Acute Q fever in southern Taiwan: atypical manifestations of hyperbilirubinemia and prolonged fever

Overview of infection causing hepatitis other than non-A to E hepatitis virus during pregnancy

Abnormal liver function tests during pregnancy are common. While hepatic injury during pregnancy mostly has minimal adverse influence on maternal and fetal outcomes, severe maternal and fetal morbidities, and even death, sometimes occur. Here, we review the epidemiology, clinical features, diagnosis, and management of hepatitis during pregnancy caused by the less common pathogens, including Epstein-Barr virus (EBV), cytomegalovirus (CMV), herpes simplex viruses (HSVs), dengue fever, malaria, leptospirosis, Q fever, typhoid fever, and other occasional infections, as well as the implications on breastfeeding of the infants. Hepatitis during pregnancy with fever and systemic clinical presentations, which are not attributable to the common infectious agents, should raise the suspicion of infection with above-mentioned pathogens, and appropriate laboratory tests are required. Early recognition of severe hepatitis or acute liver failure is critical in initiating appropriate and specific therapy, together with systemic supportive care, to reduce maternal and fetal mortality and long-term sequelae.

Characteristics of scrub typhus, murine typhus, and Q fever among elderly patients: Prolonged prothrombin time as a predictor for severity

BACKGROUND/PURPOSE

The clinical manifestations of scrub typhus, murine typhus and acute Q fever in the elderly are not clear.

METHODS

We conducted a retrospective study to identify the characteristics of the elderly aged ≥65 years with a comparison group aged 18-64 years among patients with scrub typhus, murine typhus, or acute Q fever who were serologically confirmed at three hospitals in Taiwan during 2002-2011.

RESULTS

Among 441 cases, including 187 cases of scrub typhus, 166 acute Q fever, and 88 murine typhus, 68 (15.4%) cases were elderly patients. The elderly had a higher severe complication rate (10.3% vs. 3.5%, p = 0.022), but did not have a significantly higher mortality rate (1.47% vs. 0.54%, p = 0.396). Compared with those without severe complications, we found the elderly (p = 0.022), dyspnea (p = 0.006), less relative bradycardia (p = 0.004), less febrile illness (p = 0.004), prolonged prothrombin time (PT) (p = 0.002), higher levels of initial C-reactive protein (p = 0.039), blood leukocyte counts (p = 0.01), and lower platelet counts (p = 0.012) are significantly associated with severe complications. Only prolonged prothrombin time was associated with severe complications in multivariate analysis (p = 0.018, CI 95% 0.01-0.66). Among clinical symptoms and laboratory data, multivariate analysis revealed chills was less frequently occurred in the elderly (p = 0.012, 95% confidence interval [CI]: 1.33-9.99).

CONCLUSION

The elderly cases with scrub typhus, murine typhus, or acute Q fever would be more likely to have severe complications, for which prothrombin time prolongation is an important predictor for severe complications.

Acute Q fever in febrile patients in northwestern of Iran

BACKGROUND

Q fever is an endemic disease in different parts of Iran. This study aimed to investigate the prevalence of acute Q fever disease among at-risk individuals in northwestern Iran.

METHODOLOGY

An etiological study was carried out in 2013 in Tabriz County. A total of 116 individuals who were in contact with livestock and had a nonspecific febrile illness were enrolled in the study. IgG phase II antibodies against Coxiella burnetii were detected using ELISA.

PRINCIPAL FINDINGS

The prevalence of acute Q fever was 13.8% (95% confidence interval [CI]: 8.0, 21.0%). Headache (87.5%) and fatigue and weakness (81.3%) were the dominant clinical characteristics among patients whit acute Q fever. Acute lower respiratory tract infection and chills were poorly associated with acute Q fever. Furthermore, 32% (95% CI: 24, 41%) of participants had a history of previous exposure to Q fever agent (past infection). Consumption of unpasteurized dairy products was a weak risk factor for previous exposure to C. burnetii.

CONCLUSION

This study identified patients with acute Q fever in northwestern of Iran. The evidence from this study and previous studies conducted in different regions of Iran support this fact that Q fever is one of the important endemic zoonotic diseases in Iran and needs due attention by clinical physicians and health care system.

Identification of factors for physicians to facilitate early differential diagnosis of scrub typhus, murine typhus, and Q fever from dengue fever in Taiwan

BACKGROUND

Dengue fever, rickettsial diseases, and Q fever are acute febrile illnesses with similar manifestations in tropical areas. Early differential diagnosis of scrub typhus, murine typhus, and Q fever from dengue fever may be made by understanding the distinguishing clinical characteristics and the significance of demographic and weather factors.

METHODS

We conducted a retrospective study to identify clinical, demographic, and meteorological characteristics of 454 dengue fever, 178 scrub typhus, 143 Q fever, and 81 murine typhus cases in three Taiwan hospitals.

RESULTS

Case numbers of murine typhus and Q fever correlated significantly with temperature and rainfall; the scrub typhus case number was only significantly related with temperature. Neither temperature nor rainfall correlated with the case number of dengue fever. The rarity of dengue fever cases from January to June in Taiwan may be a helpful clue for diagnosis in the area. A male predominance was observed, as the male-to-female rate was 2.1 for murine typhus and 7.4 for Q fever. Multivariate analysis revealed the following six important factors for differentiating the rickettsial diseases and Q fever group from the dengue fever group: fever ≥8 days, alanine aminotransferase > aspartate aminotransferase, platelets >63,000/mL, C-reactive protein >31.9 mg/L, absence of bone pain, and absence of a bleeding syndrome.

CONCLUSION

Understanding the rarity of dengue in the first half of a year in Taiwan and the six differentiating factors may help facilitate the early differential diagnosis of rickettsial diseases and Q fever from dengue fever, permitting early antibiotic treatment.

Murine typhus in southern Taiwan during 1992-2009

Clinical information regarding murine typhus in Taiwan is limited. In this study, 81 cases of serologically documented murine typhus during 1992-2009 at four referral hospitals in southern Taiwan were analyzed. There was a significant correlation between average environmental temperature and case numbers of murine typhus (r = 0.747, P = 0.005). Acute hepatitis was found in 67% of cases, and hyperbilirubinemia (serum total bilirubin ≥ 23.9 μmol/L) was found in 38%. The intervals between the initiation of appropriate therapy to defervescence were longer in patients with hyperbilirubinemia than those without hyperbilirubinemia (6.1 versus 4.1 days; P = 0.015). Nine (11.1%) showed development of severe illnesses such as acute respiratory distress syndrome (2 patients), aseptic meningitis (3), and acute renal failure (4). Only one died of acute respiratory distress syndrome. Cases of murine typhus were often found during the summer and had acute febrile hepatitis. Those patients with hyperbilirubinemia tended to have a delayed recovery even with appropriate therapy.

[Prolonged fever and jaundice in a patient with alcoholic liver disease]

We report the case of a 40-year-old man with underlying alcoholic liver disease who presented with prolonged fever, jaundice and liver failure associated with Coxiella burnetii infection. After diagnosis and appropriate antibiotic treatment, the patient made a complete recovery. We describe aspects of this case and provide a practical review of the literature on the topic. We also discuss the importance of this infection and the need for its inclusion in the differential diagnosis of this clinical picture.

Epidemiology of acute q Fever, scrub typhus, and murine typhus, and identification of their clinical characteristics compared to patients with acute febrile illness in southern taiwan

BACKGROUND/PURPOSE

In Taiwan, acute Q fever, scrub typhus, and murine typhus (QSM diseases) are the most common rickettsioses, but their epidemiology and clinical characteristics have not been clarified. Diagnosis of these three diseases based on clinical manifestations is difficult, and most of their reported characteristics are identified by describing the predominant manifestations, without being compared with other diseases.

METHODS

Serological tests for QSM diseases were examined simultaneously in patients suspected of the three diseases, regardless of which one was suspected. Clinical manifestations were recorded retrospectively from their charts. The characteristics of QSM diseases were identified by comparison with patients who had non-QSM diseases.

RESULTS

From April 2004 to April 2007, a total of 226 cases of suspected QSM diseases were included. One hundred (44.2%) cases were serologically confirmed as QSM diseases (68 acute Q fever, 23 scrub typhus, and 9 murine typhus), and 126 (55.8%) cases were non-QSM diseases. Only 33 cases (33.0%) of QSM diseases were initially suspected at the time of hospital visit, whereas 54 cases (42.9%) of non-QSM diseases were incorrectly suspected as QSM diseases. Cases of Q fever and scrub typhus were distributed over plain and mountain areas, respectively. By multivariate analysis, relative bradycardia (OR [95% CI], 2.885 [1.3-6.4]; p = 0.009), radiographic hepatomegaly (OR [95% CI], 4.454 [1.6-12.3]; p = 0.004), and elevated serum aminotransferases (OR [95% CI], 5.218 [1.2-23.1]; p = 0.029) were independent characteristics for QSM diseases, and leukocytosis (OR [95% CI], 0.167 [0.052-0.534]; p = 0.003) was negative for the diagnosis of QSM diseases.

CONCLUSION

In southern Taiwan, acute Q fever is the most common rickettsiosis. QSM diseases should be suspected in febrile patients who present with relative bradycardia, hepatomegaly, and elevated serum aminotransferases, but without leukocytosis.