Primary and secondary arterial fistulas during chronic Q fever

Homemade pericardial bifurcated graft for Q fever-infected abdominal aortic aneurysm open repair: a case report

Q fever is a zoonotic infection caused by Coxiella burnetii. In rare cases, it can lead to vascular complications, including infected aneurysms. Successful treatment involves surgery and antibiotics, but there is no established consensus or clear recommendation for the choice of material graft. We report a case of abdominal aortic aneurysm infected by C. burnetii treated by open surgery with complete resection of the aneurysm and homemade bovine pericardial bifurcated graft reconstruction and long-term antibiotherapy using doxycycline. One year postoperatively, the patient had no sign of persistent infection or vascular complication. Moreover, C. burnetii immunoglobulins titers decreased 6 months postoperatively.

Inpatient Q Fever Frequency Is on the Rise

Background

Q fever is a zoonotic bacterial infection caused by Coxiella burnetii that is reportable in the USA. This infection is often asymptomatic; acute infection usually manifests as a self-limited febrile illness, hepatitis, or pneumonia. Chronic infection (usually infective endocarditis) often affects patients with valvulopathy or immunosuppression. Herein, we study the inpatient frequency of Q fever in the United States.

Methods

We used a nationwide inpatient sample (NIS) for our retrospective cohort study to include hospitalizations with a diagnosis of Q fever between 2010 and 2019. Survey procedures were applied to accommodate for complex sampling design of NIS. Chi-square and least-square means were used for categorical and continuous variables, respectively. Jonckheere-Terpstra test was used to study the trends over the years. SAS 9.4 was used for data mining and analysis.

Results

A total of 2,685 hospitalizations with a diagnosis of Q fever were included, among which 451 (17%) cases had a concurrent diagnosis of infective endocarditis. The mean age of patients was 58 years, and less than a third was female. Our analysis demonstrated that infective endocarditis was the most common cardiac complication associated with Q fever and was associated with increased inpatient mortality (p value <0.001). There is a trend of an increase in cases of inpatient Q fever with or without endocarditis over the years (p value <0.05). Q fever cases were more common across the Pacific and the South Atlantic divisions.

Conclusion

Physicians should be aware of an increasing trend of hospitalized patients with Q fever and the significant association with infective endocarditis. Further studies are needed.

Primary and subsequent secondary aorto-enteric fistulae in the setting of chronic Q fever

We report the case of an 80-year-old male with stage three kidney disease, who survived a primary aorto-enteric fistula (AEF) in the setting of chronic Q fever after presenting with melena and syncope. His initial surgical treatment included endovascular aortic repair. Type 2 endoleak was present post-operatively. Six months later, he was diagnosed with a secondary AEF after syncope and large volume hematemesis. He was definitively treated with an open explant of his stent, repair of the duodenum and bilateral axillofemoral bypass. Two years later, he remains active and independent on life-long antibiotics.

Molecular diagnosis of Coxiella burnetii in culture negative endocarditis and vascular infection in South Korea

BACKGROUND

Q fever endocarditis is a major cause of culture-negative endocarditis. The role of Coxellia burnetii is underestimated because it is difficult to diagnose. We investigated the significance of C. burnetii as the cause of culture-negative endocarditis and vascular infection by examining blood and tissue specimens using serological testing and polymerase chain reaction (PCR).

METHODS

All patients with infective endocarditis or large vessel vasculitis were prospectively enrolled at a tertiary-care hospital from May 2016 through September 2020. Q fever endocarditis and vascular infection were diagnosed based on: (1) positive PCR for a cardiac valve or vascular tissue, (2) positive PCR for blood or phase I immunoglobulin G (IgG) ≥ 6400, or (3) phase I IgG ≥ 800 and < 6400 with morphologic abnormality. PCR targeted C. burnetii transposase gene insertion element IS1111a.

RESULTS

Of the 163 patients, 40 (25%) had culture-negative endocarditis (n = 35) or vascular infection (n = 5). Of the 40 patients, 24 (60%) were enrolled. Eight (33%) were diagnosed with Q fever endocarditis or vascular infection. Of these 8 patients, 6 had suspected acute Q fever endocarditis or vascular infection with negative phase I IgG. Six patients were not treated for C. burnetii, 4 were stable after surgery. One patient died due to surgical site infection after 5 months post-operatively and one died due to worsening underlying disease.

CONCLUSIONS

Approximately one-third of patients with culture-negative endocarditis and vascular infection was diagnosed as Q fever. Q fever endocarditis and vascular infection may be underestimated in routine clinical practice in South Korea.KEY MESSAGEQ fever endocarditis and vascular infection may be underestimated in routine clinical practice, thus, try to find evidence of C. burnetti infection in suspected patients by all available diagnostic tests including PCR.

A systematic review of therapies for aortobronchial fistulae

OBJECTIVE

The aim of the study was to summarize epidemiologic data about aortobronchial fistulas and compare outcomes (mortality, recurrence, re-operation) of open, staged, and endovascular repair of aortobronchial fistula.

METHODS

A systematic literature review was conducted to identify eligible studies published between January of 1999 and December of 2019. The Cochrane Library, PubMed and Scopus databases were used as search engines. Eligible studies included articles reporting postoperative outcomes (death/follow-up). Literature review revealed only case reports and small case series and thus, only descriptive data with data heterogeneity was available. The corresponding authors were contacted to provide additional information or outcome updates (recurrence/reoperation/death).

RESULTS

Overall, 214 patients (90 studies) underwent 271 procedures (including re-do procedures and staged procedures). Most of the patients were treated by endovascular means (72.42%). Open surgical repair was performed in 21.96% and staged procedures in 5.6%. Aortobronchial fistulae located most often in the descending thoracic aorta (Zone 3,4) (64,6%) and in Zone 2 (23,8%). Fourteen percent of aortobronchial fistulae developed after thoracic endovascular aneurysm repair. Recurrence or infection occurred in 20% (43 patients). Recurrences were at some extend associated with the presence of endoleak. Long-term antibiotic administration (>1 month) was instituted in 63 patients (29.4%), whilst 90 patients (42%) did not receive antibiotics beyond hospitalization. From the remaining 61, 3 received life-long antibiotics and for 58 patients data were not available. Considering outcomes, mean follow-up was 25.1 months (0-188 months) and not significantly different among treatments.

LIMITATIONS

Literature review has revealed only case reports and small case series and thus, only descriptive data were available. Randomized controlled trials are not available due to the rarity of the disease which significantly decreases the power of the present study. Also, this study reflects significant data heterogeneity due to the nature of the analyzed manuscripts and would benefit from large patient cohort studies which till today have not been conducted.

CONCLUSION

Aortobronchial fistula is a complex disease. Endoleaks may be involved in the development and in recurrence process and they should not be disregarded. Considering major outcomes (length of follow-up), the available treating strategies are equal and thus, surgeons should feel confident to apply the treatment of their choice, taking in mind their experience, patient's age, and clinical condition.

Polymicrobial Infections Among Patients with Vascular Q Fever, France, 2004-2020

We report 5 cases of vascular Q fever complicated by polymicrobial superinfection in patients who had no risk factors for acute Q fever. Q fever was diagnosed by serologic and molecular assays for Coxiella burnetii. We confirmed additional infections using conventional graft cultures.

Imaging features of mycotic aortic aneurysms

Infectious aortitis (IA) is a rare and life-threatening cardiovascular disease. Early diagnosis and timely intervention are crucial for reducing mortality associated with mycotic aortic aneurysms (MAAs); however, early diagnosis is challenging due to the nonspecific symptoms. Some cases are diagnosed at an advanced stage or after developing complications, such as rupture or aortic fistula. Current state-of-the-art imaging modalities-including computed tomography (CT), magnetic resonance imaging (MRI), and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT-can detect infected aneurysms in clinically suspicious cases. MAA features on imaging include lobulated pseudoaneurysm, indistinct irregular arterial wall, perianeurysmal gas, perianeurysmal edema, perianeurysmal soft tissue mass, aneurysmal thrombosis, and high metabolic activity with increased uptake of FDG. Enlarged lymph nodes are often found adjacent to the aneurysm, while iliopsoas abscess (IPA), spondylitis, and aortic fistulas are commonly associated complications. After surgery or endovascular repair, radiological features-including ectopic gas, peri-graft fluid, thickening of adjacent bowel, pseudoaneurysm formed at the graft anastomosis, and increased uptake of FDG-may indicate an infection of aortic graft. This article provides an overview of the clinical and imaging features of MAAs. Thus, familiarity with the imaging appearances of MAAs may assist radiologists in the diagnosis and facilitation of timely treatment.

Q fever aortic infection causing an aortoduodenal fistula after endovascular aneurysm repair

An aortoduodenal fistula is a rare complication of endovascular aortic aneurysm repair. Q fever infection is known for its vascular tropism, and arterial fistulas have been reported in association with Coxiella burnetii infections. We report the case of a 78-year-old patient who had developed an aortoduodenal fistula secondary to vascular Q fever 5 years after he had been treated with an aortic endograft. Explantation of the endograft, autogenous reconstruction using the neo-aortoiliac system procedure, and duodenal repair were performed as a curative surgical treatment of this serious vascular condition. At the 9-month follow-up examination, the patient showed no signs of recurrent vascular infection and was instructed to complete an 18-month antibiotic regimen.

A systematic review on the health outcomes associated with non-endocarditis manifestations of chronic Q fever

The aim of this study was to systematically review the non-endocarditis manifestations of chronic Q fever and understand the significance of non-specific symptoms like pain and fatigue in chronic endovascular, osteomyelitis and abscess due to chronic Q fever. We performed a systematic review using Pub Med (the National Library of Medicine (NLM)) and Scopus databases. All studies in English on chronic Q fever that listed clinical manifestations other than infective endocarditis (IE) and chronic fatigue syndrome (CFS). Meta-analysis was carried out to investigate the effects of patient's health outcomes (pain, fatigue, the need for surgery and mortality) on vascular infections, osteomyelitis and abscess. Among cases not presenting as IE or CFS, vascular infections and osteomyelitis were the most common chronic Q fever disease manifestations. There were distinct regional patterns of disease. Compared with infective endocarditis, these are significantly associated with increased risk of pain: osteomyelitis (relative risk (RR) = 4.13, 95% confidence interval (CI) 3.36-5.07), abscess (RR = 3.59, 95% CI 3.28-3.93) and vascular infection (RR = 2.46, 95% CI 1.99-3.03). The strongest significant association was observed between osteomyelitis and pain. There was no significant association between fatigue and these manifestations. Clinicians have to be aware of uncommon manifestations of chronic Q fever as they present with non-specific symptoms and are significantly associated with increased risk of morbidity and mortality. The findings emphasise the need to investigate patients with positive chronic Q fever serology presenting with acute or chronic pain for possible underlying complications.

Chronic Q Fever with Vascular Involvement: Progressive Abdominal Pain in a Patient with Aortic Aneurysm Repair in the United States

Q fever is a zoonotic bacterial infection caused by Coxiella burnetii. Chronic Q fever comprises less than five percent of all Q fever cases and, of those, endocarditis is the most common presentation (up to 78% of cases), followed by vascular involvement. Risk factors for chronic Q fever with vascular involvement include previous vascular surgery, preexisting valvular defects, aneurysms, and vascular prostheses. The most common symptoms of chronic Q fever with vascular involvement are nonspecific, including weight loss, fatigue, and abdominal pain. Criteria for diagnosis of chronic Q fever include clinical evidence of infection and laboratory criteria (antibody detection, detection of Coxiella burnetii DNA, or growth in culture). Treatment of chronic Q fever with vascular involvement includes a prolonged course of doxycycline and hydroxychloroquine (≥18 months) as well as early surgical intervention, which has been shown to improve survival. Mortality is high in untreated chronic Q fever. We report a case of chronic Q fever with vascular involvement in a 77-year-old man with prior infrarenal aortic aneurysm repair, who lived near a livestock farm in the southeastern United States.

Clinical Features and Complications of Coxiella burnetii Infections From the French National Reference Center for Q Fever

IMPORTANCE

Q fever remains widespread throughout the world; the disease is serious and causes outbreaks and deaths when complications are not detected. The diagnosis of Q fever requires the demonstration of the presence of Coxiella burnetii and the identification of an organic lesion.

OBJECTIVE

To describe the hitherto neglected clinical characteristics of Q fever and identifying risk factors for complications and death.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study conducted from January 1, 1991, through December 31, 2016, included patients treated at the French National Reference Center for Q fever with serologic findings positive for C burnetii and clinical data consistent with C burnetii infection. Clinical data were prospectively collected by telephone. Patients with unavailable clinical data or an unidentified infectious focus were excluded.

MAIN OUTCOMES AND MEASURES

Q fever complications and mortality.

RESULTS

Of the 180 483 patients undergoing testing, 2918 had positive findings for C burnetii and 2434 (68.8% men) presented with clinical data consistent with a C burnetii infection. Mean (SD) age was 51.8 (17.4) years, and the ratio of men to women was 2.2. At the time of inclusion, 1806 patients presented with acute Q fever, including 138 with acute Q fever that progressed to persistent C burnetii infection, and 766 had persistent focalized C burnetii infection. Rare and hitherto neglected foci of infections included lymphadenitis (97 [4.0%]), acute Q fever endocarditis (50 [2.1%]), hemophagocytic syndrome (9 [0.4%]), and alithiasic cholecystitis (11 [0.4%]). Vascular infection (hazard ratio [HR], 3.1; 95% CI, 1.7-5.7; P < .001) and endocarditis (HR, 2.4; 95% CI, 1.1-5.1; P = .02) were associated with an increased risk of death. Independent indicators of lymphoma were lymphadenitis (HR, 77.4; 95% CI, 21.2-281.8; P < .001) and hemophagocytic syndrome (HR, 19.1; 95% CI, 3.4-108.6; P < .001). The presence of anticardiolipin antibodies during acute Q fever has been associated with several complications, including hepatitis, cholecystitis, endocarditis, thrombosis, hemophagocytic syndrome, meningitis, and progression to persistent endocarditis.

CONCLUSIONS AND RELEVANCE

Previously neglected foci of C burnetii infection include the lymphatic system (ie, bone marrow, lymphadenitis) with a risk of lymphoma. Cardiovascular infections were the main fatal complications, highlighting the importance of routine screening for valvular heart disease and vascular anomalies during acute Q fever. Routine screening for anticardiolopin antibodies during acute Q fever can help prevent complications. Positron emission tomographic scanning could be proposed for all patients with suspected persistent focused infection to rapidly diagnose vascular and lymphatic infections associated with death and lymphoma, respectively.