Acute Q fever hepatitis in Taiwan

[Severe cholestatic hepatitis due to Q fever: report of a case]

Severe cholestatic hepatitis due to Coxiella burnetii is a rare form of clinical presentation of acute Q fever that is only occasionally detected in association with this infectious disease. We report a case of severe cholestatic hepatitis due to acute Q fever, with clinical signs of hepatic insufficiency, marked cholestasis, and renal insufficiency. The results of the initial serologic study using a complement fixation test were negative on two occasions, and transjugular biopsy and serological analysis with indirect immunofluorescence were required to establish the diagnosis. Despite treatment with doxycycline and ciprofloxacin, the cholestasis progressively worsened, with the development of hepatic and renal insufficiency, which rapidly disappeared after corticosteroid treatment.

A case of acute q Fever with severe acute cholestatic hepatitis

Minimal hepatic dysfunction can be common in acute Q fever, but severe acute cholestatic hepatitis is rarely reported. We report on a 55-year-old male with acute Q fever and severe acute cholestatic hepatitis. He complained of fever, jaundice, ascites, and restlessness on admission. A liver biopsy revealed the presence of compact fibrin-ring granulomas. Serologic titers for C. burnetii IgM and IgG were 2048:1 and 1024:1, respectively. C. burnetii DNA was detected by a nested polymerase chain reaction on the liver tissue.

Acute Q fever: an emerging and endemic disease in southern Taiwan

Acute Q fever is a worldwide zoonosis caused by Coxiella burnetii infection. In Taiwan, cases of acute Q fever increased during 3 y of observation, especially at Kaohsiung County and City in southern Taiwan. From 15 April 2004 to 15 April 2007, a total of 67 cases of acute Q fever were identified at E-Da hospital located at Kaohsiung County. 19 (28.4%) patients had a history of travel in rural areas and only 1 had been outside southern Taiwan. 21 (31.3%) patients had a history of animal contact. 20 (30.8%) of the 65 examined patients had underlying chronic hepatitis B or hepatitis C virus infection. Fever (98.5%), chills (79.1%), headache (79.1%), relative bradycardia (44.8%), elevated aminotransferases (100%), and thrombocytopenia (74.6%) were common manifestations. 12 (19.0%) cases had abnormal findings on chest X-ray. Fatty liver (50.0%) and hepatomegaly and/or splenomegaly (41.9%) were found by abdominal image examinations. 42 (76.4%) of 55 cases had defervescence within 3 d after treatment, whereas 4 (7.3%) had spontaneous remission. Acute Q fever is an endemic infectious disease with hepatitis rather than pneumonia as the major presentation in southern Taiwan and the emergence of Q fever is due to increased alertness for the disease by physicians.

Acute Q fever hepatitis in patients with and without underlying hepatitis B or C virus infection

BACKGROUND

Although hepatitis is one of the major presentations of acute Q fever, the possible influence of viral hepatitis in Q fever has, to our knowledge, never been investigated. It is an important issue in regions where Q fever hepatitis and viral hepatitis are prevalent, such as Taiwan. We conducted a study to investigate the possible influence of viral hepatitis in cases of acute Q fever hepatitis.

METHODS

Cases of acute Q fever confirmed by serologic examination were included in the study. All patients who were found to be positive for Q fever were tested for hepatitis B surface antigen and antibody to hepatitis C virus, and those with positive results had their viral loads determined. Demographic data, clinical manifestations, results of laboratory and imaging examinations, and responses to treatment were recorded retrospectively from charts.

RESULTS

A total of 58 patients with acute Q fever hepatitis were studied, of whom 16 (27.6%) had viral hepatitis (hepatitis B virus infection in 12 and hepatitis C virus infection in 4). Patients with and patients without viral hepatitis did not differ with regard to clinical manifestations and responses to treatment, except that chills (100% vs. 73.8%; P=.02) and nausea and/or vomiting (18.8% vs. 2.4%; P=.03) were significantly more common among patients with viral hepatitis. The change in hepatitis B and C virus loads between the acute and convalescent phase was <1.0 log(10).

CONCLUSIONS

The clinical manifestations of acute Q fever hepatitis differ little in patients with and patients without underlying viral hepatitis, and replication of hepatitis virus is not influenced by acute Q fever hepatitis.

Granulomatous hepatitis associated with scrub typhus

A 56 year old patient with scrub typhus infection having unusual presentation of hepatic injury resembling acute hepatitis is described. The clinical features of fever, headache, eschar, lymphadenopathy, lymphocytosis and high Rickettsia tsutsugamushi immunofluorescence titres confirmed the diagnosis of scrub typhus. Acute hepatitis was proven by hepatic biochemical tests and liver biopsy. The patient had a complete recovery soon after antibiotic treatment. The presentation of this case suggests that scrub typhus infection should be included in the list of differential diagnosis of acute hepatitis or granulomatous hepatitis, at least in the Asian Pacific region where scrub typhus still prevails.