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Author: ENS Nicholas R. Rocco - Uniformed
Services University, Class of 2013
Introduction: Q fever is a zoonotic disease
endemic to the Middle East, including Iraq and Afghanistan, with an
increasing incidence of infection among deployed US military
personnel and civilian contractors. The lack of standardized assays
for detection makes Q fever a diagnostic challenge.
Case Presentation: A 53-year-old male
contractor with a history of recent travel to the Philippines
presented to the Bagram Air Force Base, Afghanistan with nausea,
emesis, frontal headache, and myalgias. He had recently been
re-deployed to Afghanistan after working for eight years in Iraq.
Upon arrival he was stable and afebrile, with a heart rate of 115
beats per minute, oxygen saturation of 93% on room air. A chest
radiograph showed hilar fullness without infiltrates and he was
released with symptomatic treatment for a presumed diagnosis of a
viral syndrome. Several days later, he returned complaining of
worsening symptoms. Physical exam revealed a temperature of 105.9
degrees, heart rate of 142 beats per minute, oxygen saturation 81%
on room air. He was found to be delirious, with tender hepatomegaly
and purpura. Serological studies revealed a white blood cell count
of 20.2k/µL with 93% segmented neutrophils, hematocrit of
21.4%, platelet count of 93k/ µL, sodium of 128 mmol/L,
bilirubin of 20 mg/dL. Urinalysis revealed 100 mg/dL of protein.
The patient was subsequently airlifted to Landstuhl Regional
Medical Center (LRMC) where his course was complicated by a
loculated pleural effusion necessitating Video-Assisted Thoracic
Surgery (VATS). Further testing at Walter Reed Army Medical Center
(WRAMC) was negative for malaria, leptospirosis, hepatitis,
rickettsial-borne diseases, dengue, HIV, Legionella, tuberculosis,
syphilis and schistosomiasis. Serology forCoxiella burnetii was
notable for a phase 2 IgM positive at 1:64 dilution, suggesting a
diagnosis of acute Q fever. A trans-esophageal echocardiogram (TEE)
showed no valvular damage or vegetations. He was prescribed a
21-day course of oral doxycycline, and showed gradual clinical
improvement and resolution of his laboratory abnormalities.
Discussion: This case illustrates the
importance of maintaining a high clinical suspicion for Q fever in
patients returning from endemic areas with febrile symptoms. Though
the classic presentation includes pneumonia and hepatitis, it may
have protean manifestations. If left untreated, it can progress to
chronic infection and valvular heart disease. Rapid diagnosis and
treatment are therefore necessary to avoid these potentially
September 2012 Issue of IMpact