Concomitant zoonotic infections with ovine Chlamydia and 'Q' fever in pregnancy: clinical features, diagnosis, management and public health implications. Case report

Gestational psittacosis: A case report and literature review

Gestational psittacosis is a rare disease that is associated with significant maternal and fetal morbidity and mortality. Currently, there is no examination method which allows for a quick diagnosis. We report a case of gestational psittacosis that could not be diagnosed as psittacosis during treatment and resulted in maternal and fetal death despite intensive treatment. We also reviewed 23 cases of gestational psittacosis. Fetal and maternal mortality was 82.6% (19/23) and 8.7% (2/23), respectively. In pregnant women with high fever and flu-like symptoms, we should suspect Chlamydia psittaci infection if at least one of the following is present; contact with sheep, parrots, parakeets or goats; normal or moderately decreased leucocyte count, thrombocytopenia and hepatic and/or renal dysfunction; cough and/or lobe consolidation or infiltration on chest X-ray. Antibiotic therapy with macrolide prenatally, macrolide or tetracycline postnatally and termination of pregnancy should be considered.

Q Fever during pregnancy: a cause of poor fetal and maternal outcome

Q fever is a worldwide zoonosis caused by Coxiella burnetii. Q fever may be present as an acute or a chronic infection and can be reactivated during subsequent pregnancies. Although its exact prevalence remains unknown, it is likely that the number of cases of Q fever in pregnant women is underestimated. During pregnancy, the illness is likely to be asymptomatic, and diagnosis is based on serology. Acute infection results in appearance of IgM and IgG antibodies mainly directed against the avirulent form of C. burnetii (phase II). Chronic Q fever results in particularly high level of IgG and IgA antibodies directed against both virulent (phase I) and avirulent (phase II) forms of the bacterium. Q fever may result in adverse pregnancy outcome, including spontaneous abortion, intrauterine growth retardation, oligoamnios, intrauterine fetal death (IUFD), and premature delivery. Obstetric complications occur significantly more often as C. burnetii infects the patient at an early stage of her pregnancy. Occurrence of IUFD is correlated with the presence of placental infection by C. burnetii and might be the consequence of direct infection of the fetus. The mother is exposed to the risk of chronic Q fever and endocarditis with potential fatal evolution. Long-term cotrimoxazole therapy prevents from placental infection, IUFD, and maternal chronic Q fever. Such treatment should be used to treat pregnant women with Q fever. Women with previous history of Q fever should have a regular serological follow up. Obstetricians' knowledge about Q fever must be improved.

Emerging Chlamydial Infections

Chlamydiae are important intracellular bacterial pathogens of vertebrates. In the last years, novel members of this group have been discovered: Parachlamydia acanthamoebae and Simkania negevensis seems to be emerging respiratory human pathogens, while Waddlia chondrophila might be a new agent of bovine abortion. Various species have been showed to infect also the herpetofauna and fishes, and some novel chlamydiae are endosymbionts of arthropods. In addition, molecular studies evidenced a huge diversity of chlamydiae from both environmental and clinical samples, most of such a diversity could be formed by novel lineages of chlamydiae. Experimental studies showed that free-living amoebae may support multiplication of various chlamydiae, then could play an important role as reservoir/vector of chlamydial infections. Here we reviewed literature data concerning chlamydial infections, with a particular emphasis on the novely described chlamydial organisms.

Managing Q fever during pregnancy: the benefits of long-term cotrimoxazole therapy

BACKGROUND

Q fever is a zoonosis caused by Coxiella burnetii. During pregnancy, it may result in obstetric complications, such as spontaneous abortion, intrauterine growth retardation, intrauterine fetal death, and premature delivery. Pregnant women are exposed to the risk of chronic Q fever.

METHODS

We included 53 pregnant women who received a diagnosis of Q fever. We compared the incidence of obstetric and maternal Q fever complications for women who received long-term cotrimoxazole treatment (n=16) with that for women who did not receive long-term cotrimoxazole treatment (n=37); long-term cotrimoxazole treatment was defined as oral administration of trimethoprim-sulfamethoxazole during at least 5 weeks of pregnancy.

RESULTS

Obstetric complications were observed in 81.1% of pregnant women who did not receive long-term cotrimoxazole therapy: 5 (13.5%) women experienced spontaneous abortions, 10 (27%) experienced intrauterine growth retardation, 10 (27%) experienced intrauterine fetal death, and 10 (27%) experienced premature delivery. Oligoamnios was observed in 4 patients (10.8%). Obstetric complications were found to occur significantly more often in patients infected during their first trimester of pregnancy than in those infected later (P=.032). The outcome of the pregnancy was found to depend on placental infection by C. burnetii (P=.013). Long-term cotrimoxazole treatment protected against maternal chronic Q fever (P=.001), placental infection (P=.038), and obstetric complications (P=.009), especially intrauterine fetal death (P=.018), which was found to be related to placental infection (P=.008).

CONCLUSIONS

Q fever during pregnancy results in severe obstetric complications, including oligoamnios. Because of its ability to protect against placental infection, intrauterine fetal death, and maternal chronic Q fever, long-term cotrimoxazole treatment should be used to treat pregnant women with Q fever.

Q fever

Q fever is a zoonosis with a worldwide distribution with the exception of New Zealand. The disease is caused by Coxiella burnetii, a strictly intracellular, gram-negative bacterium. Many species of mammals, birds, and ticks are reservoirs of C. burnetii in nature. C. burnetii infection is most often latent in animals, with persistent shedding of bacteria into the environment. However, in females intermittent high-level shedding occurs at the time of parturition, with millions of bacteria being released per gram of placenta. Humans are usually infected by contaminated aerosols from domestic animals, particularly after contact with parturient females and their birth products. Although often asymptomatic, Q fever may manifest in humans as an acute disease (mainly as a self-limited febrile illness, pneumonia, or hepatitis) or as a chronic disease (mainly endocarditis), especially in patients with previous valvulopathy and to a lesser extent in immunocompromised hosts and in pregnant women. Specific diagnosis of Q fever remains based upon serology. Immunoglobulin M (IgM) and IgG antiphase II antibodies are detected 2 to 3 weeks after infection with C. burnetii, whereas the presence of IgG antiphase I C. burnetii antibodies at titers of >/=1:800 by microimmunofluorescence is indicative of chronic Q fever. The tetracyclines are still considered the mainstay of antibiotic therapy of acute Q fever, whereas antibiotic combinations administered over prolonged periods are necessary to prevent relapses in Q fever endocarditis patients. Although the protective role of Q fever vaccination with whole-cell extracts has been established, the population which should be primarily vaccinated remains to be clearly identified. Vaccination should probably be considered in the population at high risk for Q fever endocarditis.

Gestational psittacosis in a Montana sheep rancher

In humans, psittacosis is primarily a flulike illness following exposure to psittacine birds. In rare cases, pregnant women exposed to Chlamydia psittaci can contract gestational psittacosis: atypical pneumonia, sepsis, and placental insufficiency resulting in premature birth or miscarriage. In the United States, only two cases of gestational psittacosis have been reported, both from exposure to psittacine birds. Eleven other cases have been reported worldwide, mostly in the United Kingdom, all from exposure to infected birth fluids and membranes of farm mammals, notably sheep and goats. In these mammals, C. psittaci inhabit the reproductive tract, are transmitted sexually or by the fecal-oral route, and cause miscarriages. The case of gestational psittacosis in a Montana sheep rancher is the first farm animal-related case reported in the United States. Pregnant women should avoid close contact with C. psittaci-infected animals, particularly sheep and goats during the birthing season. Obstetricians should consider this diagnosis along with early antibiotic treatment and cesarean section delivery in the context of the patient's case history.

Ovine chlamydiosis in an abattoir worker

The strain of Chlamydia psittaci causing enzootic abortion in ewes (the EAE strain) may cause serious infection in pregnant women, often resulting in hepatic and renal dysfunction, disseminated intravascular coagulation and fetal loss. The first case of such an infection in an abattoir worker is described and the possibility of human-to-human transmission considered. Direct handling of sheep or their products of conception can usually be established but this is not always so. There is much still to be learned about this uncommon but severe zoonosis.

Ovine psittacosis and sarcoidosis in a pregnant woman

A woman in the first trimester of pregnancy presented with pneumonia and hilar lymphadenopathy after exposure to lambing ewes. She subsequently aborted. Infection with Chlamydia psittaci of ovine origin was confirmed. Pregnant women are susceptible to this infection, which may cause life threatening disease. The patient also had features of sarcoidosis, and the two conditions ran a similar time course. There is a possibility that ovine psittacosis caused an illness indistinguishable from sarcoidosis.

Unknown sequence amplification: application to in vitro genome walking in Chlamydia trachomatis L2

A recently described technique, 'Chemical Genetics' unknown sequence amplification method, which requires only one specific oligonucleotide, has broadened the applicability of the polymerase chain reaction to DNA of unknown sequence. We have adapted this technique to the study of the genome of Chlamydia trachomatis, an obligate intracellular bacterium, and describe modifications that significantly improve the utility of this approach. These techniques allow for rapid genomic analysis entirely in vitro, using DNA of limited quantity or purity.

Sheep-acquired severe Chlamydia psittaci infection in pregnancy

There have been five confirmed cases of severe Chlamydia psittaci infection during pregnancy, three having been treated in Edinburgh, Scotland. The most recent case is presented and previous experience is reviewed. The illness usually causes thrombocytopenia with disseminated intravascular coagulation, renal failure and hepatic dysfunction during the late second and early third trimester. The outcome for the fetus is usually fatal and the infection only resolves after delivery or abortion. The main hope is for education to prevent infection occurring in susceptible populations.