Q fever: epidemiology, diagnosis, and treatment

Diagnosis of Acute Q Fever in a Patient by Using Metagenomic Next-Generation Sequencing: A Case Report

Background

Q fever is a zoonotic disease caused by Coxiella burnetii infection, with domestic ruminants as the main source of infection and tick bites as one of the transmission vectors. The clinical manifestations of Q fever are varied and atypical. For the reason that C. burnetii is a strictly intracellular pathogen, it is difficult to be diagnosed by traditional culture methods. Additionally, serological and molecular diagnostic methods to assist in the diagnosis of Q fever are not routinely performed in most clinical laboratories. Therefore, early and rapid diagnosis of Q fever is a challenge.

Case Presentation

In the present study, a 34-year-old male patient presented with an acute onset and symptoms such as high fever, lethargy, pulmonary infection, and liver damage. In addition, he had a history of tick bites. Despite conducting relevant laboratory and radiological examinations, the etiology remained unknown. Subsequently, we detected the sequence reads of C. burnetii in a venous blood sample using metagenomic next-generation sequencing (mNGS), and the symptoms of patients were significantly improved after timely treatment with the special drug tetracycline. To our knowledge, this is the first report of Q fever associated with C. burnetii detected directly from venous blood sample in Wuhan, China.

Conclusion

Metagenomic next-generation sequencing is a new diagnostic technology that provides rapid and accurate detection of unexplained infections, including Q fever. Its application plays a crucial role in clinical diagnosis for identifying elusive pathogens.

Seroprevalence of Q Fever and Risk Factors Affecting Transmission of Coxiella burnetii in Industrial Slaughterhouse; A Survey from Northeastern Iran

Background: Q fever is a generally neglected infection caused by Coxiella burnetii. Slaughterhouse workers exposed to livestock are among occupationally at-risk people. Objectives: This study was conducted to investigate the seroprevalence of anti-Coxiella burnetii (Q fever) IgG antibody among industrial slaughterhouse workers and factors affecting the risk of infection. Methods: In this cross-sectional study serum samples were taken from 91 individuals working at the central industrial abattoir in Mashhad, Iran using a convenient sampling method. Sera were kept at -80°C until assayed for specific anti-Coxiella burnetii IgG antibodies (phase 1) using the commercial ELISA kit. The participants filled out a checklist addressing potential risk factors of acquiring the infection. SPSS 11.5 was used for data analysis considering a significance level of P < 0.05. Results: The participants’ mean age was 38.7 ± 8 years. Fifty-six percent of the studied individuals (51 out of 91) were found positive for anti-Coxiella burnetii antibodies. The most prevalent cases were sheep (29, 57%) and cow (18, 35%) butchers. The odds of Q fever infection increased among those with a history of accidental hand cuts of more than five times during the previous years (OR = 2.56, CI95% = 1.02 - 6.33, P-value = 0.04) and those dealing with sheep as the primary livestock (OR = 2.9, CI95% = 1.09 - 7.66, P = 0.02). Conclusions: The high seropositivity rate of anti-Coxiella burnetii IgG reflects high exposure rate of workers to this potentially serious pathogen in slaughtherhouses; therefore, careful education, follow-up, and revision of decontamination policies and improved occupational care and environmental hygiene should be strictly implemented in slaughterhouses to reduce the risk.

Coxiella burnetii vascular graft infection

Q fever, a zoonotic infection caused by Coxiella burnetii, can present with a wide spectrum of clinical manifestations. The organism is typically transmitted from sheep, goats, or cattle to humans via contaminated aerosols. On average, 1–5% of patients with acute Q fever will develop chronic infection months to decades after their primary infections. We report a case of a chronic vascular graft infection due to Coxiella burnetii in a 61-year-old man without direct exposure to animals who presented with recurrent fever. Indium-111-labeled white blood cell scan with single-emission positron computed tomography demonstrated findings suggesting a graft infection. C. burnetii phase I and phase II IgG antibody titers were > 1:32,768 and polymerase chain reaction performed on the explanted graft was positive for C. burnetii. Q fever should be considered in the differential diagnosis of vascular infections in patients who have a pre-existing lesion such as an aneurysm, or vascular prosthesis even in the absence of a history of direct animal exposure.

Coxiella burnetii: international pathogen of mystery

Coxiella burnetii is an intracellular bacterium that causes acute and chronic Q fever. This unique pathogen has been historically challenging to study due to obstacles in genetically manipulating the organism and the inability of small animal models to fully mimic human Q fever. Here, we review the current state of C. burnetii research, highlighting new approaches that allow the mechanistic study of infection in disease relevant settings.

Q Fever in Southern California: a Case Series of 20 Patients from a VA Medical Center

Query fever (Q fever), caused by Coxiella burnetii, was first described in southern California in 1947. It was found to be endemic and enzoonotic to the region and associated with exposure to livestock. We describe a series of 20 patients diagnosed with Q fever at a Veterans Affairs hospital in southern California, with the aim of contributing toward the understanding of Q fever in this region. Demographics, laboratory data, diagnostic imaging, risk factors, and treatment regimens were collected via a retrospective chart review of patients diagnosed with Q fever at our institution between 2000 and 2016. Cases were categorized as acute or chronic and confirmed or probable. The majority presented with an acute febrile illness (90%). There was a delay in ordering diagnostic serology from the time of symptom onset (acute cases, average 31.9 days; chronic cases, average 63 days), and 15% progressed from acute to chronic infection. Of the chronic cases, 22.2% had endocarditis, 22.2% had endovascular infection, and 11.1% had both endocarditis and endovascular infection. The geographic distribution revealed that 20% resided in rural areas. Of the cases of Q fever that died, death attributed to Q fever was associated with an average diagnostic delay of 65.5 days. Acute Q fever is underreported in this region largely because of its often nonspecific clinical presentation.

Q fever: A neglected disease of camels in Giza and Cairo Provinces, Egypt

Background and Aim

Q fever is a zoonotic disease caused by Coxiella burnetii. Cattle, sheep, and goat are the main reservoir of C. burnetii. In Egypt, the epidemiological data about C. burnetii in camels are limited. Therefore, the current study was conducted to identify C. burnetii infection in camels by different molecular tools and to estimate its seropositivity through the detection of anti-C. burnetii antibodies in camel sera.

Materials and Methods

Blood samples were collected 112 from camels in Giza and Cairo Provinces, Egypt. All blood samples were screened by trans-quantitative polymerase chain reaction (trans-qPCR) for C. burnetii and positive samples subjected to standard PCR using the superoxide dismutase enzyme coding gene of C. burnetii. Sera of studied camels were examined for the presence of antibodies against C. burnetii using enzyme-linked immunosorbent assay.

Results

Out of 112 camels, 19 were positive for C. burnetii by qPCR with an overall prevalence of 16.9% (18.6% in Giza and 15.1% in Cairo Provinces, respectively). The seroprevalence of anti-C. burnetii IgG antibodies in the examined camels was 4.5% (5/112).

Conclusions

Trans-qPCR assay is a rapid and sensitive tool for the detection of C. burnetii in acute stage. Camels should be considered one of the major reservoirs for C. burnetii in Egypt.

Molecular and immunological characterization of Hyalomma dromedarii and Hyalomma excavatum (Acari: Ixodidae) vectors of Q fever in camels

BACKGROUND AND AIM

Q fever Coxiella burnetii is a worldwide zoonotic disease, and C. burnetii was detected in mammals and ticks. Ticks play an important role in the spread of C. burnetii in the environment. Therefore, the aims of this study were to detect Q fever C. burnetii in camels and ixodid ticks by molecular tools and identification of Hyalomma dromedarii and Hyalomma excavatum using molecular and immunological assays.

MATERIALS AND METHODS

A total of 113 blood samples from camels and 190 adult ticks were investigated for the infection with C. burnetii by polymerase chain reaction (PCR) and sequencing the targeting IS30A spacer. The two tick species H. dromedarii and H. excavatum were characterized molecularly by PCR and sequencing of 16S ribosomal RNA (16S rRNA) and cytochrome oxidase subunit-1 (CO1) genes and immunologically by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and western blot.

RESULTS

A total of 52 camels (46%) were positive for Q fever infection. Only 10 adult ticks of H. dromedarii were infected with C. burnetii. The IS30A sequence was around 200 bp in length for C. burnetii in H. dromedarii ticks with a similarity of 99% when compared with reference data in GenBank records. The length of 16S rDNA and CO1 was 440 and 850 bp, respectively, for both H. dromedarii and H. excavatum. The phylogenetic status of H. dromedarii was distant from that of H. excavatum. SDS-PAGE revealed seven different bands in the adult antigens of either H. dromedarii or H. excavatum with molecular weights ranged from 132.9 to 17.7 KDa. In western blot analyses, the sera obtained from either infested camel by H. dromedarii or infested cattle by H. excavatum recognized four immunogenic bands (100.7, 49.7, 43.9, and 39.6 kDa) in H. dromedarii antigen. However, the infested camel sera identified two immunogenic bands (117 and 61.4 kDa) in H. excavatum antigen. Furthermore, the sera collected from cattle infested by H. excavatum recognized three immunogenic bands (61.4, 47.3, and 35 kDa) in H. excavatum antigen.

CONCLUSION

Molecular analyses indicated that both camels and ticks could be sources for infection of animals and humans with Q fever. Furthermore, the molecular analyses are more accurate tools for discriminating H. dromedarii and H. excavatum than immunological tools.

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.

Erythema induratum of Bazin and Ponçet's arthropathy as epiphenomena of hepatic tuberculosis

A 42-year-old black woman presented with fever, polyarthritis, livedo reticularis, subcutaneous calf nodules and hepatomegaly. She had been diagnosed with depression 6 weeks prior. Blood analysis showed anaemia, elevated erythrocyte sedimentation rate and C reactive protein, elevated liver enzymes, and positive antinuclear and antiribonucleoprotein antibodies. Abdominal ultrasound revealed heterogeneous hepatomegaly with necrotic lymphadenopathy around the caeliac trunk and splenic hilum. We considered the following diagnoses: lymphoma, connective tissue disease, tuberculosis and sarcoidosis. Subcutaneous nodule histology was compatible with erythema induratum of Bazin, and liver biopsy evidenced granulomatous hepatitis. Although microbiological examinations were negative in tissue samples, a presumptive diagnosis of hepatic tuberculosis was admitted. Having excluded other causes, erythema of Bazin, livedo reticularis and polyarticular involvement (Ponçet's arthropathy) were accepted as immunological epiphenomena associated with tuberculosis. Empirical antituberculous treatment was started and after 3 weeks the patient improved substantially. This clinical response was a further confirmation of the diagnosis.

Characterization of a lipopolysaccharide-targeted monoclonal antibody and its variable fragments as candidates for prophylaxis against the obligate intracellular bacterial pathogen Coxiella burnetii

Our previous study demonstrated that treatment of Coxiella burnetii with the phase I lipopolysaccharide (PI-LPS)-targeted monoclonal antibody (MAb) 1E4 significantly inhibited C. burnetii infection in mice, suggesting that 1E4 is a protective MAb. To determine whether passive transfer of antibodies (Abs) can provide protection against C. burnetii natural infection, we examined if passive transfer of 1E4 would protect SCID mice against C. burnetii aerosol infection. The results indicated that 1E4 conferred significant protection against aerosolized C. burnetii, suggesting that 1E4 may be useful for preventing C. burnetii natural infection. To further understand the mechanisms of 1E4-mediated protection and to test the possibility of using humanized 1E4 to prevent C. burnetii infection, we examined whether the Fab fragment of 1E4 (Fab1E4), a recombinant murine single-chain variable fragment (muscFv1E4), and a humanized single-chain variable fragment (huscFv1E4) retained the ability of 1E4 to inhibit C. burnetii infection. The results indicated that Fab1E4, muscFv1E4, and huscFv1E4 were able to inhibit C. burnetii infection in mice but that their ability to inhibit C. burnetii infection was lower than that of 1E4. In addition, treatment of C. burnetii with Fab1E4, muscFv1E4, or huscFv1E4 can block C. burnetii infection of macrophages. Interestingly, treatment of C. burnetii with huscFv1E4 can significantly reduce C. burnetii infectivity in human macrophages. This report provides the first evidence to demonstrate that the humanized variable fragments of an LPS-specific MAb can neutralize C. burnetii infection and appears to be a promising step toward the potential use of a humanized MAb as emergency prophylaxis against C. burnetii exposure.

Serological follow-up in patients with aorto-iliac disease and evidence of Q fever infection

The aim of this study was to provide data on the risk of developing chronic Q fever in patients with aorto-iliac disease and evidence of previous Q fever infection. Patients with an aortic and/or iliac aneurysm or aorto-iliac reconstruction (aorto-iliac disease) and evidence of previous Q fever infection were included. The presence of phase I and II Coxiella burnetii IgG antibodies was assessed periodically using immunofluorescence assay. A total of 111 patients with aorto-iliac disease were divided into three groups, based upon the serological profile [mean follow-up: 16 ± 9 months (mean ± standard deviation)]. Group 1 consisted of 30 patients with a serological trace of C. burnetii infection (negative IgG phase I, IgG phase II titer of 1:32). Of these, 36.7% converted to serological profile matching past resolved Q fever. Group 2 included 49 patients with negative IgG phase I titer and IgG phase II titer ≥1:64. No patients developed chronic Q fever, but 14.3% converted to a positive IgG phase I titer. Group 3 consisted of 32 patients with positive IgG phase I and positive IgG phase II titers, of which 9.4% developed chronic Q fever (significantly different from group 2, p = 0.039). The IgG phase I titer increased in 28.1% of patients (from 1:64 to 1:4,096). The risk of developing chronic Q fever in patients with aorto-iliac disease and previous Q fever infection with a positive IgG phase I titer was 9.4%. The IgG phase I titer increases or becomes positive in a substantial number of patients. A standardized serological follow-up is proposed.

Serosurvey and observational study of US Army Veterinary Corps officers for Q fever antibodies from 1989 to 2008

Since World War II, the military has experienced outbreaks of Q fever among deploying units including recent case reports of Q fever in US military personnel returning from serving in the Middle East during Operation Iraqi Freedom and Operation Enduring Freedom. Occupational exposure and prevalence of Q fever among US Army Veterinary Corps officers have not been examined. A retrospective serosurvey and observational study of 500 military veterinarians were conducted using archived serum specimens from military veterinarians who entered and served between 1989 and 2008 and were tested for exposure to Coxiella burnetii. Corresponding longitudinal health-related, demographic, medical and deployment data were examined. A total of 69 (13.8%) individuals at military entry and 85 (17%) had late career positive titres. A total of 18 (3.6%) individuals showed seroconversion. Women were more likely to be seropositive after military service [prevalence ratio (PR) 1.96; 95% confidence interval (CI) 1.15–3.35] and were also more likely to seroconvert (incidence rate ratio 3.55; 95% CI 1.19–12.7). Women who deployed to Operation Iraqi Freedom were more likely to be seropositive (PR 3.17; 95% CI 1.03–9.71). Veterinarians with field service and pathology specialties had the highest incidence rates (7.0/1000 PY; 95% CI 4–12 and 3–19, respectively). This is the first report documenting US military veterinarians' exposure to C. burnetii. Military veterinarians are at risk prior to service, with moderate number of new cases developing during service and most maintaining titres for long periods of time. Women consistently demonstrated higher seroprevalence and incidence levels. As increasing numbers of women enter the veterinary profession and subsequently the US Army, this may warrant close monitoring. This study likely underestimates exposure and risk and does not address chronic health effects, which may be valuable to explore in future health studies.

Presence and persistence of Coxiella burnetii in the environments of goat farms associated with a Q fever outbreak

Q fever is a zoonotic disease caused by inhalation of the bacterium Coxiella burnetii. Ruminant livestock are common reservoirs for C. burnetii, and bacteria present in aerosols derived from the waste of infected animals can infect humans. The significance of infection from material deposited in the environment versus transmission directly from infected animals is not known. In 2011, an outbreak of Q fever cases on farms in Washington and Montana was associated with infected goats. A study was undertaken to investigate the quantity and spatial distribution of C. burnetii in the environment of these goat farms. Soil, vacuum, and sponge samples collected on seven farms epidemiologically linked to the outbreak were tested for the presence of C. burnetii DNA by quantitative PCR. Overall, 70.1% of the samples were positive for C. burnetii. All farms had positive samples, but the quantity of C. burnetii varied widely between samples and between farms. High quantities of C. burnetii DNA were in goat housing/birthing areas, and only small quantities were found in samples collected more than 50 m from these areas. Follow-up sampling at one of the farms 1 year after the outbreak found small quantities of C. burnetii DNA in air samples and large quantities of C. burnetii persisting in soil and vacuum samples. The results suggest that the highest concentrations of environmental C. burnetii are found in goat birthing areas and that contamination of other areas is mostly associated with human movement.

Q Fever: an old but still a poorly understood disease

Q fever is a bacterial infection affecting mainly the lungs, liver, and heart. It is found around the world and is caused by the bacteria Coxiella burnetii. The bacteria affects sheep, goats, cattle, dogs, cats, birds, rodents, and ticks. Infected animals shed this bacteria in birth products, feces, milk, and urine. Humans usually get Q fever by breathing in contaminated droplets released by infected animals and drinking raw milk. People at highest risk for this infection are farmers, laboratory workers, sheep and dairy workers, and veterinarians. Chronic Q fever develops in people who have been infected for more than 6 months. It usually takes about 20 days after exposure to the bacteria for symptoms to occur. Most cases are mild, yet some severe cases have been reported. Symptoms of acute Q fever may include: chest pain with breathing, cough, fever, headache, jaundice, muscle pains, and shortness of breath. Symptoms of chronic Q fever may include chills, fatigue, night sweats, prolonged fever, and shortness of breath. Q fever is diagnosed with a blood antibody test. The main treatment for the disease is with antibiotics. For acute Q fever, doxycycline is recommended. For chronic Q fever, a combination of doxycycline and hydroxychloroquine is often used long term. Complications are cirrhosis, hepatitis, encephalitis, endocarditis, pericarditis, myocarditis, interstitial pulmonary fibrosis, meningitis, and pneumonia. People at risk should always: carefully dispose of animal products that may be infected, disinfect any contaminated areas, and thoroughly wash their hands. Pasteurizing milk can also help prevent Q fever.

Chronic q Fever with no elevation of inflammatory markers: a case report

We describe the case of a 55-year-old man with a biological prosthetic aortic valve who suffered from epigastrium and right hypochondrium pain associated with intermittent night sweats. Liver biopsy showed infectious hepatitis pattern without pathognomonic features. Coxiella burnetii serology was suggestive of chronic Q fever, and modified Duke's criteria for endocarditis were also fulfilled. The authors present a brief literature review concerning chronic Q fever, emphasizing absent previous reports of chronic Q fever with hepatitis and endocarditis and no increase in inflammatory markers.

Acute Q fever in Portugal. Epidemiological and clinical features of 32 hospitalized patients

INTRODUCTION

Q fever is a worldwide zoonosis caused by Coxiella burnetii. The main characteristic of acute Q fever is its clinical polymorphism, usually presenting as a febrile illness with varying degrees of hepatitis and/or pneumonia. Q fever is endemic in Portugal, and it is an obligatory notifiable disease since 1999. However, its epidemiological and clinical characteristics are still incompletely described.

METHODS

We performed a retrospective study of 32 cases admitted in the Infectious Diseases Department, Santa Maria's University Hospital, from January 2001 to December 2010, in whom acute Q fever was diagnosed by the presence of antibodies to phase II Coxiella burnetii antigens associated with a compatible clinical syndrome.

RESULTS

Out of the 32 cases recorded, 29 (91%) were male, with a male:female ratio of 9.7:1. Individuals at productive age were mainly affected (88%, n=28, with ages between 25 and 64 years). Clinically, the most common manifestation of acute Q fever was hepatic involvement (84%, n=27), which occurred isolated in 53% (n=17) of the cases. Hepatitis was more severe, presenting with higher values of liver function tests, in patients presenting both pulmonary and hepatic involvement. Additionally, we report one case of myocarditis and another one with neurological involvement. Empiric but appropriate antibiotic therapy was given in 66% (n=21) of the cases. There was a complete recovery in 94% (n=30) of the patients, and one death. We confirmed the sub-notification of this disease in Portugal, with only 47% (n=15) of the cases notified.

CONCLUSION

In Portugal further studies are needed to confirm our results. From the 32 cases studied, acute Q fever presented more frequently as a febrile disease with hepatic involvement affecting mainly young male individuals. Furthermore, acute Q fever is clearly underdiagnosed and underreported in Portugal, which suggests that an increased awareness of the disease is needed, together with a broader use of serological testing.

Study and Management of a Q Fever Outbreak among Machine Tool Workers in the Basque Country (Spain)

The aim of this study is to describe a Q fever outbreak that affected the staff of a machine-tool factory in the Basque Country between 2009/12/20 and 2010/02/23. Study subjects were interviewed using a Q fever specific questionnaire and tested for Q fever serology (immunofluorescence assay with phase II antigen) and detecting Coxiella burnetii DNA using real-time PCR. We interviewed and tested 40 employees (90% of the staff). 33 employees, all of them men, had positive serology (attack rate 82.5%, 95% CI: 70.2–94.8). Mean age was 43.7 years (95% CI: 38.7–48.7) in positive men, 33.7 years (95% CI: −16.6–83.9) in negative men, and 36.25 (95% CI: 27.5–45.0) in women (all negatives). 15 cases (45.5%) were asymptomatic, 9 (27.3%) had flu-like symptoms, and the other 9 (27.3%) had developed radiologically confirmed pneumonia. We obtained 28 blood samples, 22 faeces samples, 11 milk samples, and one vaginal swab from 28 goats resting in a stable near the factory. Serology was positive in 18 goats (64.3%). All environmental samples were negative.

Cost-effectiveness of a screening strategy for Q fever among pregnant women in risk areas: a clustered randomized controlled trial

Background

In The Netherlands the largest human Q fever outbreak ever reported in the literature is currently ongoing with more than 2300 notified cases in 2009. Pregnant women are particularly at risk as Q fever during pregnancy may cause maternal and obstetric complications. Since the majority of infected pregnant women are asymptomatic, a screening strategy might be of great value to reduce Q fever related complications. We designed a trial to assess the (cost-)effectiveness of a screening program for Q fever in pregnant women living in risks areas in The Netherlands.

Methods/design

We will conduct a clustered randomized controlled trial in which primary care midwife centres in Q fever risk areas are randomized to recruit pregnant women for either the control group or the intervention group. In both groups a blood sample is taken around 20 weeks postmenstrual age. In the intervention group, this sample is immediately analyzed by indirect immunofluorescence assay for detection of IgG and IgM antibodies using a sensitive cut-off level of 1:32. In case of an active Q fever infection, antibiotic treatment is recommended and serological follow up is performed. In the control group, serum is frozen for analysis after delivery. The primary endpoint is a maternal (chronic Q fever or reactivation) or obstetric complication (low birth weight, preterm delivery or fetal death) in Q fever positive women. Secondary aims pertain to the course of infection in pregnant women, diagnostic accuracy of laboratory tests used for screening, histo-pathological abnormalities of the placenta of Q fever positive women, side effects of therapy, and costs. The analysis will be according to the intention-to-screen principle, and cost-effectiveness analysis will be performed by comparing the direct and indirect costs between the intervention and control group.

Discussion

With this study we aim to provide insight into the balance of risks of undetected and detected Q fever during pregnancy.

Trial registration

ClinicalTrials.gov, protocol record NL30340.042.09.

Seroepidemiologic survey for Coxiella burnetii among hospitalized US troops deployed to Iraq

Q fever is a zoonotic illness which frequently has a non-specific clinical presentation. Cases among deployed US military personnel have been reported in increasing numbers indicating an emerging at-risk occupational group. Banked serum specimens were utilized to estimate seroprevalence and risk factors among military personnel deployed to Iraq. Coxiella burnetii antibody testing was performed and epidemiologic data were analysed from 909 servicemembers. The overall number who seroconverted to Q fever was 88 (10%). The most common ICD-9 code assigned to Q fever cases was fever not otherwise specified (NOS) (45%). A combat occupational specialty was a risk factor for Q fever seroconversion (OR = 1.8, 95% CI: 1.1-2.8) as well as receiving a primary diagnosis of fever NOS (OR = 2.6, 95% CI: 1.6-4.1). These findings indicate that Q fever is a significant infectious disease threat to military personnel deployed to Iraq. A heightened awareness among physicians is necessary to ensure prompt diagnosis and treatment.

Coxiella burnetii infection of a Steller sea lion (Eumetopias jubatus) found in Washington State

A pregnant sea lion stranded in the State of Washington was found to have placentitis caused by a unique strain of Coxiella burnetii. This is the first description of coxiellosis in a sea lion and suggests that exposure to sea lions may be a risk factor for contracting Q fever.

The devil is in the details

The approach to clinical conundrums by an expert clinician is revealed through presentation of an actual patient's case in an approach typical of morning report. Similar to patient care, sequential pieces of information are provided to the clinician who is unfamiliar with the case. The focus is on the thought processes of both the clinical team caring for the patient and the discussant.