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The Fog of Q fever. Reasons for following up patients with Q fever Chronic Q fever Q fever endocarditis Newport follow up Conclusions. Reasons for follow up. Establish at risk patients Preventative / Pre-emptive treatment of at risk patients Diagnose Chronic Q fever

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Presentation Transcript
slide2
Reasons for following up patients with Q fever
  • Chronic Q fever
  • Q fever endocarditis
  • Newport follow up
  • Conclusions
reasons for follow up
Reasons for follow up
  • Establish at risk patients
  • Preventative / Pre-emptive treatment of at risk patients
  • Diagnose Chronic Q fever
  • Treat Q fever endocarditis before valve destruction
  • Reassurance
chronic q fever
Chronic Q Fever
  • Endocarditis
  • Hepatitis
  • Osteomyelitis
  • Osteoarthritis
  • Chronic Lung Infection
  • Vascular infection
  • Chronic Fatigue Syndrome
  • Chronic infection of Pregnancy
  • Coxiella burnetii may persist in the host even after apparent clinical recovery
endocarditis
Endocarditis
  • Raised Phase 1 IgG >800
  • Compatible clinical syndrome
    • (Dukes Criteria)
endocarditis8
Endocarditis
  • Difficult to diagnose
  • Asymptomatic
  • Clinically and histologically silent
  • No fever, normal ESR and FBC
  • Treatment is problematical
treatment vs side effects
Treatment vs Side Effects

Is the treatment worse than the disease?

follow up after acute q fever
Follow up after Acute Q fever
  • Who should you follow up?
  • How long for?
  • For what purpose?
  • Is serological follow up beneficial?
wilson et al
Wilson et al
  • Recurrence after 20 years
  • 16 patients with endocarditis
  • Longest proven interval 7 years
  • Probable intervals based on histories 20, 15, 14, 11
powell o aust ann med 1960
Powell O, Aust Ann Med, 1960
  • Patient declared episode of acute Q fever in 1945
  • Presented 1957 with endocarditis
  • Blood cultures sterile
  • Died 3 months after admission
  • Vegetations seen at autopsy
  • C. burnetii seen on histology
  • S. aureus grown from valve
palmer 1982 lancet
Palmer 1982 Lancet
  • Cases of Q fever reported to PHLS
newport outbreak 2002
Newport Outbreak 2002
  • Acute Q Fever 106
    • 80% (85) symptomatic
  • Negative 96
  • Negative + Symptoms 37
  • Uncertain serology + Sx 11
  • Uncertain serology 12
follow up
Follow up
  • All cases of acute Q fever
  • All patients with uncertain serology
  • 97 Patients seen
  • Monitoring for
    • Signs of endocarditis
    • Serological evidence of Chronic Q fever
case history
Case History
  • Pneumonia September 2002
  • Treated with doxycycline
  • Serologically negative June 2003 (9 months)
  • Low level titres (past infection) October 2005
conclusion
Conclusion
  • Serological follow up?
  • Do all cases seroconvert?
  • How long to monitor for seroconversion?
slide32
Establish patients at risk – pre-emptive treatment
  • Diagnose cases of Chronic Q fever
  • Institute early treatment before valve destruction
  • Provide reassurance
q fever endocarditis
Q fever Endocarditis
  • 1 Case
  • Diagnosed 18 months after acute infection
  • Asymptomatic
  • Phase 1 IgG 10,240
  • CFT 64
  • CRP 35
  • Treated with 2 years of Doxycycline and Hydroxychloroquine
slide36

Powell 1962,

  • Spelman 1982 95% at 1 year
  • Dupuis 1985,
  • Marmion 1985 60% at 4 months
  • Edlinger 1985 60% at 1 year
conclusion50
Conclusion
  • Phase 1 titre develops in first year
  • Length of follow up 1 year
    • ? 4 months
  • If no titre > 800 at 1 year then ? discharge
  • If titre settles ? Discharge
conclusions
Conclusions
  • Clinical syndrome + phase 1 IgG => Chronic Q Fever
  • Raised phase 1 IgG alone ??
  • Follow up uncertain
  • Management uncertain
  • Treatment problematical
  • Slow indolent infection
  • Recovered non sterilising infection
  • Recrudescence
slide54
Follow up?
  • Reassure and recommend mentioning past Q fever infection at any subsequent contact with Health Services
future plans
Future Plans
  • Clinical Study
  • Confirm current assumptions re follow up
  • Continued follow up of anybody with raised phase 1 titre
  • Regular Echocardiogram
  • Ongoing collaboration
  • PCR
acknowledgements
Acknowledgements
  • Meirion Llewelyn
  • Hugo Van Woerden
  • Graham Lloyd
  • Howard Tolley
  • James Pitman
  • Diana Westmoreland
  • Many others
modified duke criteria
Modified Duke Criteria
  • Major criteria
  • 2 separate positive BCs consistent with IE
  • 1 positive BC for C. brunetii or antiphase-I immunoglobulin G antibody titer >1:800
  • Positive echocardiogram
  • Minor criteria
  • Predisposition
  • Fever
  • Vascular phenomena
  • Microbiological evidence: positive BC that does not meet major criteria or serological evidence of infection