Q Fever

[Celeste492]

Hello Dr. Parks:

I was recently diagnosed with Q-fever and my local ID was not familiar at all with it.
I have a couple of questions regarding conversion from Phase I to Phase II.  Have you had experience with the treatment of Q-Fever?

Thanks!
Celeste

[Celeste492]

I will keep you updated and I thought we should talk about symptoms just in case it benefits another individual. I presented with many symptoms but none was fever. I told all my doctors that I fell sick after two back to back trips, first to Australia then China. I thought I had picked up something in China but no one gave me referral to an ID dr. and the one I tried wouldn't see me without such a  referral. So I saw what seems like 100 different specialist's and not one tested  for unusual bacterial infections unil Belgium.

My primary symptoms were:

Intense right "eye" headache
Vertigo
night sweats
joint pain
Diarrhea
extreme fatigue
Cognitive issues or "brain fog"
Temp. regulation issues, ie cold in August outside in Fl..
Developed rashes to normal foods, and strong reaction to mosquito bites (all new for me)

The only indicator that something was amiss was Immunoglobuin test (M) was elevated and was rising at each test and eventually the chronic diarrhea caused mag. and pot. to be low. Had co-infections including reactivated EBV, HHV7 and later coxsackie B1-B5 showed elevated even though it was neg. initially.

The doctor in Belgium runs Q-fever as part of his standard panel tests as he seeing more and more cases with individuals presenting with Chronic Fatigue like symptoms. I think doctors here should be more aware of the disease and that is more common then thought.

So..if someone travels a lot like I do, the focus should be infection first instead of last as with my case... Thanks again for the interest and help, I bet you will think Q-Fever if a patient mentions Australia (also more common in France and Netherlands).

So don't kiss any koala bear's or kangaroos anytime soon.

Celeste

[Philip D Parks, MD, MPH, MOccH, FACOEM]

The information that you presented in the most recent posting is consistent with what an infectious disease specialist in the Boston area explained to me regarding chronicity of titers with Q fever.

I am glad that you are feeling "pretty normal on most days" -- continue to stay positive and I am sure you will continue to be proactive with your health care.

Feel free to keep this line of communication open as you continue your treatment. I would also be interested in knowing what the specialist in France's opinion is regarding your case.

All the best,

~•~ Dr. Parks

This answer is not intended as and does not substitute for medical advice. The information presented in this posting is for patients’ education only. As always, I encourage you to see your personal physician for further evaluation of your individual case.

[Celeste492]

Well I do finally have some help: CDC called me and confirmed my titers would be chronic and from now on I should send blood to them for testing and monitoring. CDC does PCR but Quest doesn't.  There isn't any "gold standard" for chronic as no drug used alone has been show to be bactericidal for C burnettii. I spoke to a  specialist in Canada (no longer seeing patients)  and he told me to go to France to one of the top specialists in the world of whom you should be familiar... I had planned on going to France this summer anyhow so maybe I can get in then

Incidentally the CDC had no record of my case and said 2 weeks of doxy was not sufficient and was unsure to whom my first ID doctor spoke with at CDC.

So I am continuing low dose pulsed multiple antibiotic protocol and hopefully it works. I certainly feel pretty normal on most days! Thanks again, too bad you are not in Florida, I would definitely be a patient!

[Philip D Parks, MD, MPH, MOccH, FACOEM]

Dear Celeste:

My apologies for the delay in response to your additional questions.

From the CDC website and explains phase I and II fairly well:

http://www.cdc.gov/ncidod/dvrd/qfever/

" Coxiella burnetii  exists in two antigenic phases called phase I and phase II. This antigenic difference is important in diagnosis. In acute cases of Q fever, the antibody level to phase II is usually higher than that to phase I, often by several orders of magnitude, and generally is first detected during the second week of illness.  In chronic Q fever, the reverse situation is true.  Antibodies to phase I antigens of C. burnetii generally require longer to appear and indicate continued exposure to the bacteria.  Thus, high levels of antibody to phase I in later specimens in combination with constant or falling levels of phase II antibodies and other signs of inflammatory disease suggest chronic Q fever. Antibodies to phase I and II antigens have been known to persist for months or years after initial infection.

Recent studies have shown that greater accuracy in the diagnosis of Q fever can be achieved by looking at specific levels of classes of antibodies other than IgG, namely IgA and IgM.  Combined detection of IgM and IgA in addition to IgG improves the specificity of the assays and provides better accuracy in diagnosis.  IgM levels are helpful in the determination of a recent infection.  In acute Q fever, patients will have IgG antibodies to phase II and IgM antibodies to phases I and II.  Increased IgG and IgA antibodies to phase I are often indicative of Q fever endocarditis."  

The reporting of diseases to CDC is usually by way of a medical provider. The CDC is usually quite responsive and helpful in my experience.

You might consider calling one of the major national laboratories such as Quest for information regarding PCR testing.

I hope this is helpful to you and you're welcome to keep the dialogue going.

Any updates?

~•~ Dr. Parks

This answer is not intended as and does not substitute for medical advice. The information presented in this posting is for patients’ education only. As always, I encourage you to see your personal physician for further evaluation of your individual case.

[Celeste492]

Happy Friday!

Thanks for your interest and response, hopefully this dialogue will be helpful to both doctors and individuals.. Also, I used to live in Winchester MA, and still get up to bean town in the summer.
I am 43 and have had hashimoto hypothyroiditis for 12 years. (And that has been hard to regulate during this period, and of course we fixated on thyroid as being the cause when it truly was affected by the q-fever infection).

First I noticed I made a mistake in my dates. I meant to say Summer of 2006 is when I went to Australia not 2005 so my diagnosis was this Nov/Dec...

1) I never went back to the ID here because I was so disappointed in his response to my case (I was actually diagnosed first by a doctor in Belgium in Nov. and validated  by Quest labs in Dec. ). The cardiologist didn't seemed concerned at all but my research showed quite a few cases that didn't show anything on the echo but later turned into endocarditis. My plan is to have echo's done quarterly to monitor my heart.

2) I still am somewhat confused on what exactly Phase 1 means with Q-Fever. I see many people don't  progress to phase 1. Is phase 1 just length of time you have harbored the bacteria? There are ratio's you can perform on the Quest results but my doctor didn't do this. "ratio of titer of phase II to phase I may indicate stage of disease: ie acute, granulomatous hepatitis, chronic or endocarditis . .  It doesn't specify which titer.

3) PCR testing. Do you happen to know which lab does this or how to request for PCR. After I complete the antibiotic protocol I am currently on, I would like the PCR done instead of the IFAT.

4) CDC: This is supposedly to be reportable..I contacted the Viral and Rickettsial Zoonoses Branch by email for some help/referral and they didn't even email back...Is this normal for CDC?

And how do you have time for this forum, your probably spent more time on this then my own doctor?

[Philip D Parks, MD, MPH, MOccH, FACOEM]

Dear Celeste,

By the way, how "young" are you?

And, do you have any other medical problems (hypertension, coronary artery disease, tobacco abuse, diabetes, hypothyroidism, etc)?

And, by the way Roault is prominently cited in the medical literature.

To address your questions...

1. Also, I cannot say with 100% certainty with regard to your future risk of endocarditis; nevertheless I will try to provide some information. If you have had a recent echocardiogram and the cardiologist did not see “vegetations” on the heart valves (and your heart valves are "normal"), then, it is unlikely that you will go on to develop endocarditis. However, there are case reports in the medical literature of recurrent endocarditis in the presence of a negative blood culture. The majority of these cases occur in patients with abnormal heart valves prior to contracting Q fever. It is really important for the cardiologist to have examined the echocardiogram specifically for signs that the heart valves were infected (this is standard protocol especially in the setting of your diagnosis). Mild tricuspid regurgitation is relatively common in the general population and may have been an incidental finding [What does your physician say about the mitral valve regurgitation?]

2. Your antibody profile could be because you were untreated for such an extended period of time and then were only briefly treated with a single drug (doxycycline).
3. Chronic fatigue symptoms that wax and wane are common sequelae to acute Q fever infection.
4. It is possible to perform a PCR test for Coxiella burnetii (the bacteria that causes Q fever). This may be a “send out” (to a private or government laboratory) laboratory test and I do not know the pricing.

I hope that this is helpful. Please feel free to keep the dialogue going.

~•~ Dr. Parks

This answer is not intended as and does not substitute for medical advice. The information presented in this posting is for patients’ education only. As always, I encourage you to see your personal physician for further evaluation of your individual case.

[Celeste492]

Well you said it!  I haven't been able to find anyone with experience here, and only one at John Hopkins and I believe another at Mass. Gen. So, instead  I have researched much from  Dr. Didier Raoult and various Australia researchers but really am missing the following:

1) Echo. done and it showed a mild tricuspid regurgitation. I did not have this symptom when I had echo done years ago. Any idea how the heart handles infection, if it has affected heart but not cased apparent inflammation, how likely will we see progression to Endocarditis?

2) What is % of cases that move from phase II to phase I? I read you can have acute levels (Igm to phase II) for as long as 18 months, is this accurate? I am now showing neg. to IGM phase II, IGG and IGM are positive to phase I

3) We think that I got Q-fever during a visit to Australia summer of 2005. Which means I had it over 1.5 years before diagnoses and treatment. (Was very sick for approx 8 months and then started feeling somewhat better but would relapse (Chronic fatigue like symptoms))
4)Can you test for the chronic forms of the bacteria here in the states and/or PCR? Australia has it but I don't know  if US has it?

(The ID doctor only had me on 2 weeks of doxy. Now I am on a new protocol basically low dose pulsed multiple antibiotics (mino, azithro and next clindy).

I think you are providing a wonderful public service with this forum, I sincerly appreciate your comments, input, suggestions! I

[Philip D Parks, MD, MPH, MOccH, FACOEM]

Dear Celeste:

Yes, but not extensive experience -- it is rare to find providers with lots of experience with Q fever.

What are your questions?

I'll do my best.

~*~ Dr. Parks