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

Q fever in Greece: Findings of a 13 years surveillance study

Q fever is an endemic disease in different parts of Greece. The current study aimed to investigate the prevalence of acute Q fever disease in Greece through the operation of the national reference centre for Q fever. A total of 5397 sera were received from febrile patients under the suspicion of Q fever infection during a 13 years period (2001-20013). A questionnaire was filled in by the clinicians containing certain clinical/epidemiological/demographic information. The diagnosis was based both on IFA (IgG and IgM phase II antibodies against Coxiella burnetii) and on molecular means. A total of 685 (12.7 %) samples were initially tested positive for acute Q fever. The mean (±SD) age of patients was 55.3 years (±18.7). Out of the 489 convalescent samples, 134 (27.4 %) samples indicated a minimum of a four-fold seroconversion and were considered as laboratory confirmed cases of acute Q fever. Pneumonia was the most frequently encountered clinical symptom with presence in 6.8 % of all positive samples. Forty six (46) patients were laboratory confirmed as chronic Q fever cases. Climate seemed to influence the distribution of Q fever cases throughout the years. The findings of the current study comply with past studies carried out elsewhere that had demonstrated a clear relation of the disease with temperature, south winds, etc. This study represents the first large scale attempt to gather a long period information on Q fever infection in Greece. The findings of the current study support the fact that Q fever is an important endemic zoonotic disease in Greece and needs increased awareness by clinical physicians and health care system.

The Epidemiology and Characteristics of Q fever and Co-infections with Scrub Typhus, Murine Typhus or Leptospirosis in Taiwan: A Nationwide Database Study

Q fever (QF) is a worldwide zoonosis associated with outbreaks. Only a few nationwide studies regarding the surveillance and epidemiology of human QF have been reported. Although QF is endemic in Taiwan, a nationwide database investigation of the epidemiology and characteristics of QF and its associations with scrub typhus (ST), murine typhus (MT) and leptospirosis (LS) has never been reported. We analysed nationwide databases of suspected QF, ST, MT and LS cases from October 2007 to December 2014 obtained from the Centers for Disease Control, Taiwan. A total of 468 (4.2%) QF cases were identified among 11 109 suspected QF cases. QF cases were mainly distributed in the southern and Kaohsiung-Pingtung regions but rarely in the eastern region. Compared to non-QF cases, QF cases had significantly higher percentages of males (88.7 versus 66.2%) and high-risk occupations (farming, animal husbandry or veterinary medicine) (16.2 versus 10.5%). But the percentages of specific animal contact, including cattle (0.6 versus 0.8%) and goats (0.9 versus 1.0%), were low in both. The majority of suspected QF cases (89.4%) were simultaneously suspected with ST, MT or LS, and the combinations of suspected diseases differed between regions. The number of suspected QF cases from the eastern region decreased since 2009, which was not observed in other regions. A total of 1420 (12.8%) cases had confirmed diseases, including QF (453, 4.1%), QF+ST (7, 0.06%), QF+MT (4, 0.04%), QF+LS (4, 0.04%), MT (186, 1.7%), ST (545, 4.9%), ST+LS (11, 0.1%) and LS (210, 1.9%). Compared to cases of unknown disease, QF cases had larger percentages of high-risk occupations (16.2 versus 9.6%) but similar histories of animal contact (29.8 versus 25.1%). QF is an endemic disease in southern Taiwan. It is difficult to differentiate QF from ST, MT or LS only by high-risk occupations and history of animal contact, and co-infection of QF with these diseases should be considered.

Association of Human Q Fever with Animal Husbandry, Taiwan, 2004-2012

In Taiwan, Q fever cases in humans began increasing in 2004 and peaked in 2007 but dramatically declined in 2008 and 2011. Cases were significantly correlated with the number of goats. The decline might be associated with the collateral effects of measures to control goat pox in 2008 and 2010.

Q fever in China: a systematic review, 1989-2013

Q fever, first described in 1937, is a worldwide zoonosis caused by Coxiella burnetii that has long been considered an under-reported and under-diagnosed illness. In China, the disease was initially reported in 1950 and in the last 25 years (1989-2013) there have been 29 reports on Q fever in China, nearly half of which were in the last 5 years. These publications have largely been in Chinese and in this review we summarize their findings to enable a better understanding of Q fever in China. The overall prevalence of C. burnetii infections in the reports is 10% (1139/11 209) in people, 15% (288/1918) in cattle and 12% (176/1440) in goats. These infections occurred widely in China with positive people and/or animals reported in 64 cities/municipalities from 19 provinces, particularly those in the eastern, western and northern areas. Cattle and goats had the highest seroprevalences of all the domestic animals studied and a wide variety of ticks were found to be infected. Mice were also commonly infected and had high copy numbers of C. burnetii DNA, suggesting they might be important in the epidemiology of Q fever in China.

Clinical characteristics of Q fever and etiology of community-acquired pneumonia in a tropical region of southern Taiwan: a prospective observational study

Background

The clinical characteristics of Q fever are poorly identified in the tropics. Fever with pneumonia or hepatitis are the dominant presentations of acute Q fever, which exhibits geographic variability. In southern Taiwan, which is located in a tropical region, the role of Q fever in community-acquired pneumonia (CAP) has never been investigated.

Methodology/Principal Findings

During the study period, May 2012 to April 2013, 166 cases of adult CAP and 15 cases of acute Q fever were prospectively investigated. Cultures of clinical specimens, urine antigen tests for Streptococcus pneumoniae and Legionella pneumophila, and paired serologic assessments for Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Q fever (Coxiella burnetii) were used for identifying pathogens associated with CAP. From April 2004 to April 2013 (the pre-study period), 122 cases of acute Q fever were also included retrospectively for analysis. The geographic distribution of Q fever and CAP cases was similar. Q fever cases were identified in warmer seasons and younger ages than CAP. Based on multivariate analysis, male gender, chills, thrombocytopenia, and elevated liver enzymes were independent characteristics associated with Q fever. In patients with Q fever, 95% and 13.5% of cases presented with hepatitis and pneumonia, respectively. Twelve (7.2%) cases of CAP were seropositive for C. burnetii antibodies, but none of them had acute Q fever. Among CAP cases, 22.9% had a CURB-65 score ≧2, and 45.8% had identifiable pathogens. Haemophilus parainfluenzae (14.5%), S. pneumoniae (6.6%), Pseudomonas aeruginosa (4.8%), and Klebsiella pneumoniae (3.0%) were the most common pathogens identified by cultures or urine antigen tests. Moreover, M. pneumoniae, C. pneumoniae, and co-infection with 2 pathogens accounted for 9.0%, 7.8%, and 1.8%, respectively.

Conclusions

In southern Taiwan, Q fever is an endemic disease with hepatitis as the major presentation and is not a common etiology of CAP.

Human spotted fever group rickettsioses are underappreciated in southern Taiwan, particularly for the species closely-related to Rickettsia felis

Background

Despite increased identification of spotted fever group rickettsioses (SFGR) in animals and arthropods, human SFGR are poorly characterized in Taiwan.

Methods

Patients with suspected Q fever, scrub typhus, murine typhus, leptospirosis, and dengue fever from April 2004 to December 2009 were retrospectively investigated for SFGR antibodies (Abs). Sera were screened for Rickettsia rickettsii Abs by indirect immunofluorescence antibody assay (IFA), and those with positive results were further examined for Abs against R. rickettsii, R. typhi, R. felis, R. conorii, and R. japonica using micro-immunofluorescence (MIF) tests. Polymerase chain reaction (PCR) for detection of SFGR DNA was applied in those indicated acute infections. Case geographic distribution was made by the geographic information system software.

Results

A total of 413 cases with paired serum, including 90 cases of Q fever, 47 cases of scrub typhus, 12 cases of murine typhus, 6 cases of leptospirosis, 3 cases of dengue fever, and 255 cases of unknown febrile diseases were investigated. Using IFA tests, a total of 49 cases with 47 (11.4%) and 4 (1.0%) cases had sera potentially positive for R. rickettsii IgG and IgM, respectively. In the 49 cases screened from IFA, MIF tests revealed that there were 5 cases of acute infections (3 possible R. felis and 2 undetermined SFGR) and 13 cases of past infections (3 possible R. felis and 10 undetermined SFGR). None of the 5 cases of acute infection had detectable SFGR DNA in the blood specimen by PCR. Possible acute infection of R. felis was identified in both one case of Q fever and scrub typhus. The geographic distribution of SFGR cases is similar with that of scrub typhus.

Conclusions

Human SFGR exist and are neglected diseases in southern Taiwan, particularly for the species closely-related to R. felis.

Characteristics of hospitalized acute Q fever patients during a large epidemic, The Netherlands

BACKGROUND

From 2007 to 2009, The Netherlands experienced a major Q fever epidemic, with higher hospitalization rates than the 2-5% reported in the literature for acute Q fever pneumonia and hepatitis. We describe epidemiological and clinical features of hospitalized acute Q fever patients and compared patients presenting with Q fever pneumonia with patients admitted for other forms of community-acquired pneumonia (CAP). We also examined whether proximity to infected ruminant farms was a risk factor for hospitalization.

METHODS

A retrospective cohort study was conducted for all patients diagnosed and hospitalized with acute Q fever between 2007 and 2009 in one general hospital situated in the high incidence area in the south of The Netherlands. Pneumonia severity scores (PSI and CURB-65) of acute Q fever pneumonia patients (defined as infiltrate on a chest x-ray) were compared with data from CAP patients. Hepatitis was defined as a >twofold the reference value for alanine aminotransferase and for bilirubin.

RESULTS

Among the 183 hospitalized acute Q fever patients, 86.0% had pneumonia. Elevated liver enzymes (alanine aminotransferase) were found in 32.3% of patients, although hepatitis was not observed in any of them. The most frequent clinical signs upon presentation were fever, cough and dyspnoea. The median duration of admission was five days. Acute Q fever pneumonia patients were younger, had less co-morbidity, and lower PSI and CURB-65 scores than other CAP patients. Anecdotal information from attending physicians suggests that some patients were admitted because of severe subjective dyspnoea, which was not included in the scoring systems. Proximity to an infected ruminant farm was not associated with hospitalization.

CONCLUSION

Hospitalized Dutch acute Q fever patients mostly presented with fever and pneumonia. Patients with acute Q fever pneumonia were hospitalized despite low PSI and CURB-65 scores, presumably because subjective dyspnoea was not included in the scoring systems.

Epidemiological characteristics of serologically confirmed q Fever cases in South Korea, 2006-2011

OBJECTIVES

Q fever has been reported worldwide; however, there was almost no official report of Q fever in Korea. In this study, we describe the current status of human Q fever occurrence in Korea.

METHODS

Demographic data of Q fever patients were collected from the National Notifiable Diseases Surveillance System from 2006 to 2011. Case investigation reports from regional public health departments were used for additional information, like risk factors and clinical manifestation, of the patients since 2008.

RESULTS

There were 65 serologically confirmed cases during the study period. The annual notification rate of Q fever was 0.22 cases per million persons. The majority of cases were men (87.7%), adults (98.5%), and urban inhabitants (67.7%). Relevant exposures to risk factors were identified in 45.7% of patients. The most common symptoms of acute Q fever were fever (89.3%), myalgia (67.9%) and asthenia (53.6%). Two cases with endocarditis were identified in chronic Q fever.

CONCLUSION

This study suggests that Q fever has a low endemicity in Korea. However, management and research at national level is required for prevention of a future epidemic.

High seroprevalence of Mycoplasma pneumoniae IgM in acute Q fever by enzyme-linked immunosorbent assay (ELISA)

Q fever is serologically cross-reactive with other intracellular microorganisms. However, studies of the serological status of Mycoplasma pneumoniae and Chlamydophila pneumoniae during Q fever are rare. We conducted a retrospective serological study of M. pneumoniae and C. pneumoniae by enzyme-linked immunosorbent assay (ELISA), a method widely used in clinical practice, in 102 cases of acute Q fever, 39 cases of scrub typhus, and 14 cases of murine typhus. The seropositive (57.8%, 7.7%, and 0%, p<0.001) and seroconversion rates (50.6%, 8.8%, and 0%, p<0.001) of M. pneumoniae IgM, but not M. pneumoniae IgG and C. pneumoniae IgG/IgM, in acute Q fever were significantly higher than in scrub typhus and murine typhus. Another ELISA kit also revealed a high seropositivity (49.5%) and seroconversion rate (33.3%) of M. pneumoniae IgM in acute Q fever. The temporal and age distributions of patients with positive M. pneumoniae IgM were not typical of M. pneumoniae pneumonia. Comparing acute Q fever patients who were positive for M. pneumoniae IgM (59 cases) with those who were negative (43 cases), the demographic characteristics and underlying diseases were not different. In addition, the clinical manifestations associated with atypical pneumonia, including headache (71.2% vs. 81.4%, p=0.255), sore throat (8.5% vs. 16.3%, p=0.351), cough (35.6% vs. 23.3%, p=0.199), and chest x-ray suggesting pneumonia (19.3% vs. 9.5%, p=0.258), were unchanged between the two groups. Clinicians should be aware of the high seroprevalence of M. pneumoniae IgM in acute Q fever, particularly with ELISA kits, which can lead to misdiagnosis, overestimations of the prevalence of M. pneumoniae pneumonia, and underestimations of the true prevalence of Q fever pneumonia.

Circulating cytokines and procalcitonin in acute Q fever granulomatous hepatitis with poor response to antibiotic and short-course steroid therapy: a case report

Background

Q fever is a zoonosis distributed worldwide that is caused by Coxiella burnetii infection and the defervescence usually occurs within few days of appropriate antibiotic therapy. Whether the changes of cytokine levels are associated with acute Q fever with persistent fever despite antibiotic therapy had not been investigated before.

Case Presentation

We report a rare case of acute Q fever granulomatous hepatitis remained pyrexia despite several antibiotic therapy and 6-day course of oral prednisolone. During the 18-month follow-up, the investigation of the serum cytokines profile and procalcitonin (PCT) revealed that initially elevated levels of interleukin-2 (IL-2), IL-8, IL-10, and PCT decreased gradually, but the IL-6 remained in low titer. No evidence of chronic Q fever was identified by examinations of serum antibodies against C. burnetii and echocardiography.

Conclusions

The changes of cytokine levels may be associated with acute Q fever with poor response to treatment and PCT may be an indicator for monitoring the response to treatment.

Acute Q fever and scrub typhus, southern Taiwan

Acute Q fever and scrub typhus are zoonoses endemic to southern Taiwan. Among the 137 patients with acute Q fever (89, 65.0%) or scrub typhus (43, 31.4%), we identified 5 patients (3.6%) who were co-infected with Coxiella burnetii and Orientia tsutsugamushi.

[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.

Epidemiology of acute q Fever, scrub typhus, and murine typhus, and identification of their clinical characteristics compared to patients with acute febrile illness in southern taiwan

BACKGROUND/PURPOSE

In Taiwan, acute Q fever, scrub typhus, and murine typhus (QSM diseases) are the most common rickettsioses, but their epidemiology and clinical characteristics have not been clarified. Diagnosis of these three diseases based on clinical manifestations is difficult, and most of their reported characteristics are identified by describing the predominant manifestations, without being compared with other diseases.

METHODS

Serological tests for QSM diseases were examined simultaneously in patients suspected of the three diseases, regardless of which one was suspected. Clinical manifestations were recorded retrospectively from their charts. The characteristics of QSM diseases were identified by comparison with patients who had non-QSM diseases.

RESULTS

From April 2004 to April 2007, a total of 226 cases of suspected QSM diseases were included. One hundred (44.2%) cases were serologically confirmed as QSM diseases (68 acute Q fever, 23 scrub typhus, and 9 murine typhus), and 126 (55.8%) cases were non-QSM diseases. Only 33 cases (33.0%) of QSM diseases were initially suspected at the time of hospital visit, whereas 54 cases (42.9%) of non-QSM diseases were incorrectly suspected as QSM diseases. Cases of Q fever and scrub typhus were distributed over plain and mountain areas, respectively. By multivariate analysis, relative bradycardia (OR [95% CI], 2.885 [1.3-6.4]; p = 0.009), radiographic hepatomegaly (OR [95% CI], 4.454 [1.6-12.3]; p = 0.004), and elevated serum aminotransferases (OR [95% CI], 5.218 [1.2-23.1]; p = 0.029) were independent characteristics for QSM diseases, and leukocytosis (OR [95% CI], 0.167 [0.052-0.534]; p = 0.003) was negative for the diagnosis of QSM diseases.

CONCLUSION

In southern Taiwan, acute Q fever is the most common rickettsiosis. QSM diseases should be suspected in febrile patients who present with relative bradycardia, hepatomegaly, and elevated serum aminotransferases, but without leukocytosis.