DC 6306 · 38 CFR 4.88b
Bartonellosis (Trench Fever) C&P Exam Prep
To establish the current severity, activity status, and functional impact of Bartonellosis (Trench Fever) caused by Bartonella quintana, including any residual or chronic manifestations following service-connected exposure, and to document how the condition affects the veteran's daily life and ability to work.
- Format:
- Interview + Physical
- Typical duration:
- 30-45 minutes
- DBQ form:
- Infectious_Diseases_Other_than_HIV_Related_Illness_Chronic_Fatigue_Syndrome_and_Tuberculosis (Infectious_Diseases_Other_than_HIV_Related_Illness_Chronic_Fatigue_Syndrome_and_Tuberculosis)
- Examiner:
- Infectious Disease Specialist or Internal Medicine
What the examiner evaluates
- Confirmation of Bartonellosis diagnosis and ICD coding (ICD-10 A44.1 for trench fever)
- Active vs. inactive disease status and date condition became inactive if applicable
- History of onset, course, and any relapses or recurrent febrile episodes
- Documentation of serologic testing, culture results, and other diagnostic laboratory findings
- Current and past treatment history including antibiotic regimens and cessation dates
- Presence of chronic or residual symptoms including persistent fatigue, recurring fever, shin pain, myalgia, headache, and splenomegaly
- Impact on occupational functioning and activities of daily living
- Presence of complications such as endocarditis, bacteremia, or bacillary angiomatosis
- Any co-occurring or secondary conditions attributable to Bartonellosis
Examination will be conducted in person with a physician. Bring all prior laboratory reports, treatment records, and any private physician documentation. The examiner will review your service treatment records and any VA medical records already on file. You have the right to request that the examination be recorded in most states - confirm your state's law in advance.
Measurements and tests
Serologic Testing (IFA, ELISA for Bartonella quintana antibodies)
What it measures: Presence of IgG/IgM antibodies indicating current or prior Bartonella quintana infection
What to expect: Examiner will review prior lab results; no new blood draw is guaranteed at the C&P exam itself, but results in your file will be documented
Critical thresholds
- Positive IgG titer -1:64 (IFA) Supports confirmed diagnosis; critical for establishing service connection and active vs. inactive status
- Positive IgM titer Suggests acute or recent active infection; may support active disease classification
Tips
- Bring copies of all prior serologic test results with dates
- If testing was done during service, ensure those records are in your claims file
- Request copies from private labs if VA does not have them on file
- Ask your treating physician to write a letter interpreting the results in context of your symptoms
Pain considerations: Shin bone pain (tibialgia) is a hallmark symptom of Trench Fever; be prepared to describe the character, frequency, and severity of any bone or muscle pain accurately.
Blood Culture for Bartonella quintana
What it measures: Confirms active bacteremia with Bartonella quintana
What to expect: Examiner will review any documented culture results in your medical records; cultures are slow-growing and may have required extended incubation
Critical thresholds
- Positive blood culture Definitive evidence of active or prior infection; strongly supports diagnosis and may indicate ongoing or relapsing disease
Tips
- Document dates and results of any cultures performed
- If cultures were attempted but negative, note that Bartonella quintana cultures have low sensitivity and negative results do not rule out infection
- Pair culture documentation with clinical history and serology for strongest evidence
Pain considerations: During active bacteremia, veterans may experience severe systemic symptoms; accurately describe the functional impact during those episodes.
PCR Testing (Polymerase Chain Reaction)
What it measures: Detects Bartonella quintana DNA in blood or tissue samples
What to expect: Examiner will note any PCR results in the file; PCR may be ordered if current active infection is suspected
Critical thresholds
- Positive PCR result High specificity for active infection; supports active disease status on DBQ and may elevate rating consideration
Tips
- Bring documentation of any PCR testing performed
- Note the date specimens were collected relative to symptom onset
- If PCR was not performed, discuss with examiner whether it is clinically indicated
Pain considerations: PCR is most useful during febrile episodes; if you experienced periodic fever cycles, document their timing and frequency accurately.
Echocardiogram (if endocarditis suspected)
What it measures: Evaluates for vegetations or valvular damage associated with Bartonella quintana endocarditis
What to expect: Examiner will review any imaging reports; may note cardiac complications as a separate ratable condition
Critical thresholds
- Evidence of valvular vegetations or damage Bartonella endocarditis is a serious complication that may warrant separate rating under cardiac diagnostic codes
Tips
- If you have had any cardiac workup, bring all reports
- Describe any symptoms of shortness of breath, palpitations, or chest pain accurately
- Bartonella endocarditis disproportionately affects homeless veterans and those with prior cardiac issues
Pain considerations: Chest pain or discomfort associated with cardiac complications should be described separately from musculoskeletal shin pain to ensure the examiner captures all manifestations.
Rating criteria by percentage
100%
Active infection requiring ongoing treatment, or severe systemic involvement such as Bartonella endocarditis, persistent bacteremia, or disseminated disease with major organ involvement causing near-total occupational and social impairment
Key symptoms
- Recurrent or unremitting fever cycles
- Severe fatigue precluding all work activity
- Active endocarditis or bacteremia confirmed by lab
- Significant weight loss
- Splenomegaly with clinical significance
- Inability to perform activities of daily living
- Hospitalization required for management
From 38 CFR: Active disease with severe systemic impact; chronic relapsing course with major functional impairment across all areas of life
60%
Moderately severe systemic involvement with frequent relapses, significant fatigue, recurring febrile episodes, and substantial interference with occupational and daily functioning; or inactive disease with significant residual complications
Key symptoms
- Recurring fever episodes several times per month
- Persistent severe fatigue limiting work capacity
- Moderate to severe shin bone pain (tibialgia)
- Significant myalgia and headache
- Intermittent splenomegaly
- Partial response to treatment with ongoing symptoms
From 38 CFR: Moderately severe systemic disease with frequent relapses causing significant occupational and social impairment; residual conditions following active phase requiring continued medical management
30%
Moderate systemic involvement with intermittent symptoms, occasional fever relapses, fatigue that limits but does not preclude occupational functioning, and manageable residual symptoms
Key symptoms
- Intermittent fever episodes
- Moderate fatigue affecting productivity
- Occasional shin pain or myalgia
- Headaches occurring several times per week
- Mild to moderate impact on work and social activities
- Condition partially controlled with medication
From 38 CFR: Moderate disease course with intermittent flares and some occupational impact; partially controlled with treatment but not in complete remission
10%
Mild systemic involvement with infrequent symptoms, well-controlled or inactive disease with minimal residual effects, and minimal impact on occupational and daily functioning
Key symptoms
- Rare fever episodes
- Mild fatigue not significantly limiting activity
- Occasional mild headaches
- Minimal shin discomfort
- Condition stable and well-controlled
- No significant impact on daily activities or employment
From 38 CFR: Inactive disease with minimal residual symptoms; condition controlled and causing only mild functional limitation
Describing your symptoms accurately
Recurring Fever Episodes
How to describe it: Describe the pattern of febrile episodes accurately - their frequency (e.g., how many times per month), duration of each episode, peak temperature if measured, and what activities you cannot perform during an episode. Note whether fever is cyclical, relapsing, or continuous.
Example: On my worst days, I develop a fever of 102-103-F that lasts 4 to 5 days at a time, occurring two to three times per month. During these episodes I cannot stand, concentrate, or care for myself. I have missed multiple days of work and have had to rely on family members to manage household tasks.
Examiner listens for: Frequency and duration of febrile cycles, temperature measurements if documented, functional impact during fever episodes, requirement for medical intervention or hospitalization
Avoid: Saying 'I get fevers sometimes' without quantifying frequency and functional impact. Do not minimize the disability by focusing only on symptom-free periods.
Shin Bone Pain (Tibialgia) and Myalgia
How to describe it: Accurately describe the location, character (aching, sharp, burning), severity on a 0-10 scale, frequency, and what activities provoke or worsen the pain. Note whether it disrupts sleep, limits walking, standing, or other physical activity.
Example: On my worst days my shin pain is an 8 out of 10, deep and aching. It wakes me from sleep and I cannot walk more than half a block without stopping. I cannot stand for more than 10 minutes at my job, which has caused me to be passed over for assignments requiring time on my feet.
Examiner listens for: Pain character and severity, functional limitations from pain, impact on ambulation and occupational tasks, use of pain medications
Avoid: Saying 'my legs hurt a little' instead of quantifying the pain and its functional consequences. Do not forget to mention pain at its worst, not just on an average day.
Fatigue and Weakness
How to describe it: Describe fatigue as it actually limits your life - how many hours per day you can be functional, whether you require daytime rest, how fatigue affects your ability to maintain employment, complete household tasks, or participate in social activities. Be specific about what you cannot do that you used to do.
Example: On my worst days I cannot get out of bed before noon. Even on better days I am exhausted after 2-3 hours of light activity and must rest for the remainder of the day. I have had to reduce my work hours significantly and I cannot sustain full-time employment because of this fatigue.
Examiner listens for: Severity and constancy of fatigue, impact on work capacity and daily activities, whether fatigue is disproportionate to activity level, relationship between fatigue and fever cycles
Avoid: Saying 'I get tired' without describing the functional consequence. Do not assume the examiner understands how debilitating infectious disease-related fatigue is compared to normal tiredness.
Headaches
How to describe it: Describe headache frequency (daily, weekly, episodic), severity, duration, character (throbbing, pressure, diffuse), associated symptoms (light sensitivity, nausea), and impact on concentration and ability to work or perform tasks requiring mental focus.
Example: On my worst days I have severe, pounding headaches that last most of the day, making it impossible to concentrate on work tasks, look at screens, or tolerate normal household noise. I have had to leave work early or call out sick several times per month because of these headaches.
Examiner listens for: Frequency, duration, severity, functional impact, relationship to fever episodes, medication use and effectiveness
Avoid: Mentioning headaches only briefly or as an afterthought. Headaches are a cardinal symptom of Trench Fever and should be described in full detail.
Occupational and Social Functional Impact
How to describe it: The DBQ specifically asks about functional impact on occupational and daily activities. Prepare concrete examples: days missed from work, inability to perform specific job duties, loss of employment, inability to maintain relationships or social engagements, and dependence on others for daily tasks.
Example: Because of my recurrent fever, fatigue, and pain, I have missed approximately 3-4 days of work per month, been passed over for promotion requiring full physical capacity, and had to give up recreational activities I previously enjoyed. My condition has strained my relationships because I frequently cannot fulfill commitments.
Examiner listens for: Specific examples of occupational limitation, frequency of sick days or work absences, whether veteran can sustain full-time employment, impact on relationships and self-care
Avoid: Giving vague answers like 'it affects my work sometimes.' Provide specific, quantifiable examples of how the condition limits your functioning in concrete terms.
Treatment History and Medication Side Effects
How to describe it: Accurately describe all antibiotic treatments received (doxycycline, erythromycin, etc.), duration of treatment, whether symptoms resolved completely or only partially, any relapses after treatment cessation, and any side effects from long-term antibiotic use.
Example: I completed a full course of doxycycline but my symptoms only partially resolved. I continue to have recurring fever episodes and fatigue even after treatment, suggesting a chronic or relapsing course. The antibiotics caused gastrointestinal side effects that I continue to manage.
Examiner listens for: Completeness of treatment, response to treatment, residual symptoms post-treatment, evidence of relapsing course, ongoing medical management needs
Avoid: Saying 'I took antibiotics and got better' if you still have residual symptoms or relapses. Accurately characterize partial response and ongoing symptoms.
Common mistakes to avoid
Describing only current average symptoms, not worst-day severity
Why: VA rating is based on the full picture of disability, including worst-day presentations. Describing only mild or average days leads to underrating.
Do this instead: Per M21-1 guidance, explicitly describe your worst-day symptoms when asked about your condition. State clearly: 'On my worst days...' before describing peak severity.
Impact: All levels - particularly impacts whether 30% vs. 60% or 60% vs. 100% is assigned
Failing to mention all symptoms of Bartonellosis, focusing only on fever
Why: Trench Fever has multiple cardinal symptoms including shin pain, headache, fatigue, and splenomegaly. Failing to mention all symptoms results in an incomplete picture.
Do this instead: Prepare a written symptom list covering all manifestations: fever cycles, tibialgia, myalgia, headaches, fatigue, splenomegaly, and any cardiac complications. Mention each symptom to the examiner proactively.
Impact: 30% to 60% transition
Not bringing laboratory documentation to the exam
Why: The DBQ requires documentation of diagnostic testing including serologic testing, culture results, and PCR. If this evidence is not in your file or you do not bring it, the examiner cannot document it.
Do this instead: Compile all lab results - serologic titers, culture reports, PCR results, and any echocardiogram or imaging - and bring copies to the exam. Submit copies to your claims file prior to the exam.
Impact: All levels - impacts diagnosis confirmation and active vs. inactive determination
Accepting an 'inactive' classification without discussing residual symptoms
Why: If the examiner marks your condition as inactive, this may result in a lower rating unless residual symptoms are thoroughly documented.
Do this instead: Even if your disease is currently inactive, proactively describe all residual symptoms that persist after treatment - fatigue, intermittent pain, recurring episodes, functional limitations - so the examiner documents the full impact.
Impact: 10% to 30% transition
Not reporting occupational and social functional impact
Why: The DBQ specifically includes fields asking about the impact of infectious disease on occupational functioning and daily activities. Veterans who fail to connect their symptoms to functional loss receive ratings that do not reflect true disability.
Do this instead: Prepare specific examples of work absences, lost job opportunities, inability to maintain employment, and social limitations caused by your condition. Provide this information proactively if the examiner does not ask.
Impact: 60% to 100% transition
Assuming the examiner knows Bartonellosis is a relapsing condition
Why: Some general internists may be unfamiliar with the relapsing-remitting nature of Trench Fever. If the examiner sees you on a good day they may underestimate disability.
Do this instead: Bring a brief written summary of Bartonella quintana's clinical course, including its known relapsing nature. Reference any CDC or UpToDate clinical descriptions your physician has provided. Describe multiple episodes over time, not just current status.
Impact: 30% to 60% transition
Failing to disclose complications such as endocarditis or bacillary angiomatosis
Why: These complications may warrant separate service-connected ratings under different diagnostic codes in addition to the base Bartonellosis rating.
Do this instead: Disclose all complications related to Bartonella quintana infection, including any cardiac, skin, or lymph node involvement. Ask the examiner and your VSO whether separate claims for these conditions are appropriate.
Impact: Potentially impacts total combined rating significantly
Prep checklist
- critical
Compile all diagnostic laboratory records
Gather all serologic test results (IFA, ELISA), blood culture reports, PCR results, and any other diagnostic testing related to Bartonellosis. Organize chronologically with dates and facility names. Submit copies to your VA claims file before the exam date.
before exam
- critical
Obtain all treatment records including antibiotic history
Document every antibiotic regimen prescribed for Bartonellosis including drug name, dosage, duration, prescribing physician, and treatment response. Note any relapses after treatment cessation. Include both VA and private records.
before exam
- critical
Write a detailed symptom history and timeline
Create a written document covering: date of first symptoms, service location and conditions when exposed (e.g., body louse exposure in deployed setting), progression of symptoms over time, all relapse episodes with approximate dates, current symptom status, and functional impact. Bring this to the exam.
before exam
- recommended
Request a buddy statement or lay statement from family or coworkers
Ask someone who has witnessed your symptoms - a family member, coworker, or fellow veteran - to write a buddy statement describing what they observe about your condition, including fever episodes, inability to work or perform activities, and behavioral changes during symptomatic periods.
before exam
- recommended
Obtain a supporting letter from your treating physician
Ask your treating infectious disease specialist or primary care physician to write a letter confirming the diagnosis, describing the clinical course, and opining on the chronic or relapsing nature of your condition and its functional impact. This can help educate an examiner unfamiliar with Trench Fever.
before exam
- critical
Prepare a worst-day description for each major symptom
Write down your worst-day experience for each symptom category: fever (temperature, duration, frequency), shin pain (severity 0-10, what you cannot do), fatigue (hours functional, work impact), headaches (severity, duration, frequency), and overall functional status. Practice describing these clearly and concisely.
before exam
- critical
Review your service records for documented exposure
Locate any service treatment records documenting fever, body louse exposure, deployment to endemic areas, or treatment for Bartonellosis or related symptoms during service. Note the dates and units to establish an in-service incurrence nexus.
before exam
- recommended
Research your state's recording law
Determine whether your state permits one-party or two-party consent for recording. If permitted, inform the examiner at the start that you will be recording the examination. Bring a recording device (phone is sufficient).
before exam
- recommended
Confirm exam appointment details and examiner type
Verify the date, time, location, and examiner specialty. If the assigned examiner is not an infectious disease specialist or internal medicine physician, consider raising this concern with your VSO before the exam, as the DBQ requires appropriate medical expertise.
before exam
- recommended
Submit a pre-exam statement to your claims file
Write a statement in support of claim (VA Form 21-4138) summarizing your condition history, current symptoms, and functional impact. Submit via VA.gov or certified mail before your exam date so it is in your file when the examiner reviews evidence.
before exam
- critical
Arrive reflecting your actual current condition
Do not exaggerate or minimize. Come as you are on the day of the exam. If you are experiencing symptoms on exam day, note them clearly. If you happen to be having a relatively good day, explicitly tell the examiner: 'Today is a better day than average - my worst days are significantly more debilitating.'
day of
- critical
Bring all documentation in organized physical copies
Bring two sets of organized copies: one for the examiner to reference during the exam, one for your own records. Include lab results, treatment records, physician letters, buddy statements, and your written symptom timeline.
day of
- recommended
Bring a list of all current medications
Include every medication - prescription, over-the-counter, and supplements - related to your Bartonellosis management. Note dosages and frequency. This helps the examiner document ongoing treatment needs.
day of
- optional
Bring a trusted support person if needed
You may bring a family member, VSO representative, or advocate to the waiting area. In some cases they may be permitted in the exam room. Their presence can help you recall details and ensure you do not underreport.
day of
- critical
Do not minimize symptoms or apologize for your limitations
Veterans frequently downplay symptoms out of cultural conditioning. Describe your actual experience accurately. If asked 'how are you doing today?' respond honestly: describe your condition as it truly is, not as you wish it were.
during exam
- critical
Proactively address each symptom category even if not asked
If the examiner does not ask about a specific symptom (e.g., headaches, shin pain, fatigue), proactively mention it. Say: 'I also want to make sure you're aware that I experience...' The examiner can only document what is discussed.
during exam
- critical
Use worst-day language explicitly
When describing symptoms, use the phrase 'on my worst days' followed by your peak description. Then follow with 'on average days' for your typical experience. This ensures the DBQ captures the full range of your disability.
during exam
- critical
Describe functional impact in concrete, specific terms
Instead of 'it affects my work,' say 'I have missed an average of 3 to 4 days of work per month due to fever episodes, and I have not been able to apply for promotions requiring full physical capacity.' Specificity is more persuasive and ratable.
during exam
- recommended
Confirm the examiner documents the active vs. inactive determination
Ask the examiner to confirm whether they are marking your condition as active or inactive and what criteria they are using. If inactive, ensure residual symptoms are fully documented before the exam concludes.
during exam
- recommended
Ask the examiner to note all complications
If you have had endocarditis, bacillary angiomatosis, lymphadenopathy, or other complications of Bartonellosis, ensure these are mentioned during the exam so the examiner can document them under the additional diagnosis fields of the DBQ.
during exam
- critical
Request a copy of the completed DBQ
You are entitled to a copy of the C&P examination report. Request it through MyHealtheVet, the VA release of information office, or your VSO. Review it carefully for accuracy, completeness, and whether all symptoms and functional impacts were documented.
after exam
- recommended
File a rebuttal if the DBQ is inaccurate or incomplete
If the DBQ omits symptoms you described, mischaracterizes your condition, or fails to document functional impact, submit a written rebuttal to your Regional Office via VA Form 21-4138 or work with your VSO to request a new exam citing inadequacy.
after exam
- recommended
Follow up with your treating physician
Share the DBQ findings with your treating physician. If the examiner's conclusions differ from your treating physician's assessment, ask your physician to provide a supplemental opinion or nexus letter addressing the discrepancies.
after exam
- recommended
Track your symptoms in a log going forward
Begin or continue keeping a daily or weekly symptom diary documenting fever episodes, pain levels, fatigue severity, and functional limitations. This contemporaneous evidence is invaluable for future rating increases or appeals.
after exam
Your rights during a C&P exam
- You have the right to a thorough, adequate, and contemporaneous C&P examination. An inadequate exam - one that does not address all claimed symptoms, does not review your service records, or is performed by an unqualified examiner - can be challenged under 38 CFR 3.159(c)(4).
- You have the right to request and receive a copy of your completed C&P examination report (DBQ) through the VA release of information process or MyHealtheVet.
- You have the right to record your C&P examination in states that permit single-party consent recording. Confirm your state's law before the exam. Inform the examiner at the start that you are recording for your personal records.
- You have the right to submit a rebuttal if the C&P examination is found to be inadequate, inaccurate, or fails to address all symptoms you reported. Submit your rebuttal to your Regional Office in writing with supporting evidence.
- You have the right to submit a private independent medical opinion (IMO) or nexus letter from a qualified treating physician to rebut or supplement the C&P examiner's findings. Private physician opinions carry significant evidentiary weight.
- You have the right to have a VSO, attorney, or claims agent accompany you to the C&P examination. While they may not always be permitted inside the exam room, their presence provides support and accountability.
- You have the right to request a new C&P examination if you believe the original was inadequate or if your condition has materially worsened since the prior examination. A new exam can be requested when filing a supplemental claim or appeal.
- Under the PACT Act and prior presumptive provisions, certain veterans with documented service in specific theaters or under specific conditions may have enhanced rights regarding presumptive service connection for infectious diseases. Consult your VSO for applicability.
- You have the right to a fully favorable decision if the evidence is in equipoise (approximately equal for and against your claim). The benefit of the doubt doctrine under 38 CFR 3.102 requires the VA to resolve reasonable doubt in the veteran's favor.
- You have the right to appeal any rating decision through the Supplemental Claim lane, the Higher-Level Review lane, or the Board of Veterans' Appeals. Consulting a VSO or accredited claims agent before choosing an appeal lane is strongly recommended.
Related conditions
- Endocarditis (Bartonella-Associated) Bartonella quintana is one of the leading causes of culture-negative endocarditis. Veterans with Bartonellosis who develop cardiac valve involvement may be entitled to a separate service-connected rating under cardiac diagnostic codes in addition to DC 6306.
- Rheumatic Fever Rheumatic fever (rated under DC 6301) shares some symptom overlap with Bartonellosis including fever, joint pain, and cardiac involvement. Both conditions appear on the Infectious Diseases DBQ and should be distinguished or co-documented if both are present.
- Rickettsia, Ehrlichia, and Anaplasma Infections Rickettsial infections share vector-borne transmission mechanisms and some clinical features with Bartonellosis including fever, myalgia, and rash. Veterans exposed to arthropod vectors in deployed settings may have co-infection or differential diagnosis considerations between these conditions.
- Relapsing Fever Relapsing fever (rated separately on the Infectious Diseases DBQ) shares the characteristic relapsing-remitting fever pattern with Trench Fever, but is caused by Borrelia species transmitted by ticks or lice. Both conditions may co-occur in veterans exposed to body lice in field settings.
- Chronic Fatigue Syndrome (Myalgic Encephalomyelitis) Post-infectious fatigue following Bartonella quintana infection can resemble or meet criteria for ME/CFS. Veterans with persistent disabling fatigue following Bartonellosis treatment should discuss this diagnostic consideration with their treating physician as it may support a separate or increased rating.
- Bacillary Angiomatosis Bacillary angiomatosis is a vascular proliferative skin condition caused by Bartonella quintana or Bartonella henselae, most commonly occurring in immunocompromised individuals. Veterans with Bartonellosis who develop characteristic skin lesions should ensure this complication is documented and evaluated for separate rating consideration.
- Lymphadenopathy (Infectious) Persistent lymph node enlargement is a recognized manifestation of Bartonella infection. If chronic lymphadenopathy persists as a residual of service-connected Bartonellosis, it may support additional rating consideration under appropriate diagnostic codes.
Get a personalized prep packet
This guide covers what to expect for any veteran with this condition. If you have already uploaded your medical records, sign in to generate a packet that maps your specific symptoms to the DBQ fields your examiner will fill out.
This C&P exam preparation guide is for educational purposes only and does not constitute legal, medical, or claims advice. Always consult with a qualified Veterans Service Organization (VSO) representative or VA-accredited attorney for guidance specific to your claim. Never exaggerate, minimize, or fabricate symptoms during a C&P examination.