Winning Abstracts from the 2012 Medical Student Abstract Competition: Fever in a Returned Traveler
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 life-threatening sequelae.