In December 2005, a patient aged 22 years was admitted to the emergency department of AHEPA University Hospital of Thessaloniki due to persistent (5 days) high grade of fever (38.5°C) and pharyngalgia. On physical examination no specific clinical signs were present. The initial laboratory tests were normal and chest X ray did not reveal any lung disease. Empiric antibacterial therapy (clarithromycin 500 mg × 2 for 5 days) and non-steroidal anti-inflammatory agent (nimesulid 100 mg × 2 for 3 days) for pyrexia were initiated. During the following week, fever persisted and the patient also developed fatigue, chills, anorexia, headaches, myalgia and skin rash (pink macular lesions of the trunk). When he revisited the emergency department, he was hospitalized for further diagnostic evaluation. The patient had no history of contact with animals, exposure to hepatotoxic agents, like alcohol, drugs, recent history of blood transfusion, or surgical/dental operation.
On clinical examination, jaundice, mild hepatomegaly and skin rash were detected. Chest X ray was found normal and abdominal ultrasound revealed mild hepatomegaly without biliary tract obstruction. Laboratory examinations revealed leukopenia (WBC 2.9 × 109/L), thrombocytopenia (PLT 130 × 109/L), moderate hyperbilirubinemia -mainly direct bilirubin- (T-Bil 3 mg/dL), elevated serum C-reactive protein (2.95 mg/dl) and increased hepatic enzyme levels [ALT: 250 U/L (normal:0–40 U/L), AST: 380 U/L (normal:0–39 U/L), LDH: 900 (normal:240–480 U/L)], whereas cholostatic enzymes (ALP, γ-GT) were found nearly normal.
The patient did not exhibit autoantibodies, including smooth muscle, anticardiolipin, antiphospholipid and antinuclear antibodies. Serologic tests for HIV-1, EBV, CMV, Mycoplasma, Rickettsia, Chlamydia, Bartonella, Parvovirus B19, hepatitis A, B, and C viruses were negative. Q fever was added to the list of differential diagnosis, although exposure to cattle, sheep, goats or consumption of unpasteurized products was not reported. Additionally, a heart ultrasound was performed and pericarditis or myocarditis were excluded.
The diagnosis of acute Q fever was confirmed by serologic methods. Serum samples were tested initially by enzyme-linked immunosorbent assay (ELISA) and its positive result [IgG I (1,1x cutoff), IgG II 41 IU/ml)] was confirmed by indirect immunofluorescene assay (IFA). IgG antibodies were reactive with phase I and II antigens of C. burnetii at titers 1:64 and 1:256 respectively. The patient was administered moxifloxacin 400 mg once a day per os for 14 days. The symptoms resolved within 2 weeks, whereas the levels of hepatic transaminases were mildly elevated [ALT: 55 U/L, AST:63 U/L, T-Bilirubin:1,6 mg/dl]. A convalescent-phase serum sample was obtained 3 weeks later, confirming the initial diagnosis. It was also tested by ELISA [IgG I (1,9x cutoff), IgG II 149 IU/ml)] and IFA [IgG I 1:256, IgG II 1:1024]. During a follow-up visit 3 months after hospitalization, the patient was clinically asymptomatic and had normal hepatic enzymes.