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The Fog of Q fever

The Fog of Q fever

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The Fog of Q fever

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  1. The Fog of Q fever

  2. Reasons for following up patients with Q fever • Chronic Q fever • Q fever endocarditis • Newport follow up • Conclusions

  3. 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

  4. Preventative therapyRaoult et al

  5. Early Treatment

  6. 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

  7. Endocarditis • Raised Phase 1 IgG >800 • Compatible clinical syndrome • (Dukes Criteria)

  8. Endocarditis • Difficult to diagnose • Asymptomatic • Clinically and histologically silent • No fever, normal ESR and FBC • Treatment is problematical

  9. Clinically Silent

  10. Histologically Silent

  11. Long Term Persistence

  12. Problematical Treatment

  13. Treatment vs Side Effects Is the treatment worse than the disease?

  14. Follow up after Acute Q fever • Who should you follow up? • How long for? • For what purpose? • Is serological follow up beneficial?

  15. Duration of Follow up

  16. 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

  17. 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

  18. Palmer 1982 Lancet • Cases of Q fever reported to PHLS

  19. Men

  20. Women

  21. BMJ 199912 year risk of Endocarditis

  22. Who to follow up

  23. Newport Outbreak 2002 • Acute Q Fever 106 • 80% (85) symptomatic • Negative 96 • Negative + Symptoms 37 • Uncertain serology + Sx 11 • Uncertain serology 12

  24. 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

  25. Case History • Pneumonia September 2002 • Treated with doxycycline • Serologically negative June 2003 (9 months) • Low level titres (past infection) October 2005

  26. Symptoms according to Status

  27. Conclusion • Serological follow up? • Do all cases seroconvert? • How long to monitor for seroconversion?

  28. For what purpose?

  29. Establish patients at risk – pre-emptive treatment • Diagnose cases of Chronic Q fever • Institute early treatment before valve destruction • Provide reassurance

  30. 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

  31. Who develops phase 1 and when?

  32. Powell 1962, • Spelman 1982 95% at 1 year • Dupuis 1985, • Marmion 1985 60% at 4 months • Edlinger 1985 60% at 1 year

  33. What does the phase 1 titre mean?

  34. Development of Phase 1 IgG

  35. Most recent titre vs Highest titre

  36. 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