Maternofetal consequences of Coxiella burnetii infection in pregnancy: a case series of two outbreaks.

BACKGROUND: A high complication rate of Q fever in pregnancy is described on the basis of a limited number of cases. All pregnant women with proven Q fever regardless of clinical symptoms should therefore receive long-term cotrimoxazole therapy. But cotrimoxazole as a folic acid antagonist may cause harm to the fetus. We therefore investigated the Q fever outbreaks, Soest in 2003 and Jena in 2005, to determine the maternofetal consequences of Coxiella burnetii infection contracted during pregnancy. METHODS: Different outbreak investigation strategies were employed at the two sides. Antibody screening was performed with an indirect immunofluorescence test. Medical history and clinical data were obtained and serological follow up performed at delivery. Available placental tissue, amniotic fluid and colostrum/milk were further investigated by polymerase chain reaction and by culture. RESULTS: 11 pregnant women from Soest (screening rate: 49%) and 82 pregnant women from Jena (screening rate: 27%) participated in the outbreak investigation. 11 pregnant women with an acute C. burnetii infection were diagnosed. Three women had symptomatic disease. Three women, who were infected in the first trimester, were put on long-term therapy. The remaining women received cotrimoxazole to a lesser extent (n=3), were treated with macrolides for three weeks (n=1) or after delivery (n=1), were given no treatment at all (n=2) or received antibiotics ineffective for Q fever (n=1). One woman and her foetus died of an underlying disease not related to Q fever. One woman delivered prematurely (35th week) and one child was born with syndactyly. We found no obvious association between C. burnetii infection and negative pregnancy outcome. CONCLUSIONS: Our data do not support the general recommendation of long-term cotrimoxazole treatment for Q fever infection in pregnancy. Pregnant women with symptomatic C. burnetii infections and with chronic Q fever should be treated. The risk-benefit ratio of treatment in these patients, however, remains uncertain. If cotrimoxazole is administered, folinic acid has to be added.

Central nervous system manifestations of Q fever responsive to steroids.

We report the clinical and radiological central nervous system manifestations of a 27-year-old man with Q fever who subsequently developed acute disseminated encephalomyelitis and showed a significant response to steroids. The patient presented with headache and fever and quickly progressed to develop acute respiratory failure and hepatitis. A prompt evaluation revealed positive serology for Q fever and doxycycline was initiated. Approximately 1 week into his illness he was noted to be profoundly weak. Neuroimaging with magnetic resonance imaging (MRI) revealed diffuse white matter T2/FLAIR hyperintensities, with evidence of restricted diffusion. He was given high-dose steroids for a presumed diagnosis of acute disseminated encephalomyelitis (ADEM) and within days he had both clinical and MRI improvement. In addition to well-described meningitis and encephalitis, Q fever may also be associated with diffuse CNS lesions that may be demyelinating inflammatory in pathophysiology, and therefore responsive to high-dose steroids.

Unusual causes of intrahepatic cholestatic liver disease.

We report five cases with unusual causes of intrahepatic cholestasis, including consumption of Teucrium polium (family Lamiaceae) in the form of tea, Stauffer's syndrome, treatment with tamoxifen citrate for breast cancer, infection with Coxiella Burnetii (acute Q fever), and infection with Brucella melitensis (acute brucellosis).

Q Fever pneumonia: are clarithromycin and moxifloxacin alternative treatments only?

Medical records of 77 patients with Q fever pneumonia that was serologically confirmed by enzyme-linked immunosorbent assay were studied to compare the clinical efficacy of doxycycline, clarithromycin, and moxifloxacin. The mean times to defervescence were 2.4 days for those receiving doxycycline, 1.9 days for those receiving clarithromycin, and 2.2 days for those receiving moxifloxacin. There were no interruptions of the regimens in any groups because of side effects, and outcome was favorable in all patients with no complications or relapses during follow-up. This efficacy of clarithromycin and moxifloxacin, together with their safety profiles, suggest that these alternative agents in the treatment of Q fever pneumonia could also be used as the first-line therapy.

Steroids treatment of granulomatous hepatitis complicating Coxiella burnetii acute infection.

Granulomatous hepatitis associated with Coxiella burnetii acute infection has an adverse clinical course in some patients. Surprisingly, it does not respond to antibiotic but to steroids treatment. A hypersensitivity mechanism has been implicated. A case of granulomatous hepatitis complicating C. burnetii acute infection is reported, which was refractory to antibiotics but, as in four other cases previously reported, showed a complete response to steroids. This case was found to support findings that moderate doses of steroids can be useful in patients with granulomatous hepatitis complicating C. burnetii infection and showing no response to antibiotic treatment.