench environment. Alexander Peacock examined 274 soldiers and found that 95% were infested with body lice, usually ~20 lice per soldier. Despite this sentiment, retired Army Medical Service Colonel MD O’Connell wrote in the Lancet in 1915 that the cause of trench fever was likely the atmosphere. By the end of 1916, however, the consensus was the body louse transmitted trench fever, though evidence did not come until much later.

By the end of 1917, two commissions were established to find the causative agent of trench fever: the British Expeditionary Force Pyrexia of Unknown Origin (BEF PUO) and the War office Trench Fever Investigation Commision (WO TFIC; the latter one chaired by David Bruce of Brucellosis fame). The WO Trench Fever Investigation Commission found that the body louse, via rubbing of infected louse extrecta into irritated skin, was the likely mode of transmission. Furthermore, German scientist H Topfer had discovered that lice fed on trench fever sufferers contained lots of ‘Rickettsial bodies’ which were bodies resembling diplococci. Excreta of lice that fed on trench fever patients had the same organisms previously described. The WO TFIC then carried out experiments in 200 men that involved inoculation of infected louse faeces into abraded skin or conjunctiva. The group learned several characteristics of Trench Fever:

• Headache (74%)
• Pain in shins (46%)
• Pain in loins (31%)
• Knee pain (22%)
• Ankle pain (20%)
• Thigh pain (20%)
• Chills (26%)
• Sweats (19%)
• Dizziness (12%)
• Nausea/vomiting (11%)
• Diarrhea (6%)
• Abdominal pain (8%)

Attempted therapies, such as quinine, salvarsan, antimony, mercury ointment, and convalescent serum all proved to be ineffective. Aspirin and topical menthol alleviate pain, but beyond that, nothing really seemed to work. WO TFIC reported that acriflavine and trypan red did not afford benefit. While no records of how many people were truly infected exists, the estimated incidence was over one million by the end of 1922. While soldiers were not concerned about this as there were no lethal cases reported, soldiers affected by trench fever were unfit for duty for 60-70 days.  The number of reported cases in WWII were significantly lower, and much later on, in the 1960s, Kock’s postulates were able to be fulfilled. A study of 3 volunteers (3) who were inoculated with the bacteria revealed several patterns of disease. For instance, one patient developed post-orbital headache, chills, body pains, and malaise for 3 days, followed by an asymptomatic period of a few days and then relapse for about 2 days:

He had 3 more relapses. Another patient had a more insidious progression, with vague symptoms over 2 months, while another patient developed relapsing febrile episodes weekly a month after inoculation. The overall incubation period ranged from 10 days to up to 45 days. Further investigations lead to other findings, with one review highlighting several other characteristics of B. quintana (4):

• Incubation ranging from 3 to 38 days, though it can be as short as 6 days in experimental conditions
• Abrupt fever and myalgias, mostly in the shins associated with headaches and dizziness that last 1-3 days
• Some patients will recur every 4-6 days with each subsequent attach being less severe
• Transient maculopapular rash, conjunctivitis, severe headache, myalgias
• Splenomegaly if chronic 
• Some patients can have chronic bacteremia, up to 8 years have been reported

Despite the first instances of B. quintana infections being reported in 1915, there is evidence to suggest that infections have been prevalent even several thousand years back. In one study of 400 ancient teeth from 9 European sites, qPCR was used to evaluate B. quintana positivity. 17.9% of the civilian population and 20.1% of the military population were positive for B. quintana (5):

Another report highlights the finding of B. quintana DNA in the dental pulp of a person who died 4000 in southeastern France (6). 

Microbiology

The organism is a facultative, intracellular, gram negative bacteremia that are catalase and oxidase negative (4). These are typically transmitted by the human body louse, and tend to be intracellular organisms, usually erythrocytes (7). Due to this, and its specific growth conditions, it is a fastidious (read: really difficult) organism to culture. Blood cultures take 20-40 days to grow with CO2 production being so low that it does not trigger the automatic growth center. Recovery is enhanced in lysis centrifugation blood culture systems or by subculturing into fresh chocolate agar (4), or culturing with axenic media with blood enriched agar plates (7). The difficulty of isolating this organism in culture was highlighted in a retrospective study of blood cultures from patients with Bartonella infections over a 5 year period found that the overall sensitivity of blood cultures was fairly low, with increasing sensitivities wit different methods, the highest being the blood culture broth-shell vial (8):

When grown in agar, the colonies of B. quintana tend to be smooth and flat, never pitted in a gar (9). This is in contrast to colonies of B. henselae, which are usually rough and deeply embedded in agar:

Diseases and Risk Factors

B. quintana has been implicated in several diseases, including bacillary angiomatosis, chronic bacteremia, peliosis, and culture-negative infective endocarditis. One case report highlights a patient with a 2 week history of fever, night sweats, and weight loss who had culture-negative endocarditis from B. quintana (10) and another case series highlights 5 pediatric patients with congenital heart disease who presented with B. quintana endocarditis (11). One of the risk factors commonly cited is homelessness and alcohol abuse, with one review (4) citing serological evidence of infection in 16% of hospitalized homeless patients compared to 1.8% of non-hospitalized patients and 0% of blood donors. In another study of IV drug users, the prevalence was 10% (4). This is confirmed in a seroprevalence report of 192 downtown Seattle clinic patients (12), of which 66% were homeless, and 199 blood donors found that clinic patients were more likely to have titers >1:64 (20% vs 2%). Multivariate analysis revealed that patients with serological evidence of B. quintana were more likely to be homeless, have alcohol abuse, be current smokers and IV drug users:

Those whose titers were >1:512 were more likely to be current alcohol users (RR 5.7, 95% CI 2.1-15.0), IV drug users (RR 4.2, 95% CI 1.1-5.8). A retrospective case-control study (13) compared 10 patients who presented with bartonella spp bacteremia with 2 controls per case, and univariate analysis showed that those with bacteremia were more likely to be homeless, have a history of chronic alcohol abuse, and be non-white. Another case series of homeless patients with B. quintana bacteremia found that bacteremic patients tended to be homeless for a shorter period of time prior to diagnosis, were more likely to be infected with lice, and had higher IgG titers compared to culture negative controls (15):

There were no differences in symptoms between groups, however sweats were more likely in bacteremic patients. These are highly selected patients so it is difficult to draw definitive conclusions. 

Presentation included fevers, weight loss, splenomegaly and one patient presented with aortic valve endocarditis that underwent surgical removal.  Another case series of 22 patients with Bartonella endocarditis found that, compared to those who were presenting with Bartonella henselae as the etiology, those with B. quintana tended to be homeless, have history of alcoholism, and have no prior valve pathology (14):

Of these 22 patients, only 5 had a culture positive for Bartonella with the rest of them being diagnosed via serology and PCR. It seems that anything that would put patients in contact with body lice or bad hygiene is a risk factor for B. quintana infections, and this is likely why the association with alcohol abuse and IVDU exists, rather than these being inherent risk factors for the disease. 

A certain number of patients can also progress to having chronic bacteremia, the consequence of this, however is unclear. For instance, an analysis of 71 homeless patients who presented to the emergency room found 10 of these had B. quintana bacteremia, with 5 of these 10 having reported chronic bacteremia, with 3 patients having blood culture positivity up to  6 weeks from initial presentation (16):

Differences Between B. henselae and B. quintana 

Bartonella henselae is the cause of cat-scratch disease and closely related to B. quintana. For instance, a study of 4 immunosuppressed individuals with bacillary angiomatosis found the etiology to be related to B. quintana via 16S PCR of tissue samples, which lead to the identification of B. henselae (17). In a retrospective analysis of 37 patients with bacillary angiomatosis (18), clinical symptoms that were most prevalent were skin lesions (84%), fever (62%), weight loss (35%), and a significant proportion of having lymph node involvement (46%). Analysis found that lymphadenopathies were more often with B. henselae infections (61% vs 21%), and neurological disorders were more frequently associated in B. quintana cases (21% vs 0). Furthermore, those with B. quintana were more likely to report homelessness and poor living conditions. 

A matched case-control study of 49 patients with Bacillary angiomatosis found several differences in cases caused by B. quintana and B. henselae. Those with B. quintana were more likely to involve bone while those with B. henselae were more likely to have lymph node and liver involvement (20):

Recurrent fevers (OR 14, 95% CI 3.4 to 58.5), poor appetite (OR 3.3, 95% CI 1.5-7.4), and weight loss (OR 5.6, 95% CI 2.1-14.8) were more common in cases than in controls, though there were no differences between the groups in terms of alaise, nausea, vomiting, rash, headache, and joint pains. Further, B. quintana patients were more likely to be homeless and have head, body, or pubic lice when compared to B. henselae patients:

A significant portion of these patients (92%) were HIV positive with an additional patient being on immunosuppressants. Overall, seems B. henselae has more lymph node involvement and is associated with cat exposure, in contrast to B. quintana, which is associated with body lice exposure and can have more bone manifestations. 

Therapy:

One of the difficult things about antibiotic therapy here is that in vivo efficacies do not correlate well with MICs. Bartonella spp are intracellular organisms, and isolation is performed with either cell cultures or axenic media with blood enriched agar plates (20). Susceptibility testing is used in the presence of eukaryotic cells or without cells (aka axenic media), but due to the different conditions required to grow Bartonella spp, the in vitro and in vivo susceptibilities do not match well. One review notes that in an erythrocyte coculture model, most antibiotics were bacteriostatic against Bartonella (20). When gentamicin was tested at a concentration of 0.26ug/mL (the concentration it can achieve inside an RBC), gentamicin was not bactericidal, despite being bactericidal at an MIC of 4, suggesting that the reservoir of bacteria, namely the RBC, allows the MIC of several antibiotics to drop. In other words, the RBC is actually protecting the Bartonella against antibiotics, which means that for serious infections, a regimen of 2 antibiotics is preferred. 

Recommendations for therapy for different diseases caused by Bartonella spp is highlighted below. Notably, most of this comes from retrospective cohort studies as well as case series. 

There is some confirmation to therapy in some of the more severe cases. A retrospective study of 101 patients with Bartonella spp infective endocarditis evaluated different antibiotic regimens, which included beta-lactams, aminoglycosides, and doxycycline (21). The rate of relapse and death was higher when doxycycline was used either alone or with other antibiotics (not aminoglycosides). Fluoroquinolones and beta lactams had a pretty good recovery rate, though the number of patients who got beta-lactams alone was quite small:

Notably, the action of aminoglycosides yielded a much higher recovery rate than any other antibiotic regimen. The dual-therapy approach was confirmed in a small, open-label randomized trial evaluating 2 weeks of gentamicin and 4 weeks of doxycycline versus no therapy (22). 20 patients were randomized, and eradication of bacteremia was obtained in 7/9 patients in the treatment group compared to the 2/11 in the untreated group in the ITT analysis (p-0.01). In the per-protocol analysis, eradication occurred in 7 patients in the treatment group compared to 2/9 in the no treatment group (p=0.003). While small, it reinforces the use of aminoglycosides in severe infections. 

TL;DR

• Bartonella quintana is the causative agent of Trench fever, which is characterized as periods of recurrent fevers, headaches, myalgias and shin pain. 
• Chronic bacteremia, bacillary angiomatosis, and culture-negative endocarditis are known complications
• Culture is difficult to obtain, and many diagnoses are made by PCR and serology
• Risk factors include homelesness and alcohol abuse
• Therapy is prolonged, with bacteremia and endocarditis requiring aminoglycoside therapy 

References:

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13. Spach DH, Kanter AS, Dougherty MJ, Larson AM, Coyle MB, Brenner DJ, Swaminathan B, Matar GM, Welch DF, Root RK, et al. Bartonella (Rochalimaea) quintana bacteremia in inner-city patients with chronic alcoholism. N Engl J Med. 1995 Feb 16;332(7):424-8. doi: 10.1056/NEJM199502163320703. PMID: 7529895.
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16. Brouqui P, Lascola B, Roux V, Raoult D. Chronic Bartonella quintana bacteremia in homeless patients. N Engl J Med. 1999 Jan 21;340(3):184-9. doi: 10.1056/NEJM199901213400303. PMID: 9895398.
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18. Gasquet S, Maurin M, Brouqui P, Lepidi H, Raoult D. Bacillary angiomatosis in immunocompromised patients. AIDS. 1998 Oct 1;12(14):1793-803. doi: 10.1097/00002030-199814000-00011. PMID: 9792380.
19. Koehler JE, Sanchez MA, Garrido CS, Whitfeld MJ, Chen FM, Berger TG, Rodriguez-Barradas MC, LeBoit PE, Tappero JW. Molecular epidemiology of bartonella infections in patients with bacillary angiomatosis-peliosis. N Engl J Med. 1997 Dec 25;337(26):1876-83. doi: 10.1056/NEJM199712253372603. PMID: 9407154.
20. Rolain JM, Brouqui P, Koehler JE, Maguina C, Dolan MJ, Raoult D. Recommendations for treatment of human infections caused by Bartonella species. Antimicrob Agents Chemother. 2004 Jun;48(6):1921-33. doi: 10.1128/AAC.48.6.1921-1933.2004. PMID: 15155180; PMCID: PMC415619.
21. Raoult D, Fournier PE, Vandenesch F, Mainardi JL, Eykyn SJ, Nash J, James E, Benoit-Lemercier C, Marrie TJ. Outcome and treatment of Bartonella endocarditis. Arch Intern Med. 2003 Jan 27;163(2):226-30. doi: 10.1001/archinte.163.2.226. PMID: 12546614.
22. Foucault C, Raoult D, Brouqui P. Randomized open trial of gentamicin and doxycycline for eradication of Bartonella quintana from blood in patients with chronic bacteremia. Antimicrob Agents Chemother. 2003 Jul;47(7):2204-7. doi: 10.1128/aac.47.7.2204-2207.2003. PMID: 12821469; PMCID: PMC161867.