Acute Q fever in children presenting with encephalitis

Case Report: Α Case of Endocarditis and Embolic Stroke in a Child, Suggestive of Acute Q Fever Infection

Acute Q fever is usually asymptomatic or is associated with a mild self-limited course and a favorable outcome. The occurrence of endocarditis during acute infection by Coxiella burnetii is an emerging clinical entity observed in adults that has been attributed to an autoimmune complication of early infection. Herein, we report the first case of a previously healthy 2-year-old child with endocarditis complicated by septic embolic stroke, in which the identified microbiological evidence was suggestive of acute rather than chronic C. burnetii infection. The development of endocarditis in this case occurred in the absence of any autoimmune reaction, but in the context of a very mild form of congenital heart disease, a small ventricular septal defect, which might serve as a predisposing factor for endocarditis. This case suggests that acute Q fever endocarditis may affect children as well and can be attributed not only to autoimmune mechanisms but also to a potential effect of the infectious agent per se on the cardiac endothelium in patients with underlying heart defects, regardless of their severity.

Pediatric Q Fever

Purpose of Review

The non-specific presentation of acute Q fever makes it difficult to diagnose in children, but untreated Q fever can result in chronic infections that have severe complications.

Recent Findings

Pediatric Q fever cases continue to be infrequently reported in the literature, and primarily document cases of persistent infections with Coxiella burnetii. Standardized treatment protocols for chronic Q fever in children still do not exist. Doxycycline and hydroxychloroquine are the treatment combination most utilized by healthcare providers to treat Q fever endocarditis or osteomyelitis in children, but a variety of other antibiotic combinations have been reported with varying results. The use of adjunctive therapies, such as such as interferon gamma, has produced mixed outcomes.

Summary

The true impact of Coxiella burnetii on the health of children remains unknown; long-term longitudinal follow-up of children with acute or chronic Q fever has not been reported. Both the acute and chronic forms of Q fever are underreported and underdiagnosed. Healthcare providers should consider Q fever in pediatric patients with culture-negative endocarditis or osteomyelitis.

Infectious encephalitis: Management without etiological diagnosis 48hours after onset

Introduction

The etiological diagnosis of infectious encephalitis is often not established 48 hours after onset. We aimed to review existing literature data before providing management guidelines.

Method

We performed a literature search on PubMed using filters such as “since 01/01/2000”, “human”, “adults”, “English or French”, and “clinical trial/review/guidelines”. We also used the Mesh search terms “encephalitis/therapy” and “encephalitis/diagnosis”.

Results

With Mesh search terms “encephalitis/therapy” and “encephalitis/diagnosis”, we retrieved 223 and 258 articles, respectively. With search terms “encephalitis and corticosteroid”, we identified 38 articles, and with “encephalitis and doxycycline” without the above-mentioned filters we identified 85 articles. A total of 210 articles were included in the analysis.

Discussion

Etiological investigations must focus on recent travels, animal exposures, age, immunodeficiency, neurological damage characteristics, and potential extra-neurological signs. The interest of a diagnosis of encephalitis for which there is no specific treatment is also to discontinue any empirical treatments initially prescribed. Physicians must consider and search for autoimmune encephalitis.

From Q Fever to Coxiella burnetii Infection: a Paradigm Change

Coxiella burnetii is the agent of Q fever, or "query fever," a zoonosis first described in Australia in 1937. Since this first description, knowledge about this pathogen and its associated infections has increased dramatically. We review here all the progress made over the last 20 years on this topic. C. burnetii is classically a strict intracellular, Gram-negative bacterium. However, a major step in the characterization of this pathogen was achieved by the establishment of its axenic culture. C. burnetii infects a wide range of animals, from arthropods to humans. The genetic determinants of virulence are now better known, thanks to the achievement of determining the genome sequences of several strains of this species and comparative genomic analyses. Q fever can be found worldwide, but the epidemiological features of this disease vary according to the geographic area considered, including situations where it is endemic or hyperendemic, and the occurrence of large epidemic outbreaks. In recent years, a major breakthrough in the understanding of the natural history of human infection with C. burnetii was the breaking of the old dichotomy between "acute" and "chronic" Q fever. The clinical presentation of C. burnetii infection depends on both the virulence of the infecting C. burnetii strain and specific risks factors in the infected patient. Moreover, no persistent infection can exist without a focus of infection. This paradigm change should allow better diagnosis and management of primary infection and long-term complications in patients with C. burnetii infection.

Molecular screening of Ctenocephalides felis fleas collected from stray cats in the Jerusalem District, Israel, for Bartonella spp., Rickettsia spp. and Coxiella burnetii

Four hundred and sixty seven Ctenocephalides felis fleas removed from 185 feral cats living in residential areas of Jerusalem, Israel, were screened for bacterial infections of public health importance. The fleas were screened for bartonellae, rickettsiae and Coxiella burnetii by PCR and sequencing. Bartonella DNA was detected in 156 individual fleas collected from 91 of the 185 (49.2%) cats. DNA of Bartonella clarridgeiae, Bartonella henselae and Bartonella koehlerae was detected in 112/467 (24%), 29/467 (6.2%) and 15/467 (3.2%), respectively, indicating a significantly different distribution (P<0.00001) of these Bartonella spp. among the fleas. However, no differences were observed between female and male fleas in their Bartonella-infection status (P>0.05). Ninety one individual cats carried fleas infected with 1 to 3 Bartonella species. No differences were found between fleas collected from male and female, pregnant and non-pregnant or young, juvenile and adult cats. Interestingly, a significant association was observed between the clinical status of the cat hosts (apparently healthy versus sick) and the carriage of Bartonella-positive fleas. One of the 467 (0.2%) fleas was positive for Rickettsia felis DNA and no other Rickettsia spp. or C. burnetii DNA were detected. Our findings indicate a relatively high prevalence of Bartonella spp. known to be human pathogens, and low prevalence of R. felis in fleas from the Jerusalem district cats, highlighting the abundance and importance of bartonellae for public health in this urban region.

Pediatric acute Q fever mimics other common childhood illnesses

Knowledge of Q fever has increased over the last decades, but research has mainly focused on adults. Data in children are scarce, and current knowledge is mostly based on case reports. The aim of this study was to determine predictors for acute Q fever in children in the general population. We retrospectively studied all children tested for Coxiella burnetii by serology and/or PCR upon request of their general practitioner in the regional laboratory for Medical Microbiology of the Jeroen Bosch during the Q fever outbreak in the Netherlands between 2007 and 2011. A total of 1061 patients was analyzed. Influenza-like illness and respiratory tract infection were the most common presentations of acute Q fever, mimicking other common childhood illnesses. None of the reported symptoms was significantly related to a positive test outcome and therefore presenting signs or symptoms have no predictive value in diagnosing Q-fever in children. Only diagnostic tests are reliable. As the infection generally follows a mild and uncomplicated course, we question if the difficulty of recognizing pediatric Q fever is a problem worth solving.

The uncommon causes of status epilepticus: a systematic review

This paper reports the first systematic review of uncommon causes of status epilepticus reported in the literature between 1990 and 2008. Uncommon causes are defined as those not listed in the main epidemiological studies of status epilepticus. 181 causes were identified. These were easily categorised into 5 specific aetiological categories: immunological disorders, mitochondrial disorders, infectious diseases, genetic disorders and drugs/toxins. A sixth category of 'other causes' has also been included. Knowledge of these causes is important for clinical management and treatment, and also for a better understanding of the pathophysiology of status epilepticus.

A suggested approach to the etiologic evaluation of status epilepticus in children: what to seek after the usual causes have been ruled out

Status epilepticus represents a true neurologic emergency that requires immediate treatment to stop seizure activity and prompt diagnostic evaluation to recognize potentially treatable causes. Although an etiology may be detected in many cases, in a significant number of patients the cause is not established by the usual laboratory or neuroimaging studies. We performed an extensive literature review of all unusual and often overlooked causes of status epilepticus in children, in an attempt to provide physicians with practical information on the diagnostic approach to patients, particularly those with refractory status epilepticus, for whom an etiology can not be detected by routine diagnostic protocols.