1. EIN SCHWERER FALL VON PNEUMORICKETTSIOSE
(Q FIEBER)
E.J. Soto Hurtado1, M.J. Gutiérrez Fernández2, L. Pérez Borrero3, I. Jado García4. (1) Neumology Service. Hospital Regional Universitario de Málaga.(2) Microbiology Department. AGS Serranía de Ronda, Málaga.
(3) Unit Care Service. AGS Serranía de Ronda, Málaga. (4) National Center for Microbiology. Institute of Health Carlos III, Madrid. SPANIEN
INTRODUCTION:
Q fever is a disease caused by the bacteria Coxiella burnetii which is found worldwide. The bacteria naturally infects some animals, such as goats, sheep and cattle. C. burnetii bacteria are found in the birth products (i.e. placenta, amniotic fluid), urine, feces, and milk of infected animals. People can get infected by breathing in dust that has been contaminated by infected animal feces, urine, milk, and birth products. Some people never get sick; however those that do usually develop flu-like symptoms including fever, chills, fatigue, and muscle pain.
We present a case with 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.
CASE REPORT:
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. Due to respiratory acidosis (pH 7.3; pCO2 51; pO2 31), 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. In spite of negative results and the rural enviroment, 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.
Chest CT: minimal pleural effusion, atelectasis of basal segments and hepatomegaly
DISCUSSION:
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. The signs and symptoms of Q fever are not specific, that is why it is difficult to clasiffy the cases without a serological and sometimes molecular diagnosis.