Acute Q fever in individuals with acute febrile illness & exposure to farm animals: Clinical manifestations & diagnostic approaches.

Background & objectives Q fever is an important zoonotic disease affecting humans as well as animals. The objective of this study was to assess the burden of Q fever in individuals with acute febrile illness, particularly those in close contact with animals. Various diagnostic methods were also evaluated in addition to clinical examination analysis and associated risk factors. Methods Individuals presenting with acute febrile illness who had animal exposure were enrolled (n=92) in this study. Serum samples were tested using IgG and IgM phase 2 enzyme linked immunosorbent assay (ELISA) and immunofluorescence assay (IFA). The PCR targeting the com1 and IS1111 genes was performed on blood samples. PCR amplicons were sequenced and phylogenetically analysed. Demographic data, symptoms, and risk factors were collected through a structured questionnaire. Results Among individuals with acute febrile illness, 34.7 per cent (32 out of 92) were found to be infected with Coxiella burnetii. PCR exhibited the highest sensitivity among the diagnostic methods employed. The most common clinical manifestations included headache, chills, arthralgia, and fatigue. Individuals engaged in daily livestock-rearing activities were found to be at an increased risk of infection. Interpretation & conclusions Q fever is underdiagnosed due to its varied clinical presentations, diagnostic complexities, and lack of awareness. This study underscores the importance of regular screening for Q fever in individuals with acute febrile illness, particularly those with animal exposure. Early diagnosis and increased awareness among healthcare professionals are essential for the timely management and prevention of chronic complications associated with Q fever.

Case report: membranoproliferative glomerulonephritis associated with Q fever causing chronic endocarditis.

BACKGROUND: Membranoproliferative glomerulonephritis is a rare entity which can be a result from autoimmune diseases, caused by various medications and infections. CASE PRESENTATION: We herein present the case of a 62-year-old male patient who presented with fatigue and was found to have severe anemia, impaired renal function, and nephrotic syndrome. A renal biopsy revealed membranoproliferative glomerulonephritis (MPGN) of the immune complex type with activation of the classical complement pathway. Further investigations led to the diagnosis of a chronic Coxiella burnetii-infection (Q fever), likely acquired during cycling trips in a region known for intensive sheep farming. Additionally, the patient was found to have a post endocarditic destructive bicuspid aortic valve caused by this pathogen. Treatment with hydroxychloroquine and doxycycline was administered for a duration of 24 months. The aortic valve was replaced successfully and the patient recovered completely. CONCLUSIONS: Early detection and targeted treatment of this life-threatening disease is crucial for complete recovery of the patient.

Bivalvular Endocarditis Due to Polymicrobial Coinfection with Enterococcus faecalis and Coxiella burnetii: A Case Report and Review of the Literature.

Polymicrobial endocarditis is uncommon, and polymicrobial endocarditis in combination with Coxiella burnetii is very rare. We herein describe an extremely rare case of polymicrobial bivalvular endocarditis due to coinfection with Enterococcus faecalis and Coxiella burnetii in a 62-year-old male patient, and extensively review the relevant medical literature. To the best of our knowledge, only three similar cases have been previously reported. Q fever is a worldwide endemic bacterial zoonosis, but it and its most common chronic complication, endocarditis, are still underestimated and underdiagnosed worldwide. This situation reflects the paucity of reported cases of polymicrobial endocarditis in combination with Coxiella burnetii. Clinical presentation of Q fever endocarditis is highly nonspecific, and diagnosis may be delayed or missed, leading to severe and potentially fatal disease. Our case and the previously reported similar cases emphasize the need for further evaluation of infective endocarditis due to Coxiella burnetii, in all cases of culture-negative endocarditis, and in prolonged oligo-symptomatic inflammatory syndrome, particularly in the presence of valvular heart disease. This approach should be applied even when typical pathogens are isolated, especially in endemic areas of Q fever, and with atypical presentation.

[Dyspnea with multiple bilateral lung opacities on CT scan].

A 58-year-old man was admitted with a typical presentation of acute left heart failure. However, the patient showed a partial response to the anti-heart failure therapy. Following admission, a continuous fever was monitored, and a CT scan revealed that multiple opacities on bilateral lungs had progressed. Bronchoscopy was performed, and Coxiella burnetii was detected by Metagenomic next-generation sequencing (mNGS) in bronchoalveolar lavage (BALF), and transbronchial lung biopsy showed organizing pneumonia. Considering that the patient had a history of rabbit breeding and delivery, with some newborn rabbits dying before he became ill, organizing pneumonia secondary to Q fever pneumonia was diagnosed. Anti-Q fever treatment was initiated and the patient's temperature returned to normal. Glucocorticoid was administered after adequate treatment for Q fever. The patient's symptom of dyspnea relieved soon and opacities on CT scan were absorbed remarkably. The final diagnosis was organizing pneumonia secondary to Q fever pneumonia accompanied with left heart failure.

Increased recognition of Q fever aortitis as a chronic manifestation of Q fever in tropical North Queensland, Australia.

Aortitis is a life-threatening, manifestation of chronic Q fever. We report a series of 5 patients with Q fever aortitis who have presented to our hospital in tropical Australia since 2019. All diagnoses were confirmed with polymerase chain reaction (PCR) testing of aortic tissue. Only one had a previous diagnosis of acute Q fever, and none had classical high-risk exposures that might increase clinical suspicion for the infection. All patients underwent surgery: one died and 3 had significant complications. Q fever aortitis may be underdiagnosed; clinicians should consider testing for Coxiella burnetii in people with aortic pathology in endemic areas.

Long-term health outcomes of Q-fever fatigue syndrome patients.

This study determined long-term health outcomes (≥10 years) of Q-fever fatigue syndrome (QFS). Long-term complaints, health-related quality of life (HRQL), health status, energy level, fatigue, post-exertional malaise, anxiety, and depression were assessed. Outcomes and determinants were studied for the total sample and compared among age subgroups: young (<40years), middle-aged (≥40-<65years), and older (≥65years) patients. 368 QFS patients were included. Participants reported a median number of 12.0 long-term complaints. Their HRQL (median EQ-5D-5L index: 0.63) and health status (median EQ-VAS: 50.0) were low, their level of fatigue was high, and many experienced post-exertional malaise complaints (98.9%). Young and middle-aged patients reported worse health outcomes compared with older patients, with both groups reporting a significantly worse health status, higher fatigue levels and anxiety, and more post-exertional malaise complaints and middle-aged patients having a lower HRQL and a higher depression risk. Multivariate regression analyses confirmed that older age is associated with better outcomes, except for the number of health complaints. QFS has thus a considerable impact on patients' health more than 10 years after infection. Young and middle-aged patients experience more long-term health consequences compared with older patients. Tailored health care is recommended to provide optimalcare for each QFS patient.

Organizing Pneumonia Secondary to Infection with Coxiella Burnetii: a Case Report.

BACKGROUND: Organizing pneumonia is a non-specific inflammatory response to various types of damage to the lungs. It is usually considered bacterial pneumonia that has not been absorbed for more than 4 weeks, accompanied by granulomas and fibrosis. Lung lesions in patients with organizing pneumonia are usually irreversible and the prognosis is relatively poor. Coxiella burnetii can cause Q fever. Acute Q fever usually presents as a self-limiting febrile illness with a good prognosis, but there are few cases of coexisting organizing pneumonia. We report a case of organizing pneumonia secondary to Coxiella burnetii infection. METHODS: Percutaneous lung biopsy, Next-generation sequencing (NGS). RESULTS: Percutaneous lung biopsy showed the existence of organizing pneumonia, and external examination of NGS showed the existence of Coxiella burnetii infection. After symptomatic treatment with azithromycin and glucocorticoids, the patient improved and was discharged from the hospital. CONCLUSIONS: For lesions with obvious heterogeneous enhancement on chest CT imaging, percutaneous lung biopsy or bronchoscopy should be performed promptly to obtain pathological tissue, and NGS should be used for definite diagnosis if necessary.

[Q Fever Endocarditis-Associated Immune Complex-Mediated Proliferative Glomerulonephritis: Fourth Case from Türkiye]. / Q Atesi Endokarditi Iliskili Immün Kompleks Aracili Proliferatif Glomerülonefrit: Türkiye'den Dördüncü Olgu.

Q fever is a zoonosis caused by the intracellular gram-negative bacterium Coxiella burnetii. Infection can be asymptomatic, acute or can cause chronic disease. Chronic disease often presents with infective endocarditis (IE). Diagnosis of IE is difficult because the agent does not grow easily in standard blood cultures and valve vegetations are difficult to detect. Glomerular involvement in patients with Q fever endocarditis is limited to the case reports. In addition, a total of three cases of Q fever endocarditis from Türkiye have been published so far. In this case report, a fourth case of Q fever endocarditis from Türkiye accompanied by immune complex-mediated glomerulonephritis was presented. A 35-year-old male patient with a history of mitral and aortic heart valve replacement was admitted with complaints of fever, night sweats and involuntary weight loss. Cervical lymphadenopathy and hepatosplenomegaly were found during the examination. Laboratory investigations revealed anemia inflammation, acute kidney injury (AKI), hematuria and proteinuria. While no causative agent was detected in blood and urine cultures, no diagnosis could be made as a result of bone marrow and cervical lymph node biopsies.Transesophageal echocardiography was performed for the etiology of fever and revealed 7 mm vegetation on the prosthetic mitral valve. C.burnetii phase 1 IgG tested with indirect immunofluorescent antibody method was reported positive at 1/16384 titer and doxycycline and hydroxychloroquine treatments were initiated. Kidney biopsy for the etiology of AKI revealed focal segmental endocapillary proliferative glomerulonephritis with C3, C1q and IgM immunocomplex deposition. After the addition of methylprednisolone to the treatment, the patient's symptoms improved and creatinine and proteinuria levels decreased dramatically. Although Q fever is endemic in our country, it is detected in fewer numbers than expected. In addition to the difficulties in microbiological and clinical diagnosis, the low awareness of physicians about the disease is one of the important reasons for this situation. When the disease comes to mind, the diagnosis can be easily reached by serological methods. Therefore, Q fever should be investigated in the presence of lymphoproliferative disease-like findings fever of unknown origin and culture-negative endocarditis.

Giant cell arteritis associated with acute Q fever - A case report.

Q fever is a worldwide spread zoonotic disease, caused by the gram-negative intracellular bacillus Coxiella burnetii. Apart from its most common manifestations, Q fever has been reported to occasionally mimic autoimmune diseases. We herein present a case of acute Q fever in a 69-year-old man, manifesting as prolonged fever with pneumonitis, in whom biopsy of the temporal artery revealed giant cell arteritis. Moreover, PCR testing of the biopsy specimen was positive for Coxiella burnetii, thus further supporting the possibly infectious etiology of some cases of biopsy proven giant cell arteritis, with implications for treatment.

Multiple mononeuritis with peripheral blood eosinophilia in a patient with Q fever: An unusual presentation: Case report and review of the literature.

Coxiella burnetii is a gram-negative bacterium that typically lives and multiplies within monocytes and macrophages of the host, being the etiologic agent of the zoonosis Q fever. Q fever is usually divided into acute and chronic forms, with a significant percentage of patients being asymptomatic. In the wide spectrum of the disease, neurological involvement seems to be extremely rare and peripheral neuropathy presenting with mononeuritis multiplex is one of the possible presentations with low rates of occurrence. Hereby, we present an unusual case of a 55-year-old male with fever and multiple mononeuritis attributed to Q fever and we summarize a short review of C. burnetii infection.

A systematic review on the health outcomes associated with non-endocarditis manifestations of chronic Q fever.

The aim of this study was to systematically review the non-endocarditis manifestations of chronic Q fever and understand the significance of non-specific symptoms like pain and fatigue in chronic endovascular, osteomyelitis and abscess due to chronic Q fever. We performed a systematic review using Pub Med (the National Library of Medicine (NLM)) and Scopus databases. All studies in English on chronic Q fever that listed clinical manifestations other than infective endocarditis (IE) and chronic fatigue syndrome (CFS). Meta-analysis was carried out to investigate the effects of patient's health outcomes (pain, fatigue, the need for surgery and mortality) on vascular infections, osteomyelitis and abscess. Among cases not presenting as IE or CFS, vascular infections and osteomyelitis were the most common chronic Q fever disease manifestations. There were distinct regional patterns of disease. Compared with infective endocarditis, these are significantly associated with increased risk of pain: osteomyelitis (relative risk (RR) = 4.13, 95% confidence interval (CI) 3.36-5.07), abscess (RR = 3.59, 95% CI 3.28-3.93) and vascular infection (RR = 2.46, 95% CI 1.99-3.03). The strongest significant association was observed between osteomyelitis and pain. There was no significant association between fatigue and these manifestations. Clinicians have to be aware of uncommon manifestations of chronic Q fever as they present with non-specific symptoms and are significantly associated with increased risk of morbidity and mortality. The findings emphasise the need to investigate patients with positive chronic Q fever serology presenting with acute or chronic pain for possible underlying complications.

Objective cognitive performance and subjective complaints in patients with chronic Q fever or Q fever fatigue syndrome.

BACKGROUND: Primary aim of this study was to compare cognitive performance of patients with chronic Q fever or Q fever fatigue syndrome (QFS) to matched controls from the general population, while taking performance validity into account. Second, we investigated whether objective cognitive performance was related to subjective cognitive complaints or psychological wellbeing. METHODS: Cognitive functioning was assessed with a neuropsychological test battery measuring the domains of processing speed, episodic memory, working memory and executive functioning. Tests for performance validity and premorbid intelligence were also included. Validated questionnaires were administered to assess self-reported fatigue, depressive symptoms and cognitive complaints. RESULTS: In total, 30 patients with chronic Q fever, 32 with QFS and 35 controls were included. A high percentage of chronic Q fever patients showed poor performance validity (38%) compared to controls (14%, p = 0.066). After exclusion of participants showing poor performance validity, no significant differences between patients and controls were found in the cognitive domains. QFS patients reported a high level of cognitive complaints compared to controls (41.2 vs 30.4, p = 0.023). Cognitive complaints were not significantly related to cognitive performance in any of the domains for this patient group. CONCLUSIONS: The high level of self-reported cognitive complaints in QFS patients does not indicate cognitive impairment. A large proportion of the chronic Q fever patients showed suboptimal mental effort during neuropsychological assessment. More research into the underlying explanations is needed. Our findings stress the importance of assessing cognitive functioning by neuropsychological examination including performance validity, rather than only measuring subjective cognitive complaints.

Severe acute Q fever pneumonia complicated by presumed persistent localized Q fever endocarditis in a renal transplant recipient: A case report and review of the literature.

Q fever in solid organ transplant (SOT) recipients is rarely described in the medical literature. We present a case of severe acute Q fever pneumonia that evolved into persistent localized Q fever endocarditis in a renal transplant recipient.

Q fever as a rare cause of hemophagocytic lymphohistiocytosis: Case report.

Hemophagocytic Lymphohistiocytosis (HLH) is a reactive disorder of the mononuclear phagocytic system characterized by increased histiocytic proliferation, activation and hemaphagocytosis. The underlying etiology may be genetic (primary) or acquired (secondary). Secondary causes include drugs, autoimmune diseases, malignancies and infections of which EBV is the most common. A 28-year old male patient who was a shepherd with no known concomitant comorbid disease was admitted to the Emergency Department with the complaints of abdominal pain, fever, severe fatigue. Physical examination revealed high fever, hepatosplenomegaly and laboratory examination revealed pancytopenia, hyperferritinemia and hypertriglyceridemia. Hemophagocytes were observed in the bone marrow biopsy and the patient was diagnosed as HLH. The patient was treated with cyclosporine A, dexamethasone, intravenous immunoglobulin (IvIg) and etoposide according to the HLH 2004 protocol. Coxiella burnetii was detected in the serological evaluation of the etiology and doxycycline was added to the current treatment. Fever was controlled in the second week of the treatment and the patient was discharged after complete recovery of the cytopenia in the fourth week. In the outpatient setting, treatment was completed in 8 weeks and follow-up of the patient is still ongoing without medication. To the best of our knowledge, this is the first case from Turkey of HLH secondary to Q-fever which was treated and managed successfully. Since the mortality of HLH is quite high, the etiology should be determined as soon as possible to be able to provide appropriate treatment.

Chronic Q fever associated with systemic sclerosis.

BACKGROUND: After the Q fever outbreak in the Netherlands between 2007 and 2010, more than 300 patients with chronic Q fever have been identified. Some patients were also diagnosed with systemic sclerosis, a rare immune-mediated disease. We aimed to increase awareness of concomitant chronic Q fever infection and systemic sclerosis and to give insight into the course of systemic sclerosis during persistent Q fever infection. MATERIALS AND METHODS: Chronic Q fever patients were identified after the Dutch Q fever outbreak in 2007-2010. Systemic sclerosis was diagnosed by a scleroderma expert and patients fulfilled the 2013 Classification Criteria for Systemic Sclerosis. RESULTS: Four cases presented with chronic Q fever, persistent Coxiella burnetii infection, shortly preceded or followed by the diagnosis of limited cutaneous systemic sclerosis. The three male patients of 60 years or older developed a relatively mild systemic sclerosis, which did not require immunosuppressive therapy during adequate treatment of the chronic Q fever infection. The 58-year-old female patient used immunosuppressives for her newly diagnosed systemic sclerosis at the time she likely developed a chronic Q fever infection. CONCLUSIONS: In this case series, chronic Q fever preceding systemic sclerosis was associated with a mild course of systemic sclerosis without the necessity of immunosuppressive drugs, while chronic Q fever development due to immunocompromised state was associated with a more deteriorating course of systemic sclerosis.

Acute kidney injury in acute Q fever.

Coxiella burnetii infection is not known to involve directly the kidneys. Kidney injury associated with Q fever usually manifests in the setting of chronic infection or endocarditis with development of immune complex deposition. Acute kidney injury (AKI) in the context of acute Q fever infection may be more pathologically heterogeneous. We describe two cases of severe AKI secondary to acute Q fever infection, each with marked differences in pathological characteristics, and clinical course.

Detection of the presence of Coxiella burnetii in a case of goat abortion: a first report from India.

Abortion is a major cause of economic loss to the goat industry. Coxiella burnetii the causative agent of Q fever is an important zoonotic agent known to be prevalent worldwide. In the present investigation, we detected the presence of Coxiella burnetii by the modified Ziehl Neelsen method of staining and its DNA by trans-PCR assay in the placenta obtained from the aborted goat. We also ruled out other common causes of abortion in this case. Based on a literature survey, this is the first report on the direct detection of Coxiella burnetii from an aborted goat to be reported from India.

A travel-loving woman in her eighties with lower back pain and weight loss. / En reiseglad 80-åring med ryggsmerter og vekttap.

BACKGROUND: This case report presents one of the first documented incidents of chronic Q-fever (C. burnetii) in Norway. A comprehensive workup resulted in an unexpected finding. CASE PRESENTATION: A Norwegian woman in her eighties presented to a district general hospital with lower back pain, decreased general condition and weight loss. Computer tomography (CT) revealed a large thoracic aortic aneurysm presumed to be of mycotic origin, and later magnetic resonance imaging (MRI) scans revealed osteomyelitis in the surrounding vertebrae. Conventional diagnostic workup did not identify the causative agent. After more than 6 months of different examinations, surgery, exhausting invasive procedures and antimicrobial treatment, we were ultimately successful in determining the microbial cause of chronic mycotic aneurism and osteomyelitis to be C. Burnetii (Q-fever) through serological and PCR analysis. INTERPRETATION: An increasing proportion of the population in all age groups travel abroad, and clinicians should be aware of the increasing incidence of imported infectious diseases. Obtaining a thorough medical history is still an important tool in the diagnostic process.

Should Acute Q-Fever Patients be Screened for Valvulopathy to Prevent Endocarditis?

Background: Echocardiographic screening of acute Q-fever patients and antibiotic prophylaxis for patients with cardiac valvulopathy is considered an important approach to prevent chronic Q-fever-related endocarditis. During a large Q-fever epidemic in the Netherlands, routine screening echocardiography was discontinued, raising controversy in the international literature. We followed a cohort of acute Q-fever patients to estimate the risk for developing chronic Q-fever, and we evaluated the impact of screening in patients who were not yet known to have a valvulopathy. Methods: The study population consisted of patients diagnosed with acute Q-fever in 2007 and 2008. We retrospectively reviewed all screening echocardiographs and checked for development of chronic Q-fever 8 years after the acute episode. Risks of developing chronic Q-fever in relation to the presence or absence of valvulopathy were analyzed with logistic regression. Results: The cohort included 509 patients, of whom 306 received echocardiographic screening. There was no significant difference (P-value = .22) in occurrence of chronic Q-fever between patients with a newly detected valvulopathy (2/84, 2.4%) and those with no valvulopathy (12/202, 5.9%). Two patients with a newly detected valvulopathy, who did not receive antibiotic prophylaxis, developed chronic Q-fever at a later stage. Conclusions: We found no difference in outcome between patients with and without a valvulopathy newly detected by echocardiographic screening. In retrospect, the 2 above-mentioned patients could have benefitted from antibiotic prophylaxis, but its omission must be weighed against the unnecessary large-scale and long-term use of antibiotics that would have resulted from universal echocardiographic screening.