Sandbox: q fever

History and symptoms

• 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:
• Incubation period is usually 2 to 3 weeks.

Acute Q fever:

Flu like symptoms:

The most common manifestation is flu-like symptoms with abrupt onset of:

• 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, Malaise, 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:

Chronic Q fever, characterized by infection that persists for more than 6 months is uncommon but is a much more serious disease. Patients who have had acute Q fever may develop the chronic form as soon as 1 year or as long as 20 years after initial infection.

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

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.