- Email: [email protected]
An Unusual Manifestation of Q Fever: Peritonitis
JIPH-413; No. of Pages 4
ARTICLE IN PRESS
Journal of Infection and Public Health (2015) xxx, xxx—xxx
SHORT REPORT
An Unusual Manifestation of Q Fever: Peritonitis glu a, Gülden Yılmaz a, Bengi Öztürk b, Osman Memiko˘ ¸kun a, Aysun Yalc ¸ı a, Özge Metin c,∗, Belgin Cos Hatice Ünal a, Halil Kurt a a
Ankara University, Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Ankara, Turkey b Ankara University, Faculty of Medicine, Department of Internal Medicine, Ankara, Turkey c Dr. Sami Ulus Maternity and Children’s Research and Education Hospital, Department of Pediatric Infectious Diseases, URKEYDr, Turkey Received 29 September 2014 ; received in revised form 27 December 2014; accepted 12 February 2015
KEYWORDS Q fever; Coxiella burnetii; Peritonitis
Summary Q fever has rarely been reported and can be difficult to diagnose, especially in immunocompromised patients. In the present report, we describe an unusual case of Q fever that presented as peritonitis and was treated with long-term combination therapy with doxycycline, ciprofloxacin and rifampicin for five weeks in a patient who had been on peritoneal dialysis for six years due to hypertensive nephropathy. © 2015 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Limited. All rights reserved.
Introduction Q fever is caused by Coxiella burnetii and is a worldwide zoonotic disease. The primary reservoirs of this intracellular, pleomorphic, Gram-negative ∗
Corresponding author at: Dr. Sami Ulus Kadın Do˘ gum ve C ¸ ocuk gitim ve Aras¸tırma Hastanesi Babür CadSa˘ glı˘ gı ve Hastalıkları E˘ g, Ankara, Turkey. desi No: 44, 06080 Altında˘ Tel.: +90 3123056545; fax: +90 3123170353. E-mail address: [email protected] (Ö. Metin).
microorganism are cattle, sheep and goats. The infected animals transmit the pathogen via bacterial shedding in their body secretions. Humans become infected via the inhalation of infectious aerosols either directly from the secretions of infected animals or from dust contaminated with these fluids [1,2]. Q fever can be difficult to diagnose due to its nonspecific clinical presentations. In this study, we report an unusual case of Q fever that presented as peritonitis in a patient undergoing dialysis.
http://dx.doi.org/10.1016/j.jiph.2015.02.004 1876-0341/© 2015 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Limited. All rights reserved.
Please cite this article in press as: Yılmaz G, et al. An Unusual Manifestation of Q Fever: Peritonitis. J Infect Public Health (2015), http://dx.doi.org/10.1016/j.jiph.2015.02.004
JIPH-413; No. of Pages 4
ARTICLE IN PRESS
2
G. Yılmaz et al.
Case report A 41-year-old man living in a village with sheep and goats had been on peritoneal dialysis for six years due to hypertensive nephropathy and experienced six attacks peritonitis within this period. Previous peritoneal fluid cultures yielded E. coli and coagulase-negative staphylococci. He was admitted to hospital with a 10-day history of fever, nausea, vomiting and weakness. Only fever (39 ◦ C) and abdominal tenderness were noted on physical examination. Laboratory tests revealed an elevated leukocyte count (17.3 × 109 /mm3 ), sedimentation rate (75 mm/h) and C-reactive protein level (CRP, 9.5 mg/L for normal values <3 mg/L) and anemia (with a hemoglobin level of 10.1 g/dL). Blood biochemistry tests revealed liver cholestasis (alkaline phosphatase (ALP) 161 U/L, normal values <129 U/L and gamma-glutamyl transpeptidase (GGT) 65 U/L, normal values <60 U/L) and normal transaminase and bilirubin levels. Renal function tests revealed hyperazotemia (BUN 30 mg/dL, normal values <20 mg/dL and creatinine 13.2 mg/dL, normal values <1.2 mg/dL). A peritoneal fluid examination revealed 170 cells/mm3 , and the patient was given tazobactam-piperacillin and vancomycin empirically with the preliminary diagnosis of peritonitis. Because the patient remained febrile, the antibiotic treatment was switched to imipenem and vancomycin. The blood and peritoneal fluid cultures were sterile. Due to the persistence of fever, the peritoneal catheter was removed, but no microorganisms were grown on culture. Despite treatment with broad-spectrum antimicrobials that included colistin, daptomycin and fluconazole, the fever persisted. Gruber-Widal and Wright tube agglutination tests, a viral hepatitis panel (for hepatitis A, B and C) and serologies for Epstein—Barr virus and cytomegalovirus were negative. Immunological tests indicated no autoimmune disease but were consistent with mild hypergammaglobulinemia (IgG level 21.6 g/L, normal values <16 g/L). Enzyme-linked immunosorbent assays for antiphospholipid and anticardiolipin antibodies were negative. A computed tomography (CT) scan of the thorax, abdomen and pelvis revealed bilateral minimal pleural effusion, diffuse thickening of the rectum, sigmoid colon and peritoneum and massive ascites and peritonitis (Fig. 1). Gram and ZiehlNeelsen stainings and cultures, polymerase chain reaction (PCR), cytology of the ascites fluid and a QuantiFERON test for tuberculosis were negative. Transesophageal echocardiography revealed no lesions. A bone marrow biopsy was normal, and
Figure 1 Abdominal CT scan showing diffuse thickening of the peritoneum and as cite.
a peritoneum biopsy revealed chronic inflammation. Q fever was suggested due to the history of animal exposure, and a serological survey for Coxiella burnetii was performed. Although the Phase 1 IgM-IgG and Phase 2 IgM titers were negative, the Phase 2 IgG was 1/1024 (Vircell SL, Spain). The tests were performed at the Refik Saydam National Public Health Agency of the Ministry of Health. Subsequently, a combination treatment with doxycycline and ciprofloxacin was initiated. Because the patient remained febrile on the 10th day of treatment, rifampicin was added to the therapy. The patient was afebrile on the fifth day of triple antibiotic therapy. After five weeks of therapy, his white blood cell count and CRP were in the normal ranges, the Phase 2 IgG titer decreased to a titer of 1/256, and the cell counts in the peritoneal fluid and ascites and thickening of the peritoneum resolved.
Discussion Q fever was first described in 1937 by Derrick EQ. Totals of 1168 cases between 1948 and 1977 and 436 cases between 1978 and 1999 were reported to the Centers for Disease Control and Prevention (CDC). Since 1999, Q fever has become a notifiable disease in the United States due to its potential as a biological warfare agent [1]. Since that time, reports of Q fever have increased, and from 2007 to 2010, the largest Q fever outbreak, which involved 4000 human cases, was reported in the Netherlands [3]. In Turkey, the Coxiella burnetii IgG seropositivity rates are 1.8—13.5% in healthy people and 42.4% in high-risk groups [4—6]. The factors that suggested acute Q fever in our patient were the following: a history of animal exposure, fever, headache,
Please cite this article in press as: Yılmaz G, et al. An Unusual Manifestation of Q Fever: Peritonitis. J Infect Public Health (2015), http://dx.doi.org/10.1016/j.jiph.2015.02.004
JIPH-413; No. of Pages 4
ARTICLE IN PRESS
An unusual manifestation of Q fever anemia, elevated sedimentation rate and CRP level, and hypergammaglobulinemia. Despite normal transaminase and biluribin levels, the patient exhibited elevated ALP and GGT levels that were similar to those reported in a study from France [7]. The findings that were not consistent with Q fever were the following: the absence of thrombocytopenia, and the normal levels of anticardiolipin and antiphospholipid antibodies. In a recent report from the CDC, thrombocytopenia was reported in 25% and antiphospholipid antibodies were detected in 50% of cases [2]. The spectrum of Q fever is pleomorphic, the major clinical presentations include acute febrile illness, pneumonia and hepatitis, and the disease has rarely been reported in immunocompromised hosts [1,8—10]. In a review from France, 20% of 84 chronic Q fever patients were immunosuppressed, including patients with cancer, renal transplantation, chronic myeloid leukemia, corticosteroid therapy, acquired immunodeficiency syndrome, postpartum status, chronic alcoholism and renal dialysis [11]. Our patient had been on peritoneal dialysis for six years. The absolute numbers of T cells in patients who have received dialysis for more than one year are reduced [12]. Furthermore, long-term exposure of peritoneal cells to dialysis solutions might also alter the normal immunological reactions against bacteria (e.g., decreased opsonic activities against bacteria) [13]. Because the immune control of C. burnetii is T-cell dependent, patients on renal dialysis are prone to intracellular bacteria such as C. burnetii [14]. Pericarditis, myocarditis, thyroiditis, meningoencephalitis, hemolytic anemia, nephritis, osteomyelitis and hemophagocytic syndrome are rare manifestations of Q fever [7,15,16]. In addition to the knowledge provided by our case, Chang et al. described peritonitis as a manifestation of Q fever in a patient with diabetes mellitus in Taiwan [17]. These authors observed peritoneal involvement on a gallium scan and diffuse abdominal uptake on an inflammatory scan. We were unable to isolate the bacteria, and the peritoneal fluid PCR was negative because it was performed long after the onset of the symptoms. The diagnosis of the patient was confirmed by an indirect immunofluorescence (IF) test. In suspected cases, the diagnosis of Q fever should be confirmed by serum titers (IgG and/or IgM) obtained via IF because these tests are very sensitive and specific [18]. The diagnosis of Q fever was based on the positivity of the Phase 2 IgG (1/1024). Concordant with the cases reported by Yes¸ilyurt et al., the Phase 2 IgM was negative [19]. We believe that this negativity resulted from the suppression of the immune
3 system due to chronic renal failure. Because of the poor responsiveness of the patient to doxycycline and ciprofloxacin therapy, rifampicin was added to the therapy. He recovered after 5 weeks of triple antibiotic therapy. The inflammatory markers in the serum, cell counts in the peritoneal fluid and ascites and the thickening of the peritoneum were resolved after this therapy. Long-duration combination therapy should be considered for certain patients who exhibit poor responsiveness to monotherapy, particularly immunocompromised patients. We reported an unusual case of Q fever that presented as peritonitis. Clinicians should be aware of such rare manifestations, particularly immunocompromised patients, because the infrequent consideration of Q fever in such patients could delay therapy.
Conflict of interest Funding: No funding sources. Competing interests: None declared. Ethical approval: Not required.
References [1] Raqqlt D, Marrie TJ. Coxiella burnetii (Q fever). In: Mandell GL, Bennett JE, Dolin R, editors. Principles and practice of infectious diseases. 7th ed. Philadelphia; 2010. p. 2511—9. [2] Recommendations from CDC and the Q Fever Working Group. Diagnosis and management of Q fever — United States, 2013. MMWR 2013;62(3). [3] Schimmer B, Dijkstra F, Vellema P, Schneeberger PM, Hackert V, ter Schegget R, et al. Sustained intensive transmission of Q fever in the south of the Netherlands, 2009. Euro Surveill 2009;14(19). [4] Berbero˘ glu U, Gözalan A, Kilic ¸ S, Kurto˘ glu D, Esen B. A seroprevalence study of Coxiella burnetii in Antalya, Diyarbakır and Samsun provinces. Mikrobiyol Bul 2004;38:385—91. [5] Gozalan A, Rolain JM, Ertek M, Angelakis E, Coplu N, Basbulut EA, et al. Seroprevalence of Q fever in a district located in the west Black Sea region of Turkey. Eur J Clin Microbiol Infect Dis 2010;29:465—9. [6] Eyigör M, Kırkan ¸ S, Gültekin B, Yaman S, Tekbıyık S, Aydın ¸in risk gruplarında Coxiella burnetii’ye N. Q humması ic kars¸ı olus¸an antikorların ELISA ve IFA testleri ile saptanması. ˙Infeksiyon Derg 2006;20:31—6. [7] Acquacalda E, Montaudie H, Laffont C, Fournier PE, Pulcini C. A case of multifocal chronic Q fever osteomyelitis. Infection 2011;39:167—9. [8] Levy PY, Carrieri P, Raoult D. Coxiella burnetii pericarditis: report of 15 cases and review. Clin Infect Dis 1999;29:393—7. [9] Heard SR, Ronalds CJ, Heath RB. Coxiella burnetii infection in immunocompromised patients. J Infect 1985;11:15—8. [10] Raoult D, Brouqui P, Marchou B, Gastraut JA. Acute and chronic Q fever in patients with cancer. Clin Infect Dis 1992;14:127—30.
Please cite this article in press as: Yılmaz G, et al. An Unusual Manifestation of Q Fever: Peritonitis. J Infect Public Health (2015), http://dx.doi.org/10.1016/j.jiph.2015.02.004
JIPH-413; No. of Pages 4
ARTICLE IN PRESS
4
G. Yılmaz et al.
[11] Brouqui P, Dupont HT, Drancourt M, Berland Y, Etienne J, Leport C, et al. Chronic Q fever, ninety-two cases from France, including 27 cases without endocarditis. Arch Intern Med 1993;153:642—8. [12] Raska Jr K, Raskova J, Shea SM, Frankel RM, Wood RH, Lifter J, et al. T cell subsets and cellular immunity in end-stage renal disease. Am J Med 1983;75:734—40. [13] Park MS. Factors increasing severity of peritonitis in longterm peritoneal dialysis patients. Adv Ren Replace Ther 1998;5:185—93. [14] Koster FT, Goodwin JS, Williams JC. Cellular immunity in Q fever: modulation of responsiveness by a suppressor T-cell monocyte circuit. J Immunol 1985;135:1067—72. [15] Korkmaz S, Elaldi N, Kayatas M, Sencan M, Yildiz E. Unusual manifestations of acute Q fever: autoimmune hemolytic
[16]
[17]
[18] [19]
anemia and tubulointerstitial nephritis. Ann Clin Microbiol Antimicrob 2012;11:14. Lecronier M, Prendki V, Gerin M, Schneerson M, Renvoisé A, Larroche C, et al. Q fever and Mediterranean spotted fever associated with hemophagocytic syndrome: case study and literature review. Int J Infect Dis 2013;17:629—33. Chang K, Ko WC, Li BF, Liu PY, Chiu NT. Diffuse abdominal uptake mimicking peritonitis in gallium inflammatory scan: an unusual feature of acute Q fever. Kaohsiung J Med Sci 2005;21:522—6. Fari˜ nas MT, Collado CM. Infection by Coxiella burnetii (Q fever). Enferm Infecc Microbiol Clin 2010;28:29—32. Yesilyurt M, Kılıc S, Gürsoy B, Celebi M, Yerer M. Two cases of acute hepatitis associated with Q fever. Mikrobiyol Bul 2012;46:480—7.
Available online at www.sciencedirect.com
ScienceDirect
Please cite this article in press as: Yılmaz G, et al. An Unusual Manifestation of Q Fever: Peritonitis. J Infect Public Health (2015), http://dx.doi.org/10.1016/j.jiph.2015.02.004
ARTICLE IN PRESS
Journal of Infection and Public Health (2015) xxx, xxx—xxx
SHORT REPORT
An Unusual Manifestation of Q Fever: Peritonitis glu a, Gülden Yılmaz a, Bengi Öztürk b, Osman Memiko˘ ¸kun a, Aysun Yalc ¸ı a, Özge Metin c,∗, Belgin Cos Hatice Ünal a, Halil Kurt a a
Ankara University, Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Ankara, Turkey b Ankara University, Faculty of Medicine, Department of Internal Medicine, Ankara, Turkey c Dr. Sami Ulus Maternity and Children’s Research and Education Hospital, Department of Pediatric Infectious Diseases, URKEYDr, Turkey Received 29 September 2014 ; received in revised form 27 December 2014; accepted 12 February 2015
KEYWORDS Q fever; Coxiella burnetii; Peritonitis
Summary Q fever has rarely been reported and can be difficult to diagnose, especially in immunocompromised patients. In the present report, we describe an unusual case of Q fever that presented as peritonitis and was treated with long-term combination therapy with doxycycline, ciprofloxacin and rifampicin for five weeks in a patient who had been on peritoneal dialysis for six years due to hypertensive nephropathy. © 2015 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Limited. All rights reserved.
Introduction Q fever is caused by Coxiella burnetii and is a worldwide zoonotic disease. The primary reservoirs of this intracellular, pleomorphic, Gram-negative ∗
Corresponding author at: Dr. Sami Ulus Kadın Do˘ gum ve C ¸ ocuk gitim ve Aras¸tırma Hastanesi Babür CadSa˘ glı˘ gı ve Hastalıkları E˘ g, Ankara, Turkey. desi No: 44, 06080 Altında˘ Tel.: +90 3123056545; fax: +90 3123170353. E-mail address: [email protected] (Ö. Metin).
microorganism are cattle, sheep and goats. The infected animals transmit the pathogen via bacterial shedding in their body secretions. Humans become infected via the inhalation of infectious aerosols either directly from the secretions of infected animals or from dust contaminated with these fluids [1,2]. Q fever can be difficult to diagnose due to its nonspecific clinical presentations. In this study, we report an unusual case of Q fever that presented as peritonitis in a patient undergoing dialysis.
http://dx.doi.org/10.1016/j.jiph.2015.02.004 1876-0341/© 2015 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Limited. All rights reserved.
Please cite this article in press as: Yılmaz G, et al. An Unusual Manifestation of Q Fever: Peritonitis. J Infect Public Health (2015), http://dx.doi.org/10.1016/j.jiph.2015.02.004
JIPH-413; No. of Pages 4
ARTICLE IN PRESS
2
G. Yılmaz et al.
Case report A 41-year-old man living in a village with sheep and goats had been on peritoneal dialysis for six years due to hypertensive nephropathy and experienced six attacks peritonitis within this period. Previous peritoneal fluid cultures yielded E. coli and coagulase-negative staphylococci. He was admitted to hospital with a 10-day history of fever, nausea, vomiting and weakness. Only fever (39 ◦ C) and abdominal tenderness were noted on physical examination. Laboratory tests revealed an elevated leukocyte count (17.3 × 109 /mm3 ), sedimentation rate (75 mm/h) and C-reactive protein level (CRP, 9.5 mg/L for normal values <3 mg/L) and anemia (with a hemoglobin level of 10.1 g/dL). Blood biochemistry tests revealed liver cholestasis (alkaline phosphatase (ALP) 161 U/L, normal values <129 U/L and gamma-glutamyl transpeptidase (GGT) 65 U/L, normal values <60 U/L) and normal transaminase and bilirubin levels. Renal function tests revealed hyperazotemia (BUN 30 mg/dL, normal values <20 mg/dL and creatinine 13.2 mg/dL, normal values <1.2 mg/dL). A peritoneal fluid examination revealed 170 cells/mm3 , and the patient was given tazobactam-piperacillin and vancomycin empirically with the preliminary diagnosis of peritonitis. Because the patient remained febrile, the antibiotic treatment was switched to imipenem and vancomycin. The blood and peritoneal fluid cultures were sterile. Due to the persistence of fever, the peritoneal catheter was removed, but no microorganisms were grown on culture. Despite treatment with broad-spectrum antimicrobials that included colistin, daptomycin and fluconazole, the fever persisted. Gruber-Widal and Wright tube agglutination tests, a viral hepatitis panel (for hepatitis A, B and C) and serologies for Epstein—Barr virus and cytomegalovirus were negative. Immunological tests indicated no autoimmune disease but were consistent with mild hypergammaglobulinemia (IgG level 21.6 g/L, normal values <16 g/L). Enzyme-linked immunosorbent assays for antiphospholipid and anticardiolipin antibodies were negative. A computed tomography (CT) scan of the thorax, abdomen and pelvis revealed bilateral minimal pleural effusion, diffuse thickening of the rectum, sigmoid colon and peritoneum and massive ascites and peritonitis (Fig. 1). Gram and ZiehlNeelsen stainings and cultures, polymerase chain reaction (PCR), cytology of the ascites fluid and a QuantiFERON test for tuberculosis were negative. Transesophageal echocardiography revealed no lesions. A bone marrow biopsy was normal, and
Figure 1 Abdominal CT scan showing diffuse thickening of the peritoneum and as cite.
a peritoneum biopsy revealed chronic inflammation. Q fever was suggested due to the history of animal exposure, and a serological survey for Coxiella burnetii was performed. Although the Phase 1 IgM-IgG and Phase 2 IgM titers were negative, the Phase 2 IgG was 1/1024 (Vircell SL, Spain). The tests were performed at the Refik Saydam National Public Health Agency of the Ministry of Health. Subsequently, a combination treatment with doxycycline and ciprofloxacin was initiated. Because the patient remained febrile on the 10th day of treatment, rifampicin was added to the therapy. The patient was afebrile on the fifth day of triple antibiotic therapy. After five weeks of therapy, his white blood cell count and CRP were in the normal ranges, the Phase 2 IgG titer decreased to a titer of 1/256, and the cell counts in the peritoneal fluid and ascites and thickening of the peritoneum resolved.
Discussion Q fever was first described in 1937 by Derrick EQ. Totals of 1168 cases between 1948 and 1977 and 436 cases between 1978 and 1999 were reported to the Centers for Disease Control and Prevention (CDC). Since 1999, Q fever has become a notifiable disease in the United States due to its potential as a biological warfare agent [1]. Since that time, reports of Q fever have increased, and from 2007 to 2010, the largest Q fever outbreak, which involved 4000 human cases, was reported in the Netherlands [3]. In Turkey, the Coxiella burnetii IgG seropositivity rates are 1.8—13.5% in healthy people and 42.4% in high-risk groups [4—6]. The factors that suggested acute Q fever in our patient were the following: a history of animal exposure, fever, headache,
Please cite this article in press as: Yılmaz G, et al. An Unusual Manifestation of Q Fever: Peritonitis. J Infect Public Health (2015), http://dx.doi.org/10.1016/j.jiph.2015.02.004
JIPH-413; No. of Pages 4
ARTICLE IN PRESS
An unusual manifestation of Q fever anemia, elevated sedimentation rate and CRP level, and hypergammaglobulinemia. Despite normal transaminase and biluribin levels, the patient exhibited elevated ALP and GGT levels that were similar to those reported in a study from France [7]. The findings that were not consistent with Q fever were the following: the absence of thrombocytopenia, and the normal levels of anticardiolipin and antiphospholipid antibodies. In a recent report from the CDC, thrombocytopenia was reported in 25% and antiphospholipid antibodies were detected in 50% of cases [2]. The spectrum of Q fever is pleomorphic, the major clinical presentations include acute febrile illness, pneumonia and hepatitis, and the disease has rarely been reported in immunocompromised hosts [1,8—10]. In a review from France, 20% of 84 chronic Q fever patients were immunosuppressed, including patients with cancer, renal transplantation, chronic myeloid leukemia, corticosteroid therapy, acquired immunodeficiency syndrome, postpartum status, chronic alcoholism and renal dialysis [11]. Our patient had been on peritoneal dialysis for six years. The absolute numbers of T cells in patients who have received dialysis for more than one year are reduced [12]. Furthermore, long-term exposure of peritoneal cells to dialysis solutions might also alter the normal immunological reactions against bacteria (e.g., decreased opsonic activities against bacteria) [13]. Because the immune control of C. burnetii is T-cell dependent, patients on renal dialysis are prone to intracellular bacteria such as C. burnetii [14]. Pericarditis, myocarditis, thyroiditis, meningoencephalitis, hemolytic anemia, nephritis, osteomyelitis and hemophagocytic syndrome are rare manifestations of Q fever [7,15,16]. In addition to the knowledge provided by our case, Chang et al. described peritonitis as a manifestation of Q fever in a patient with diabetes mellitus in Taiwan [17]. These authors observed peritoneal involvement on a gallium scan and diffuse abdominal uptake on an inflammatory scan. We were unable to isolate the bacteria, and the peritoneal fluid PCR was negative because it was performed long after the onset of the symptoms. The diagnosis of the patient was confirmed by an indirect immunofluorescence (IF) test. In suspected cases, the diagnosis of Q fever should be confirmed by serum titers (IgG and/or IgM) obtained via IF because these tests are very sensitive and specific [18]. The diagnosis of Q fever was based on the positivity of the Phase 2 IgG (1/1024). Concordant with the cases reported by Yes¸ilyurt et al., the Phase 2 IgM was negative [19]. We believe that this negativity resulted from the suppression of the immune
3 system due to chronic renal failure. Because of the poor responsiveness of the patient to doxycycline and ciprofloxacin therapy, rifampicin was added to the therapy. He recovered after 5 weeks of triple antibiotic therapy. The inflammatory markers in the serum, cell counts in the peritoneal fluid and ascites and the thickening of the peritoneum were resolved after this therapy. Long-duration combination therapy should be considered for certain patients who exhibit poor responsiveness to monotherapy, particularly immunocompromised patients. We reported an unusual case of Q fever that presented as peritonitis. Clinicians should be aware of such rare manifestations, particularly immunocompromised patients, because the infrequent consideration of Q fever in such patients could delay therapy.
Conflict of interest Funding: No funding sources. Competing interests: None declared. Ethical approval: Not required.
References [1] Raqqlt D, Marrie TJ. Coxiella burnetii (Q fever). In: Mandell GL, Bennett JE, Dolin R, editors. Principles and practice of infectious diseases. 7th ed. Philadelphia; 2010. p. 2511—9. [2] Recommendations from CDC and the Q Fever Working Group. Diagnosis and management of Q fever — United States, 2013. MMWR 2013;62(3). [3] Schimmer B, Dijkstra F, Vellema P, Schneeberger PM, Hackert V, ter Schegget R, et al. Sustained intensive transmission of Q fever in the south of the Netherlands, 2009. Euro Surveill 2009;14(19). [4] Berbero˘ glu U, Gözalan A, Kilic ¸ S, Kurto˘ glu D, Esen B. A seroprevalence study of Coxiella burnetii in Antalya, Diyarbakır and Samsun provinces. Mikrobiyol Bul 2004;38:385—91. [5] Gozalan A, Rolain JM, Ertek M, Angelakis E, Coplu N, Basbulut EA, et al. Seroprevalence of Q fever in a district located in the west Black Sea region of Turkey. Eur J Clin Microbiol Infect Dis 2010;29:465—9. [6] Eyigör M, Kırkan ¸ S, Gültekin B, Yaman S, Tekbıyık S, Aydın ¸in risk gruplarında Coxiella burnetii’ye N. Q humması ic kars¸ı olus¸an antikorların ELISA ve IFA testleri ile saptanması. ˙Infeksiyon Derg 2006;20:31—6. [7] Acquacalda E, Montaudie H, Laffont C, Fournier PE, Pulcini C. A case of multifocal chronic Q fever osteomyelitis. Infection 2011;39:167—9. [8] Levy PY, Carrieri P, Raoult D. Coxiella burnetii pericarditis: report of 15 cases and review. Clin Infect Dis 1999;29:393—7. [9] Heard SR, Ronalds CJ, Heath RB. Coxiella burnetii infection in immunocompromised patients. J Infect 1985;11:15—8. [10] Raoult D, Brouqui P, Marchou B, Gastraut JA. Acute and chronic Q fever in patients with cancer. Clin Infect Dis 1992;14:127—30.
Please cite this article in press as: Yılmaz G, et al. An Unusual Manifestation of Q Fever: Peritonitis. J Infect Public Health (2015), http://dx.doi.org/10.1016/j.jiph.2015.02.004
JIPH-413; No. of Pages 4
ARTICLE IN PRESS
4
G. Yılmaz et al.
[11] Brouqui P, Dupont HT, Drancourt M, Berland Y, Etienne J, Leport C, et al. Chronic Q fever, ninety-two cases from France, including 27 cases without endocarditis. Arch Intern Med 1993;153:642—8. [12] Raska Jr K, Raskova J, Shea SM, Frankel RM, Wood RH, Lifter J, et al. T cell subsets and cellular immunity in end-stage renal disease. Am J Med 1983;75:734—40. [13] Park MS. Factors increasing severity of peritonitis in longterm peritoneal dialysis patients. Adv Ren Replace Ther 1998;5:185—93. [14] Koster FT, Goodwin JS, Williams JC. Cellular immunity in Q fever: modulation of responsiveness by a suppressor T-cell monocyte circuit. J Immunol 1985;135:1067—72. [15] Korkmaz S, Elaldi N, Kayatas M, Sencan M, Yildiz E. Unusual manifestations of acute Q fever: autoimmune hemolytic
[16]
[17]
[18] [19]
anemia and tubulointerstitial nephritis. Ann Clin Microbiol Antimicrob 2012;11:14. Lecronier M, Prendki V, Gerin M, Schneerson M, Renvoisé A, Larroche C, et al. Q fever and Mediterranean spotted fever associated with hemophagocytic syndrome: case study and literature review. Int J Infect Dis 2013;17:629—33. Chang K, Ko WC, Li BF, Liu PY, Chiu NT. Diffuse abdominal uptake mimicking peritonitis in gallium inflammatory scan: an unusual feature of acute Q fever. Kaohsiung J Med Sci 2005;21:522—6. Fari˜ nas MT, Collado CM. Infection by Coxiella burnetii (Q fever). Enferm Infecc Microbiol Clin 2010;28:29—32. Yesilyurt M, Kılıc S, Gürsoy B, Celebi M, Yerer M. Two cases of acute hepatitis associated with Q fever. Mikrobiyol Bul 2012;46:480—7.
Available online at www.sciencedirect.com
ScienceDirect
Please cite this article in press as: Yılmaz G, et al. An Unusual Manifestation of Q Fever: Peritonitis. J Infect Public Health (2015), http://dx.doi.org/10.1016/j.jiph.2015.02.004