On the Streets and in the Trenches

Everyone has heard of the trench coat. Probably quite a few people have also heard of trench foot, trench knife, trench mouth, trench tool and trench fever. All of these things have there origins in the brutal trench warfare of World War I. Except for the trench coat, you probably would not expect to find many of these implements and aliments in modern-day Maryland. But you’d be wrong. Trench fever is a re-emerging infection in many parts of the world. Today, the urban homeless often provide opportunities for trench fever to gain footholds in places not traditionally thought of as dirty or dangerous. Recently, researchers at the Centers for Disease Control and Prevention (CDC) and the Johns Hopkins School of Public Health found a surprising number of trench fever cases in downtown Baltimore. The cases occurred among some 630 inner-city residents taking part in studies of intravenous drug use and HIV infections. Almost ten percent of the 630 tested residents showed evidence of having had this infection. Trench fever is a bacterial infection caused by Bartonella quintana. Historically, body lice (not to be confused with common head lice) have transmitted this microorganism from person to person. The lice like to move from hot (feverish) bodies or cold (dead) bodies to warm, healthy bodies. Not surprisingly, the crowded, unsanitary conditions of warfare and refugee camps led to frequent epidemics of trench fever. About a million people were infected on both fronts during World War I. Trench fever is rarely fatal, but its wildly variable symptoms often cause delays in diagnosis and treatment. Typical symptoms include a relapsing fever, headache, malaise,


weight-loss, a drop in blood platelets, and leg pains. Endocarditis (heart infection) is a symptom more commonly seen in today’s urban patients than among soldiers of past wars. Untreated, the bacteria can persist in the bloodstream for years. The good news—and ‘good’ is a relative term here—is that body lice did not seem to play a role in the Baltimore cases, according to the lead investigator, Dr. James Comer at the CDC. The bad news is the researchers could not say how these people became infected, but sharing dirty needles is one likely means. Who are these Baltimore residents? Well, eighty percent of them are HIV-positive. Most are male. Ninety-three percent have an annual income of less than $5,000, and forty-four percent never finished high school. Fifteen percent reported being homeless during the previous six months and sixty-one percent reported using injectable drugs during that same period. Homelessness and disease, however, are not unique to Baltimore’s downtown streets and alleyways. Ten years ago, Seattle had a small outbreak of B. quintana among homeless alcoholics living in the downtown area. Last year, the Los Angeles County Department of Health Services checked patients who visited a free clinic in LA’s ‘skid row’ district. Almost ten percent of them tested positive for evidence of trench fever. Even Paris, the City of Light, is not immune from the problems of urban homelessness and disease. In 2001, physicians at the Hopital Saint-Louis in Paris found that half of 57 homeless patients were positive for trench fever. The high percentage of infected homeless people in Paris may have been due to “cutaneous parasitic infestations.” That’s a fancy way of saying these patients had body lice. (This is one of those incidences when Charm City looks better than the City of Light.)


The appearance of trench fever, and the body lice that carry B. quintana, are evidence of a breakdown in social order and personal hygiene. They are also a reminder that life on the streets of Seattle, Baltimore, or even Paris is never easy. Poverty, malnutrition and substance abuse are not new problems in modern societies. So why the re-emergence of this Dough Boy disease? No one is certain. Better diagnostic may account for some of the increase in detected cases. HIV-infected patients with weakened immune systems also may provide a larger pool of individuals susceptible to trench fever. Finally, shared syringes could provide a new and quicker means of spreading disease than lice. Whatever the reasons, it is another problem for social services and emergency rooms. Fortunately, an inexpensive combination of the antibiotics doxycycline and gentamicin can usually eradicate the infection and make life on the street a little less painful.

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