A 37‐year‐old man with no significant PMH was admitted for evaluation of a 3‐week history of high fevers, fatigue, decreased appetite, and flulike symptoms. As an outpatient, he had been seen by his primary care physician many times and on the last visit was started on Zithromax and Omnicef for persistent fevers. On physical examination, the patient had a fever of 103°F and mild tenderness in the right upper quadrant. His occupational history revealed he had been directly handling newborn goats and other livestock for the last few months. Labs demonstrated a white blood cell count of 15.6 K, T. Bili of 4.3, AP of 274, SGOT of 172, and SGPT of 309. The results of an infectious workup including CXR, hepatitis panel, EBV serology, CMV antigenemia, and blood cultures were negative. An abdominal CT scan showed nonspecific splenic infarcts. Transthoracic and transesophageal echocardiograms did not show any vegetation. Because Q fever was suspected, the appropriate serology was sent, and patient was started on doxycycline empirically. Over the next 3 days, the patient's fever defervesced, and he was discharged. On outpatient follow‐up, serology testing for Q fever was markedly positive, with phase II IgM at 1:1024 and phase II IgG mildly elevated at 1:64, confirming the diagnosis of acute Q fever hepatitis. The patient continued to do well after completion of his course of doxycycline.
Q fever is a zoonotic disease caused by Coxiella burnetii, whose primary reservoirs are cattle, sheep, and goats. Coxiella is excreted in milk, urine, feces, placenta, and amniotic fluid during the parturition of infected animals. Q fever is the only rickettsial infection acquired by aerosol inhalation. The incubation period of Q fever is 1‐3 weeks. Only half of all infected patients show signs and symptoms of clinical illness. Common clinical manifestations include self‐limited febrile illness, pneumonia, and hepatitis. In the United States, 61.9% of all cases of Q fever manifest as hepatitis. Physical examination can often be unremarkable. Laboratory data may show leukocytosis, throm‐bocytopenia and elevated LFTs. The radiographic picture of Q fever pneumonia is variable. Exposure history, unexplained fevers, atypical pneumonia, and elevated LFTs can be clues to the diagnosis. Confirming a diagnosis of Q fever requires serologic testing to detect antibodies to Coxiella burnetii antigens. Elevated IgM antibody to phase II antigen and/or a 4‐fold rise in phase II IgG titers between acute and convalescent serum samples is diagnostic for acute Q fever. The treatment for acute Q fever is doxycycline for 2‐3 weeks. The mortality rate of acute Q fever is about 2%. Chronic Q fever is uncommon and most commonly presents as culture‐negative endocarditis.
Hospitalists are often the first health care professionals to encounter patients with fever of uncertain etiology. A detailed history with attention to occupational and exposure history can lead to consideration of Q fever and help to guide the workup and treatment.
A. Khurana, None; W. W. Hoffman, None; N. Vinayek, None.
To cite this abstract:Khurana A, Hoffman W, Vinayek N. Query Fever. Abstract published at Hospital Medicine 2007, May 23-25, Dallas, Texas Abstract 130. Journal of Hospital Medicine. 2007; 2 (suppl 2). https://www.shmabstracts.com/abstract/query-fever/. Accessed June 18, 2019.