Q fever pneumonia

Chest CT findings in community-acquired pneumonia due to Coxiella burnetii (Q fever) compared to Streptococcus pneumoniae, a cross sectional study in French Guiana, 2013-2017

OBJECTIVES

Few and small studies previously examined chest CT-scan characteristics of Coxiella burnetii (Cb) community-acquired pneumonia (CAP). Larger studies are needed to guide physicians towards diagnosis of Q fever in case of pneumonia.

METHODS

We conducted a single-center retrospective observational study between 2013 and 2017. All patients with Cb or Streptococcus pneumoniae (Sp) CAP who had a chest CT-scan on admission at Cayenne Hospital (French Guiana) were included. Chest CT-scan were all analyzed by the same expert radiologist.

RESULTS

We included 75 patients with Cb CAP and 36 with Sp CAP. Fifty-nine percent of all patients were men (n = 66) and median age was 52 [IQR = 38-62]. Chest CT-scans of Cb CAP patients revealed 67 alveolar condensations (89 %), 52 ground-glass opacities (69 %), 30 cases of lymphadenopathy(ies) (40 %) and 25 pleural effusions (33 %). Parenchyma lesions caused by Cb were predominantly unilateral (67 %). We found high numbers of alveolar condensations in both Cb and Sp CAP (89 % and 75 %; respectively), but the presence of ground-glass opacities was significantly associated with Cb CAP (69 % versus 30 %; p < 0.01). Cb CAP were associated with more lymphadenopathies (40 % vs 17 %; p = 0.01) while Sp CAP showed more bronchial thickening (19 % versus 3 %; p < 0.01) and (micro)nodule(s) ≤1 cm (25 % vs 3 %, p < 0.01).

CONCLUSIONS

This large study shows that the most typical aspect of chest CT-scan in case of Cb CAP in French Guiana is a unilateral alveolar consolidation associated with ground glass opacities and lymphadenopathies. C. burnetti and S. pneumoniae both most often cause alveolar consolidations, but present some significantly different CT-scan patterns. This could help physicians through therapeutic choices.

From cell culture to cynomolgus macaque: infection models show lineage-specific virulence potential of Coxiella burnetii

Coxiella burnetii is an obligate intracellular pathogen that causes the zoonotic disease Q fever in humans, which can occur in either an acute or a chronic form with serious complications. The bacterium has a wide host range, including unicellular organisms, invertebrates, birds and mammals, with livestock representing the most significant reservoir for human infections. Cell culture models have been used to decipher the intracellular lifestyle of C. burnetii, and several infection models, including invertebrates, rodents and non-human primates, are being used to investigate host-pathogen interactions and to identify bacterial virulence factors and vaccine candidates. However, none of the models replicate all aspects of human disease. Furthermore, it is becoming evident that C. burnetii isolates belonging to different lineages exhibit differences in their virulence in these models. Here, we compare the advantages and disadvantages of commonly used infection models and summarize currently available data for lineage-specific virulence.

The Coxiella Burnetii type IVB secretion system (T4BSS) component DotA is released/secreted during infection of host cells and during in vitro growth in a T4BSS-dependent manner

Coxiella burnetii is a Gram-negative intracellular pathogen and is the causative agent of the zoonotic disease Q fever. To cause disease, C. burnetii requires a functional type IVB secretion system (T4BSS) to transfer effector proteins required for the establishment and maintenance of a membrane-bound parasitophorous vacuole (PV) and further modulation of host cell process. However, it is not clear how the T4BSS interacts with the PV membrane since neither a secretion pilus nor an extracellular pore forming apparatus has not been described. To address this, we used the acidified citrate cysteine medium (ACCM) along with cell culture infection and immunological techniques to identify the cellular and extracellular localization of T4BSS components. Interestingly, we found that DotA and IcmX were secreted/released in a T4BSS-dependent manner into the ACCM. Analysis of C. burnetii-infected cell lines revealed that DotA colocalized with the host cell marker CD63 (LAMP3) at the PV membrane. In the absence of bacterial protein synthesis, DotA also became depleted from the PV membrane. These data are the first to identify the release/secretion of C. burnetii T4BSS components during axenic growth and the interaction of a T4BSS component with the PV membrane during infection of host cells.

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.

Q fever: a contemporary case series from a Belgian hospital

OBJECTIVES

Q fever is a global zoonosis that can cause both acute and chronic infections in humans through aerogenic transmission. Although Q fever was discovered already 80 years ago, this infectious disease remains largely unknown. We studied a case series in a Belgian tertiary care hospital.

METHODS

A laboratory and file query at our department was performed to detect patients who were newly diagnosed with Q fever from 01 January 2005 to 01 October 2014.

RESULTS

In total, 10 acute Q fever and 5 chronic Q fever infections were identified. An aspecific flu-like illness was the prevailing manifestation of acute Q fever, while this was infective endocarditis in chronic Q fever cases. Noteworthy are the high percentage of myocarditis cases in the acute setting and one case of amyloidosis as a manifestation of chronic Q fever. No evolution from acute to chronic Q fever was noted; overall outcome for both acute and chronic Q fever was favourable with a 94% survival rate.

DISCUSSION

Q fever is an infectious disease characterised by a variable clinical presentation. Detection requires correct assessment of the clinical picture in combination with a laboratory confirmation. Treatment and follow-up are intended to avoid a negative outcome.

Community-acquired pneumonia related to intracellular pathogens

Community-acquired pneumonia (CAP) is associated with high rates of morbidity and mortality worldwide; the annual incidence of CAP among adults in Europe has ranged from 1.5 to 1.7 per 1000 population. Intracellular bacteria are common causes of CAP. However, there is considerable variation in the reported incidence between countries and change over time. The intracellular pathogens that are well established as causes of pneumonia are Legionella pneumophila, Mycoplasma pneumoniae, Chlamydophila pneumoniae, Chlamydophila psittaci, and Coxiella burnetii. Since it is known that antibiotic treatment for severe CAP is empiric and includes coverage of typical and atypical pathogens, microbiological diagnosis bears an important relationship to prognosis of pneumonia. Factors such as adequacy of initial antibiotic or early de-escalation of therapy are important variables associated with outcomes, especially in severe cases. Intracellular pathogens sometimes appear to cause more severe disease with respiratory failure and multisystem dysfunction associated with fatal outcomes. The clinical relevance of intracellular pathogens in severe CAP has not been specifically investigated. We review the prevalence, general characteristics, and outcomes of severe CAP cases caused by intracellular pathogens.

Efficient activation of T cells by human monocyte-derived dendritic cells (HMDCs) pulsed with Coxiella burnetii outer membrane protein Com1 but not by HspB-pulsed HMDCs

BACKGROUND

Coxiella burnetii is an obligate intracellular bacterium and the etiologic agent of Q fever; both coxiella outer membrane protein 1 (Com1) and heat shock protein B (HspB) are its major immunodominant antigens. It is not clear whether Com1 and HspB have the ability to mount immune responses against C. burnetii infection.

RESULTS

The recombinant proteins Com1 and HspB were applied to pulse human monocyte-derived dendritic cells (HMDCs), and the pulsed HMDCs were used to stimulate isogenic T cells. Com1-pulsed HMDCs expressed substantially higher levels of surface molecules (CD83, CD40, CD80, CD86, CD54, and CD58) and a higher level of interleukin-12 than HspB-pulsed HMDCs. Moreover, Com1-pulsed HMDCs induced high-level proliferation and activation of CD4(+) and CD8(+) cells, which expressed high levels of T-cell activation marker CD69 and inflammatory cytokines IFN-γ and TNF-α. In contrast, HspB-pulsed HMDCs were unable to induce efficient T-cell proliferation and activation.

CONCLUSIONS

Our results demonstrate that Com1-pulsed HMDCs are able to induce efficient T-cell proliferation and drive T cells toward Th1 and Tc1 polarization; however, HspB-pulsed HMDCs are unable to do so. Unlike HspB, Com1 is a protective antigen, which was demonstrated by the adoptive transfer of Com1-pulsed bone marrow dendritic cells into naive BALB/c mice.

Coxiella burnetii isolates cause genogroup-specific virulence in mouse and guinea pig models of acute Q fever

Q fever is a zoonotic disease of worldwide significance caused by the obligate intracellular bacterium Coxiella burnetii. Humans with Q fever may experience an acute flu-like illness and pneumonia and/or chronic hepatitis or endocarditis. Various markers demonstrate significant phylogenetic separation between and clustering among isolates from acute and chronic human disease. The clinical and pathological responses to infection with phase I C. burnetii isolates from the following four genomic groups were evaluated in immunocompetent and immunocompromised mice and in guinea pig infection models: group I (Nine Mile, African, and Ohio), group IV (Priscilla and P), group V (G and S), and group VI (Dugway). Isolates from all of the groups produced disease in the SCID mouse model, and genogroup-consistent trends were noted in cytokine production in response to infection in the immunocompetent-mouse model. Guinea pigs developed severe acute disease when aerosol challenged with group I isolates, mild to moderate acute disease in response to group V isolates, and no acute disease when infected with group IV and VI isolates. C. burnetii isolates have a range of disease potentials; isolates within the same genomic group cause similar pathological responses, and there is a clear distinction in strain virulence between these genomic groups.

Atypical pneumonias: current clinical concepts focusing on Legionnaires' disease

PURPOSE OF REVIEW

This review provides clinicians with an overview of the clinical features of the atypical pneumonias. Atypical community-acquired pneumonia pathogens cause systemic infections with pneumonia. The key to the clinical diagnosis of atypical pneumonias depends on recognizing the characteristic pattern of extrapulmonary organ involvement different for each pathogen. As Legionella is likely to present as severe pneumonia and does not respond to beta-lactams, it is important to presumptively diagnose Legionnaires' disease clinically so that Legionella coverage is included in empiric therapy. This study reviews the clinical features and nonspecific laboratory markers of atypical pathogens, focusing on Legionnaires' disease.

RECENT FINDINGS

Case reports/outbreaks increase our understanding of Legionnaires' disease transmission. Both Mycoplasma pneumoniae and Chlamydophilia pneumoniae may cause asthma. Antimicrobial therapy of Chlamydophilia pneumoniae/Mycoplasma pneumoniae is important to decrease person-to-person spread and to decrease potential long-term sequelae.

SUMMARY

Atypical pulmonary pathogens cause systemic infections accompanied by a variety of characteristic extrapulmonary features. Clinically, it is possible to differentiate Legionnaires' disease from the other typical/atypical pneumonias. Rapid clinical diagnosis of atypical pathogens, particularly Legionnaires' disease, is important in selecting effective empiric therapy and prompting definitive laboratory testing.

[Occupational infectious respiratory diseases]

INTRODUCTION

Occupational infectious respiratory diseases are underestimate pathology because of an asymptomatic infection or the general, unspecific symptoms.

STATE OF THE ART

The most part of patients are among health care and agriculture or forestry workers (15% employee exposure of infectious risks in according with SUMMER study 2003). Biological risks interest two-third of health care workers, one-third of agriculture and food industry employees and one-forth of house-workers. Occupational diseases occur as flu-like illness, pneumonia, lung abscess or pleurisy. A possible classification for this pathology is by clinical manifestations: with respiratory predominance like tuberculosis, pasteurelosis, psittacosis or diseases like anthrax, brucellosis or tularemia with non respiratory predominance.

PERSPECTIVES AND CONCLUSION

The authors remind the data of occupational respiratory infectious diseases, microbiological data and links between clinical symptoms and patients professions leading to diagnosis.

Prevalence of Coxiella burnetti infection in wild and farmed ungulates

The aim of this study was to evaluate by serology and PCR analyses the prevalence of Coxiella burnetti infection in ungulates in Spain. Sera were collected from red deer (Cervus elaphus; n=116), roe deer (Capreolus capreolus; n=39), fallow deer (Dama dama; n=13) and cattle (n=79). Sera were tested for anti-C. burnetii antibody detection by means of an immunofluorescence antibody assay (IFA) and C. burnetii DNA was amplified by PCR in samples from ungulates that had antibodies to phase II antigens. Twenty-nine, 15 and 39 percent of the red deer, roe deer and cattle had antibodies against C. burnetii, respectively. None of the fallow deer sera tested positive. Seroprevalence was statistically higher in farmed than in wild red deer and higher in northern than in southern populations, whereas an inverse pattern was observed for the roe deer. Most of the seropositive animals had only anti-C. burnetii phase II antibodies, thus showing the acute nature of infections in the sampled ungulates. These results show that C. burnetii circulates in wild ungulates in Spain and suggest that they can act as pathogen reservoirs for both domestic animals and humans.

Community-acquired pneumonia: aetiologic changes in a limited geographic area. An 11-year prospective study

The aim of this study is to describe the changes in the aetiology of hospitalised patients with community-acquired pneumonia (CAP) during an 11-year observational period in a limited geographic area. Eight hundred and one (801) adult patients with CAP hospitalised were included. The patients were divided into three groups according to the time of presentation. Comprehensive microbiological laboratory tests were performed and differences in aetiology were analysed. In 228 patients (31%), a pathogen was detected, with Coxiella burnetii being the most common (20.1%). Significant variations in the prevalence of Chlamydophila pneumoniae were found between groups but not in other pathogens. In conclusion, long-term epidemiological studies may contribute to the knowledge of actual CAP aetiology.

Q Fever Community-Acquired Pneumonia in a Patient With Crohn’s Disease on Immunosuppressive Therapy

Community-acquired pneumonia (CAP) may be caused by typical or atypical pathogens. The three most common zoonotic atypical pathogens are Chlamydophila psittaci (psittacosis), Francisella tularensis (tularemia), and Coxiella burnetii (Q fever). Atypical CAPs are suggested by a distinctive pattern of extrapulmonary organ involvement. Zoonotic CAP may be differentiated from nonzoonotic CAP (Chlamydia pneumoniae, Mycoplasma pneumoniae, Legionnaire's disease) by a recent zoonotic vector contact history. Zoonotic atypical CAP occurs sporadically, but not randomly, and require close association with the appropriate zoonotic vector to transmit the infection. CAP accompanied by the extrapulmonary finding of splenomegaly in a normal host limits differential diagnostic possibilities to Q fever and psittacosis. Splenomegaly does not occur with other typical or atypical CAP. Another common extrapulmonary finding occurs with some atypical pneumonias, that is, Q fever, psittacosis, and Legionnaire's disease is early mild/transient elevations of serum transaminases indicative of (hepatic) extrapulmonary organ involvement. The case presented is a middle-aged man with longstanding Crohn's disease who was further immunosuppressed by chronic prednisone therapy. The patient presented with CAP and extrapulmonary findings, that is, splenomegaly and increased serum transaminases. He denied recent contact with birds or animals. Because Crohn's disease and Q fever CAP may be accompanied by splenomegaly, the cause of his splenomegaly was a diagnostic dilemma. The patient was treated with levofloxacin. Serologic tests for atypical pathogens (Q fever, psittacosis, Legionnaire's disease, C. pneumoniae, and M. pneumoniae) were ordered. Enzyme-linked immunosorbent assay serology for Q fever was positive with elevated acute immunoglobulin-M (phase II) titers. Re-questioning of the patient revealed a recent exposure to a neighbor's parturient cat, providing the necessary zoonotic vector contact history for Q fever. The patient responded to levofloxacin, which resulted in resolution of the patient's symptoms, right lower lobe pneumonia, and splenomegaly. Because a prior abdominal computed tomography scan indicated no splenomegaly and his splenomegaly resolved with antimicrobial therapy, the splenomegaly was related to Q fever CAP.

Clinical and pathologic changes in a guinea pig aerosol challenge model of acute Q fever

Acute Q fever is a zoonotic disease caused by the obligate intracellular bacterium Coxiella burnetii and can manifest as a flu-like illness, pneumonia, or hepatitis. A need exists in Q fever research for animal models mimicking both the typical route of infection (inhalation) and the clinical illness seen in human cases of Q fever. A guinea pig aerosol challenge model was developed using C. burnetii Nine Mile phase I (RSA 493), administered using a specialized chamber designed to deliver droplet nuclei directly to the alveolar spaces. Guinea pigs were given 10(1) to 10(6) organisms and evaluated for 28 days postinfection. Clinical signs included fever, weight loss, respiratory difficulty, and death, with the degree and duration of response corresponding to the dose of organism delivered. Histopathologic evaluation of the lungs of animals infected with a high dose showed coalescing panleukocytic bronchointerstitial pneumonia at 7 days postinfection that resolved to multifocal lymphohistiocytic interstitial pneumonia by 28 days. Guinea pigs receiving a killed whole-cell vaccine prior to challenge with the highest dose of C. burnetii were protected against lethal infection and did not develop fever. Clinical signs and pathological changes noted for these guinea pigs were comparable to those seen in human acute Q fever, making this an accurate and valuable animal model of human disease.

Clinicopathologic aspects of animal and zoonotic diseases of bioterrorism

We live in an era of emerging infectious diseases and the threat of bioterrorism. Most of the infectious agents of modern concern, from plague to avian influenza H5N1, are zoonotic diseases: infectious agents that reside in quiet animal reservoir cycles that are transmitted occasionally to humans. The public health, health care, and veterinary communities have an enormous challenge in the early recognition, reporting, treatment, and prevention of zoonotic diseases. An intimate understanding of the natural ecology, geographic distribution, clinical signs, lesions, and diagnosis of these diseases is essential for the early recognition and control of these diseases.

Antibiotic selection and resistance issues with fluoroquinolones and doxycycline against bioterrorism agents

Bacillus anthracis (anthrax), Yersinia pestis (plague), Francisella tularensis (tularemia), Coxiella burnetti (Q fever), and Brucella sp (brucellosis) are all potential bioterrorism agents. Their known virulence, potential lethality, and ability to develop resistance to known antibiotic treatments make these pathogens particularly dangerous. We reviewed the scientific literature by searching MEDLINE databases and published abstracts from the Interscience Conference on Antimicrobial Agents and Chemotherapy and the Infectious Diseases Society of America from 1989-2005 for studies of each of these biologic agents with the specific aim of examining whether doxycycline or a fluoroquinolone should be stockpiled for mass-scale postexposure prophylaxis. An evidence-based approach was used to determine whether doxycycline or fluoroquinolones were efficacious (both in vitro and in vivo) against these biologic agents and to examine these drugs' respective susceptibility patterns and differences in cost, based on available data. Little published data are available on these pathogens, and much of the data are from studies that used older strains obtained from patient or animal sources in outbreaks decades ago. Doxycycline appears to show comparable minimum inhibitory concentrations to those of the fluoroquinolone class in most clinical and in vitro studies, perhaps with the exception of inhalation plague. Studies also suggest that development of antibiotic resistance is less likely to occur with doxycycline. Doxycycline is several-fold less expensive than most fluoroquinolones and appears to have similar efficacy in most scenarios based on clinical case studies and established Clinical and Laboratory Standards Institute (formerly known as the National Committee for Clinical Laboratory Standards) breakpoints for staphylococci. Therefore, doxycycline should be considered as a first-line antibiotic in the management of bioterrorism agents.

Hemolytic uremic syndrome; pathogenesis, treatment, and outcome

PURPOSE OF REVIEW

The hemolytic uremic syndrome (HUS) is the most common cause of acute renal failure in infants and young children, and is a substantial cause of acute mortality and chronic morbidity. It is therefore relevant and appropriate that pediatricians remain familiar with the various subsets of the disease including its classification, management, and outcome.

RECENT FINDINGS

This review will focus on recent information relative to epidemiology, pathogenesis, treatment, and outcome. It will include some of the newer associations between HUS and a variety of infections, including, but not limited to E. coli 0157:H7 (Shiga toxin-mediated) HUS, as well as the ever-increasing number of associations between HUS and a variety of drugs. It will review some of the newer therapies for the more common subsets, but will acknowledge that choosing evidence-based therapies is often limited by our incomplete understanding of the various pathogenic cascades, and that with the possible exception of Shiga toxin-mediated HUS(D+HUS), long-term outcome information is often limited by small numbers and limited follow-up.

SUMMARY

This review should provide a framework for making the proper diagnosis, implementing appropriate treatment, and advising the family about anticipated outcome.

Stimulation of toll-like receptor 2 by Coxiella burnetii is required for macrophage production of pro-inflammatory cytokines and resistance to infection

Innate and adaptive immune responses are initiated upon recognition of microbial molecules by Toll-like receptors (TLRs). We have investigated the importance of these receptors in the induction of pro-inflammatory cytokines and macrophage resistance to infection with Coxiella burnetii, an obligate intracellular bacterium and the etiological agent of Q fever. By using a Chinese hamster ovary/CD14 cell line expressing either functional TLR2 or TLR4, we determined that C. burnetii phase II activates TLR2 but not TLR4. Macrophages deficient for TLR2, but not TLR4, produced less tumor necrosis factor-alpha and interleukin-12 upon C. burnetii infection. Furthermore, it was found that TLR2 activation interfered with C. burnetii intracellular replication, as macrophages from TLR2-deficient mice were highly permissive for C. burnetii growth compared with macrophages from wild type mice or TLR4-deficient mice. Although LPS modifications distinguish virulent C. burnetii phase I bacteria from avirulent phase II organisms, electrospray ionization-mass spectrometry analysis showed that the lipid A moieties isolated from these two phase variants are identical. Purified lipid A derived from either phase I or phase II LPS failed to activate TLR2 and TLR4. Indeed, the lipid A molecules were able to interfere with TLR4 signaling in response to purified Escherichia coli LPS. These studies indicate that TLR2 is an important host determinant that mediates recognition of C. burnetii and a response that limits growth of this intracellular pathogen.