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Chronic Q Fever: A Rare Case of Endocarditis and Embolism FREE TO VIEW

Sharad Sharma, MD; Jen Wong, BS; Amy Ivanovic, MS; Faraz Baig, BS; Fariborz Rezai, MD; Kristin Fless, MD; Nirav Mistry, MD; Frantz Pierre-Louis, MD; Paul Yodice, MD
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Newark Beth Israel Medical Center, Newark, NJ

Chest. 2014;146(4_MeetingAbstracts):308A. doi:10.1378/chest.1991706
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SESSION TITLE: Critical Care Student/Resident Case Report Posters III

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Coxiella burnetii is the cause of Q fever, a zoonotic illness resembling influenza with pneumonia or hepatitis. Chronic disease develops in 1-5% of patients months to years after infection. Chronic Q fever has been challenging to diagnose due to the non-specific presentation but can lead to severe complications including heart failure. We describe a case of chronic Q fever endocarditis with embolic complications.

CASE PRESENTATION: A 57-year-old Latin American man presented with nausea, vomiting and headache and a three month history of fever, weight loss, and cough. Electrocardiogram showed a junctional escape rhythm. A prior chest radiograph showed pulmonary markings consistent with atypical pneumonia and a granuloma. MRI revealed a left superior cerebellar artery infarct with tonsillar migration for which the patient underwent placement of external ventricular drain and suboccipital decompression. Multiple laboratory abnormalities were noted including leukocytosis, thrombocytopenia, hyperbilirubinemia, elevated INR, cardiac enzymes and liver enzymes. Initial pan cultures were negative. Subsequent imaging revealed left femoral and bilateral gastric vein thrombosis that warranted heparin therapy and filter placement. The patient developed left hand and foot swelling which progressed to gangrenous changes. Echocardiography revealed an enlarged left ventricle with thrombus, left ventricular and right atrial filling defects, moderate mitral regurgitation, severe tricuspid regurgitation, and an ejection fraction of 20%. Serology revealed positive Q fever phase I IgM and phase II IgG titers. Treatment involved doxycycline and hydroxychloroquine.

DISCUSSION: Chronic Q fever typically develops in patients with underlying valvular damage or immunocompromise. Endocarditis is the most common clinical manifestation and is often fatal without treatment. Here we describe a patient who presented with several features of Q fever with subsequent embolic stroke. He had no ascertainable epidemiological basis for infection but developed both infarction and cyanosis of embolic origin. Embolic phenomena are rare but have been reported in advanced disease. C burnetii is diagnosed through serology. Phase II antigens predominate in acute infection whereas elevated phase I IgG titers are characteristic of chronic disease. Follow-up after infection promotes early detection of progression to chronic disease.

CONCLUSIONS: Delayed diagnosis of chronic Q fever results in significant morbidity and mortality. Therefore, the fitting clinical symptoms and serology must be pooled to form a diagnosis in cases where acute C burnetii remains undetected.

Reference #1: Raoult D, Marrie T. Q fever. Clin Infect Dis 1995;20:489-95.

Reference #2: Turck WP, Howitt G, Turnberg LA, et al. Chronic Q fever. Q J Med 1976;45:193-217.

Reference #3: Anderson A, Bijlmer H, Fournier PE, et al. Diagnosis and management of Q fever - United States, 2013: Recommendations from CDC and the Q fever working group. MMWR Recomm Rep. 2013;62:1-30.

DISCLOSURE: The following authors have nothing to disclose: Sharad Sharma, Jen Wong, Amy Ivanovic, Faraz Baig, Fariborz Rezai, Kristin Fless, Nirav Mistry, Frantz Pierre-Louis, Paul Yodice

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