Chest Infections: Fellow Case Report Poster - Chest Infections II |

Q Fever Endocarditis FREE TO VIEW

Yue Lu, MD; Keren Fogelfeld, MD; Dennis Yick, MD
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Cedars-Sinai Medical Center, Los Angeles, CA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):126A. doi:10.1016/j.chest.2016.08.135
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SESSION TITLE: Fellow Case Report Poster - Chest Infections II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Q fever endocarditis is a rare diagnosis. In patients with fevers of unknown origin and with history of exposure to farm animals as an outpatient.

CASE PRESENTATION: 51 male with history of epidermolysis bullosa acquista with SOB, sharp substernal CP and DOE for 1 month. He was febrile at 38oC, HR=40, BP=11/89. O2 sat=96% on 100% NRB. His CXR showed dense R consolidation and cardiomegaly. ECHO showed EF<10% with an LV thrombus. Pt was started on heparin drip, aspirin, plavix, Lasix, ceftriaxone, azithromycin and vancomycin. Pt was intubated and a PA catheter was inserted to distinguish between cardiogenic vs septic shock. CO=5.83, CI=3.29, PAPm=30, PAWP=18, SVR=850, PVR=165 which are numbers supporting septic shock. CT scan showed dense consolidation of bilateral lower lobes with a left sided pleural effusion. Pt continued to spike temperatures, his antibiotics was changed to cefepime and flagyl. On day 5, thoracentesis was done showing clear yellow transudative fluid. On day 6, he got a ET tube mucus plug and had a tube exchange and bronchoscopy with BAL which grew out aspergillus. He was started on voriconazole. On day 13, ID recommended sending Q fever serologies, bartonella, hensilae, toxocoara, leptospira, paracocci, cocci, Chagas, Brucella given exposure to farm animals. On day 16, pt started on doxycycline and levaquin for positive Q fever titers, he had titers rechecked and Q fever PCR checked prior to starting doxycycline. On day 21, TEE done for constant fevers which showed a possible AV vegetation vs infected LV thrombus (Image 1). On day 16, his Q fever titers increased four fold and PCR was positive and he was diagnosed with Q fever endocarditis (Table 1).

DISCUSSION: Q fever is caused by Coxiella burnetti, a small gram negative intracellular bacteria acquired from exposure to cattle or goat. Pt met the criteria for acute Q fever infection and he had high IgG level and a positive anticardiolipin which is associated with endocarditis (1). Although his IgG phase I antibiotics were not detected, his positive IgM titers, positive PCR and AV vegetation also meet diagnositic critieria for Q fever endocarditis (2).

CONCLUSIONS: With persistent fevers in patient with pneumonia exposed to farm animals, Q fever endocarditis should be considered.

Reference #1: Million M, et al. Immunoglobulin G Anticardiolipid Abs and Progression to Q fever endocarditis. Clinical Infectious Disease. 2013:57.

Reference #2: Anderson A, et al. Recommendations from the CDC and Q fever working troup. MMWR; 3/29/13: Vol 6: No 3.

DISCLOSURE: The following authors have nothing to disclose: Yue Lu, Keren Fogelfeld, Dennis Yick

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