Rickettsial infections and their clinical presentations in the Western Province of Sri Lanka: a hospital-based study.

BACKGROUND: Rickettsial infections are re-emerging. A study of the geographical distribution of rickettsial infections, their clinical manifestations, and their complications would facilitate early diagnosis. METHODS: Thirty-one selected patients from the Western Province of Sri Lanka were studied for rickettsial species, clinical manifestations, and complications. RESULTS: Of 31 patients with possible rickettsioses, 29 (94%) fell into the categories of confirmed, presumptive, or exposed cases of acute rickettsial infections (scrub typhus was diagnosed in 19 (66%), spotted fever group in eight (28%)). Early acute infection or past exposure was suggested in two (7%) cases; cross-reactivity of antigens or past exposure to one or more species was suggested in nine (31%). Seventeen out of 19 (89%) patients with scrub typhus had eschars. Nine out of 29 (32%) patients had a discrete erythematous papular rash: seven caused by spotted fever group, two by scrub typhus. Severe complications were pneumonitis in eight (28%), myocarditis in five (17%), deafness in four (14%), and tinnitus in two (7%). The mean duration of illness before onset of complications was 12.0 (SD 1.4) days. All patients except one made a good clinical recovery with doxycycline or a combination of doxycycline and chloramphenicol. CONCLUSIONS: In a region representing the low country wet zone of Sri Lanka, the main rickettsial agent seems to be Orientia tsutsugamushi. Delay in diagnosis may result in complications. All species responded well to current treatment.

Clinical and epidemiological features of hospitalized acute Q fever cases from Split-Dalmatia County (Croatia), 1985-2002.

BACKGROUND: Q fever shows a wide diversity of clinical manifestation. Q fever is endemic in northern Croatia, but the epidemiological and clinical characteristics of this disease in various ecological areas of southern Croatia are unclear. MATERIAL/METHODS: From January 1985 to December 2002, acute Q fever cases hospitalized at Split University Hospital were analyzed. Acute Q fever was defined as fever (>38 degrees C) with clinical findings in lung and/or liver verified by serologic testing with Coxiella burnetii phase II antigen. RESULTS: During the period of observation, 155 acute Q fever cases were hospitalized. The mean incidence of acute Q fever in the study region was 0.20/100,000/year (95%CI:0-0.78) in the coastal area and 4.64/100,000/year (95%CI:0.44-8.85) in the non-coastal areas, with a male predominance (chi2=60.0; p=0.0000) and a mean male to female ratio of 4.2:1. People of essentially all ages (4-76 years) were affected, the highest rate of infection being recorded in 20- to 49-year-old age groups. In contrast to adults, girls were more frequently affected than boys (2:1). No case of acute Q fever was recorded on any of the nearby islands. Clinically, acute Q fever most commonly presented with both pneumonia and hepatitis (60.0%), followed by pneumonia (25.8%), hepatitis (9.0%), and nonspecific febrile illnesses (5.2%). CONCLUSIONS: C. burnetii is endemic in rural, coastal, and non-coastal areas of southern Croatia and is associated with stock breeding. In these areas, Q fever occurs sporadically and epidemically. Males 20-49 years of age were the prevalent cases.

Acute Q fever pneumonia: a review of 80 hospitalized patients.

STUDY OBJECTIVES: To emphasize epidemiologic, clinical, or radiologic characteristics whose detection could lead to an early diagnosis and to enhance therapeutic efficacy. PATIENTS: Eighty hospitalized patients from 1982 to 1996. DESIGN: The diagnosis of Q fever infection was serologically confirmed in all the patients (phase II Coxiella burnetii antibody) using the complement fixation test and/or the indirect immunofluorescence antibody test. RESULTS: Patients from rural and urban areas were noted in the same proportion; however, the usual epidemiologic factors such as contact with cats or farm animals were found in 40% of the patients. Mean age+/-SD was 49+/-20 years, and there was a higher sex ratio of male to female patients (1:3.44). We found a specific seasonal distribution since 80% of the cases occurred between February and May. Delay before referring to hospital was 8.2+/-7.8 days, while 69.3% of the patients received an antibiotic treatment that was mainly penicillin or cephalosporin. The dominant clinical features were dry cough and high fever, as the maximal temperature reached more then 40 degrees C in 58% of the patients. Digestive symptoms were rare. WBC count remained within normal range in 80% of the cases with a low proportion of lymphocytes in half of the patients, and the sedimentation rate was usually elevated (55+/-34 mm). Altered liver function consisted more frequently in an elevated level of alkaline phosphatase (70% of the cases) than transaminases, while hyponatremia was frequently mentioned (28.2% of the patients). We found radiologic evidence of unique lobar or segmental alveolar opacity involving more likely the lower lobes in 55 patients, and multiple or interstitial opacities in the others. Chest radiographs were considered normal in eight patients. The clinical response was favorable in all the patients with a reduction in fever 4.8+/-3.9 days after the start of treatment with the second antibiotic that included mainly erythromycin or quinolones, and chest radiographs returned to normal in 81% of the patients within the first month.

Adenosine deaminase activity in the aetiological diagnosis of community-acquired pneumonia.

A prospective study was undertaken to assess the usefulness of serum adenosine deaminase (ADA) activity in the aetiological diagnosis of 75 patients (mean age 58 years) with community-acquired pneumonia who required hospitalization. Measurements of ADA were also carried out in 35 healthy subjects (mean age 52 years). The serum ADA activity in patients with typical bacterial pneumonia (TBP) was 21 +/- 7 IU/l and in controls 22 +/- 9 IU/l. In 43 patients with atypical pneumonia (AP), ADA levels (43 +/- 23 IU/l) were significantly higher than in the previously related groups (p < 0.001). Analysis within the group of atypical pneumonia showed significant differences for infections caused by Coxiella burnetii (61 +/- 19 IU/l, p < 0.001), Mycoplasma pneumoniae (44 +/- 26 IU/l, p < 0.001) and Legionella pneumophila (39 +/- 15 IU/l, p < 0.05), as compared with patients with bacterial pneumonia and normal control subjects. We conclude that serum ADA in patients with community-acquired pneumonia requiring hospitalization may provide useful additional diagnostic information on the aetiology of pulmonary infection.

[A Q-fever pneumonia epidemic in Dusseldorf]. / Eine Q-Fieber-Pneumonie-Epidemie in Düsseldorf.

There was an unusually high incidence of atypical pneumonias in the catchment area of the Rhine river near the university of Düsseldorf in July 1994 during a long period of hot and dry weather. The 18 patients described in this paper (5 women and 13 men) complained of sudden onset of fever up to over 40 degrees C, often associated with severe headache and dry cough. Almost all of these patients had previously been healthy and active and of young to middle age (average 38 years) without any bronchopulmonary anamnesis. Radiology revealed that all the patients had in most cases defined pulmonary infiltrates without any specific preference for a particular site. Serology was initially negative, but four weeks later the complement fixation reaction titre was positive for Coxiella burnetii antibodies in 14 patients (78%). All patients became symptom-free within a few days'time when treated with a combination of antibiotics which included doxycycline, whereas the infiltrates receded completely only after several weeks. The occurrence of pulmonary Q-fever in a large northern German conurbation had been rare at that time. Such epidemics, however, were also noted in Berlin (1992) and in Dortmund (1993). The epidemic reported in this article probably originated from one of the frequent flocks of sheep grazing along the banks of the Rhine river near Düsseldorf. The infections were probably acquired by inhalation of airborne organisms in infected aerosols derived from infected sheep, promoted by the long-term very hot and dry weather which was at the same time very windy, leading to an unusually extensive spreading of the pathogens throughout a very large infected aerosol area.

Q fever in the Greek Island of Crete: epidemiologic, clinical, and therapeutic data from 98 cases.

A retrospective study was undertaken in Crete, Greece, to investigate the epidemiologic, clinical, and therapeutic aspects of Q fever. Over a period of 5 years (1989-1993), 1,298 patients were examined and 98 cases were identified. Individuals who were aged 20-29 years and 30-39 years appeared to have an increased risk of infection. Contact with animals was found to be a major risk factor for acquisition of Q fever. The predominant clinical manifestations of the infection were fever (91.7% of patients) and respiratory disease (88.5%), whereas hepatitis was the dominant feature in only a minority (7.1%) of patients. Chest radiographs frequently revealed pulmonary interstitial changes (36.4% of patients) and alveolar changes (34.4%). Abnormal echocardiographic findings were also observed. There was no difference in the duration of fever whether the patient received therapy with tetracycline or erythromycin, a finding that may be explained by the delay in initiating tetracycline therapy.

Pneumonia and carcinoma of the lung.

In a prospective study of 1269 patients with community-acquired pneumonia, 25 (1.97%) were found to have carcinoma of the lung. In 23 cases, the diagnosis was confirmed histologically. For nine of the 23 patients, this episode of pneumonia was the initial manifestation of carcinoma of the lung. The diagnosis of carcinoma was first suggested by the radiologist as the result of a chest radiograph in five of the nine cases. One patient with bronchoalveolar cell carcinoma presented with rapidly progressive diffuse airspace disease. The diagnosis in this case was made by means of open lung biopsy. Two of the 25 patients (8%) had pneumonia caused by Coxiella burnetii, a rate that was 2.4 times higher than that for the other patients with pneumonia. We conclude that pneumonia is uncommonly the presenting manifestation of carcinoma of the lung but is usually evident before the patient leaves hospital. The rate of pneumonia caused by C. burnetii among patients with carcinoma of the lung seems to be higher than that among patients who have pneumonia without carcinoma of the lung.

[Acute respiratory insufficiency secondary to Coxiella burnetii pneumonia: a rare complication]. / Insuficiencia respiratoria aguda secundaria a neumonía por Coxiella burnetii: una complicación excepcional.

Acute respiratory failure secondary to Coxiella burnetii infection is an extremely rare but serious complication that usually has a good prognosis after appropriate treatment. We describe a female patient who developed acute respiratory failure secondary to Coxiella burnetii pneumonia requiring mechanical ventilation and antibiotic therapy.

Atypical pneumonias. Clinical and extrapulmonary features of Chlamydia, Mycoplasma, and Legionella infections.

Pneumonias caused by atypical organisms usually have extra-pulmonary features. Chlamydial pneumonia often starts with hoarseness and fever, and respiratory tract symptoms may not appear for days. Mycoplasmal pneumonia may manifest with ear pain and a nonproductive cough. Legionnaires' disease presents with high fevers and central nervous system and gastrointestinal abnormalities. Diagnosis of chlamydial infection is accomplished with serologic testing. Patients are unresponsive to erythromycin treatment and should be started on empirical doxycycline (Doryx, Vibramycin) therapy. The presence of cold agglutinins in the appropriate clinical setting permits a presumptive diagnosis of mycoplasmal infection. Clinical diagnosis of Legionella pneumonia may be made in patients with pneumonia who also have relative bradycardia with elevated serum transaminases or hypophosphatemia with gastrointestinal or central nervous system symptoms. Erythromycin is the mainstay of treatment of legionnaires' disease, but treatment failures have been reported. Doxycycline is less expensive, has a better safety profile, and is better tolerated than erythromycin.

Epidemiologic features and clinical presentation of acute Q fever in hospitalized patients: 323 French cases.

PURPOSE: To contribute to the knowledge of epidemiologic and clinical features of patients hospitalized with Q fever in France. METHODS: We conducted a retrospective analysis of 22,496 sera submitted between 1982 and 1990 to the French National Reference Center for Rickettsial Diseases (NRC). The diagnosis of acute Q fever was based on an IgG titer greater than or equal to 1:200 and an IgM titer greater than or equal to 1:25 against phase II Coxiella burnetii antigen on an indirect immunofluorescence test (IFA). Fifteen cases prior to 1985 were diagnosed on the basis of a complement fixation titer greater than or equal to 1:8. A serosurvey of blood donors from Marseille was also conducted in 1988 on 924 sera, using IFA with a cutoff titer of 1:25. RESULTS: The serosurvey conducted in 1988 showed a seroprevalence of 4.03%, without age or sex prediction. The incidence rate of acute Q fever detection at the NRC was 0.58 per 100,000 inhabitants over the 9-year period. Three hundred twenty-three clinical cases were diagnosed, rising from 1 in 1982 to 107 in 1990. In patients hospitalized for acute Q fever, there was a significantly higher sex ratio of males to females (2.3), which, coupled with the age distribution, indicated that elder males, who are overrepresented due to our recruitment bias, are more susceptible to C. burnetii infections. The mean age of the patients was 45.5 years, while the risk was increased in the 30 to 39 age group as well as in the 60 to 69 age group. Usual epidemiologic risk factors were found in 20.1% of the cases. Hepatitis (61.9%) was a more common clinical presentation in our patients with Q fever than pneumonia (45.8%). This might reflect differences in strains of C. burnetii or the biology of the host. However, French farmers and stock breeders commonly drink unpasteurized raw milk from their cattle, which might indicate a relationship between hepatitis and infection via the digestive tract. CONCLUSION: Our results indicate that many cases of acute Q fever are undiagnosed. A greater awareness of the disease and more extensive serologic testing of patients with symptoms compatible with Q fever may improve the situation.

Rapidly fatal Q-fever pneumonia in a patient with chronic granulomatous disease.

Acute Q-fever is a systemic illness which rarely has a fatal outcome. Fatal cases do occur with the chronic form of the disease and associated with endocarditis. This report presents the case of a fatal, acute Q-fever pneumonia in an 11-year-old patient with chronic granulomatous disease. Complement fixation antibody titer rose to 1:1,024 with positive IgM in immunofluorescence. Giemsa stained lung sections and indirect immunofluorescence demonstrated the microorganisms in the tissues. The Coxiella burnetii infection was probably contracted during a holiday trip to rural France. Despite the fact that the patient received a variety of antimicrobial agents with broad spectrum activity against bacteria and fungi, coverage for Q-fever, i.e. chloramphenicol or tetracyclines, was not included.

The radiological appearances of 'Q' fever pneumonia.

The chest film findings in a series of 21 cases of serologically proven 'Q' fever with radiological evidence of pneumonia were reviewed retrospectively. Segmental opacities which were slow to clear, often with loss of volume and sometimes lobar consolidation, were the most usual findings. Lesions were occasionally multiple and sometimes became rounded during resolution. The appearances were not considered sufficiently distinctive to allow the diagnosis to be made in the acute phase of the illness, although the appearance of round pneumonias which are slow to resolve should alert the radiologist to this possible diagnosis. The findings are discussed in relation to previously reported series.

Q fever encephalitis.

Encephalitis is a rare but documented complication of acute Q fever. We report here the case of a 48-year-old lady who presented with an acute illness characterised by influenza-like symptoms, pneumonia and neurological disturbance but in whom the serology was suggestive of chronic rather than acute Q fever.

[Treatment of pneumonia caused by Legionella, Mycoplasma, Chlamydiae and Rickettsia using ofloxacin]. / Traitement des pneumonies dues aux légionelles, mycoplasmes, Chlamydiae et rickettsies par l'ofloxacine.

To asses the efficacy and the safety of ofloxacin as therapy of pneumonia caused by intracellular pathogens, 35 patients were studied (26 male, 9 female, mean age: 52.5 +/- 16.6 years). Causative pathogens were Chlamydia psittaci (n = 13), Legionella pneumophila (n = 10), Mycoplasma pneumoniae (n = 7) and Coxiella burnetii (n = 5). Ofloxacin was administered orally in 32 cases (200 mg b.i.d. in 80% of cases) and by I.V. route in 3 cases. All patients were cured without any side effects. In conclusion, ofloxacin appears, in our study, as an efficient therapy for these pneumonias. It could be considered as a valuable alternative to other antimicrobial agents with intra-cellular activity.