Severe case of acute Q fever
23 February 2017 (online)
Q fever (Coxiella burnetii) case report: multiorgan failure, attended at Intensive Care. Broad spectrum antibiotic was initially used without clinical response. Serological tests and molecular technologies were essential to diagnose, right treatment and proper management.
Male of 46 years, without medical history of interest. He lives in rural environment (farm animal contact), but works in an office. He was attended in Primary Care with 1 week symptoms: influenzalike febrile illness and severe asthenia. Without clinical improvement, patient went to Emergency Room and was admitted at Internal Medicine Department, where antibiotic treatment was set (ceftriaxone). After 6 days the patient got worse (initially he needed oxygen through nasal cannula, progressing to high flow mask) and was transferred to Intensive Care with multiorgan failure: hepatic, renal and respiratory. Chest CT: minimal pleural effusion, atelectasis of basal segments and hepatomegaly. Due to respiratory acidosis, severe tachipnea and intercostal retractions, required non invasive ventilation (NIV): (BIPAP: 16/6.5; FiO2 0.80).
Vasoactive drugs and broader spectrum antibiotics were used (piperaciline-tazobactam, linezolid, anfotericine B and doxicicline). Serology was performed: B.abortus, R.connorii, C.burnetii, M.pneumoniae, B.burgdorferi, E. granulosus, VEB, CMV, VHC, HIV and VHS1/2. All results were negative.
Other serological test and molecular techniques (real time PCR) were performed: L. donovanni, Leptospira spp, B. henselae, B. quintana, Enterovirus, Anisakis, C. burnetii, F. tularensis and Lepstospira spp. All negative. Patient's rural environment led us to use PCR real time, against Coxiella spp, being positive. Genotype SNP6 was isolated.
Antibiotics were reduced to doxicicline and quinolone. After 3 weeks patient clinical and analytically improved and serology confirmed diagnose: C. burnetii phase II IgG: titule 1/800 and IgM: 1/200.
Clinical relevancy of this case covers torpid progression (respiratory, renal and hepatic failure) with absence of predisposing factors, aggressive and unusual genotype.
Management with NIV for acute respiratory failure avoids the adverse effects of invasive ventilation, and has the added advantage of patient comfort.