Sandbox: q fever

Q fever can present with a wide variety of symptoms related to multiple organs involved. Q fever can be classified into acute and chronic based on the onset of symptoms:

Acute Q fever:

Flu like symptoms: High grade fevers: Fever is usually accompanied by chills and night sweats. Headaches: retrobulbar and associated with photophobia. Arthralgias.

Pneumonia: Usually mild and accidentally discovered on X rays If accompanied by cough, cough is dry and non productive. Dyspnea Pleuritic chest pain Rarely progresses to ARDS which can be life threatening.

Hepatitis: Abdominal right upper quadrant pain Jaundice GI symptoms as nausea, vomiting, diarrhea and bloating.

Rare acute Q fever symptoms:

Pericarditis and myocarditis: Myocarditis is rare but carries a bad prognosis. Chest pain Dyspnea Palpitation

Neurologic findings: Q fever can present with meningioencephalitis. Headache Confusion Seizures

Dermatologic findings: Maculopapular rash Diffuse punctate rash Erythema nodosum

Q fever during pregnancy: Most C. brutenii infection during pregnancy pass asymptomatic but in rare cases it can be complicated with: Intrauterine growth retardation (IUGR) Intrauterine fetal death (IUFD).

Infection during first trimester and placental infection are associated with increased risk of fetal compromise.

Chronic Q fever:

Endocarditis:

Endocarditis is the main manifestation of Q fever. Characterized by being culture negative endocarditis. Patients who are predisposed to endocarditis include patients with valvular lesions, prosthetic valves and immunocompromised patients. Presents with:

• • Low grade fevers
  • Palpitations
  • Dyspnea
  • Embolic manifestations

Skeletal manifestations: Bone and joint infections are common manifestations of chronic Q fever. Presents with:

• • Low grade fever
  • Bone and joint pain as in chronic osteomyelitis

Vascular lesions: Usually in previously affected vessel (e.g. aneurysm)

Cardiopulmonary affection: Chronic pleural or pericardial effusion and Interstitial pulmonary fibrosis present with dyspnea and fatigue.

Hepatic manifestations: Liver fibrosis or cirrhosis presents with symptoms of chronic hepatic decompensation (e.g jaundice, abdominal pain, fatigue, etc)

Chronic fatigue syndrome: Presents in up to 10% of chronic Q fever patients.

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Physical examination:

Vital signs: Fever: High grade fevers that is usually accompanied by chills and night sweats. Tachycardia Tachypnea

General: Patient looks ill

Skin: Maculopapular or punctate rash Erythema nodosum Spider nevi if hepatic decompensation is present

HEENT: Jaundice Congested neck veins if endocarditis or myocarditis is complicated by heart failure

Lungs: Minimal auscultatory findings in most of the cases Crackles especially in the lower lung fields Decreased breath sounds if pleural effusion is present

Abdomen: Hepatomegaly Ascites if chronic hepatitis ensues

Heart: S3 due to hyperdynamic circulation New onset murmer if endocarditis is present Pericardial rub and distant heart sounds if pericarditis and pericardial effusion is present.

Neurological examination: Neck rigidity and positive brudsiniski and kuring signs. Signs of increased intracranial pressure (vomiting, convulsions, papilledema, etc)

Extremities: Tenderness on palpation of the affected joints and bones. Lower limb edema in presence of heart failure.