Q Fever

Experiences in the Wheatbelt

Introduction

I will discuss 2 cases of a cluster of 5 cases in 2016

There was another cluster of 3-5 in 2013

Which will show the difficulty of treatment and management of this disease .

Case 1 – RB male born 1959

Work – local abattoir – about 10 months

No Q fever test or vaccination

O/E - Pulse 55, BP 115/73, nil else

Abdo – soft tender epigastrium and RUQ

In view of history and type of work , commenced on treatment for Q Fever, ie Clinical Diagnosis

Doxycycline 100mg BD.

Time off work , for review in 1 week.

Reviewed in 1 week – Abnormal LFT , reduced WCC

4/4/16 – feeling better

11/4/16 – positive Q Fever , notified Health Department

Presented on 14/3/16 –

History of – High temp for 4 days

Severe joint aches

Chest pains

Bilateral Loin pain

Increasing Back Pain

Throat ok, no cough

PMH – Chronic back pain

IHD

Smoker

RB was seen intermittently for a number of other problems over next few months

16/11/16 – Complaining of lethargy, severe joint pain again - ESR 64 (1-15) - recommenced on Doryx

Diagnosis – Chronic Q Fever – referred to Infectious Diseases Specialist 14/11/16 – Positive Influenza Type A , Chlamydia Pneumonia 71.1 (Positive) consistent with past or recent infection

Case 2 GD male born 1978

Admitted to Hospital – IV Rocephin for 3/7 with little improvement

IV fluids

Work – Local Abattoir – on floor doing kills for about 1 year

9/3/16 still had temperature , feeling better, few creps and wheeze Right Base

Diagnosis Q Fever and Commenced on Doxycycline

Abdo – soft non tender , Bowel sounds present

CXR – increased lung markings Right Base

10/3/16 Doxycycline 100mg QID commenced 11/3/16 Home on Doxycycline BD Bloods – Hb 134, WCC Normal , ESR -8, - slight increase in Alk Phos -LFT – increased Alt and GGT -CRP 331 Q Fever – neg 19/4/16 Positive Q Fever - Health Department Notified

8/3/16 – unwell 3-4 days Temp 38-40, general aches, headache ++, Back pain, slight cough . throat

Clinical Examination - RLL pneumonia

O/E Temp 39.3, Dry tongue, Heart Sounds Dual, Resps – Creps Right base wt 96.5 Past History – Ca Testicle 2010, chemotherapy, orchidectomy

Diagnosis - ? Pneumonia, ? Q Fever

Q Fever - an acute disease characterised by sudden onset of fever, headache, malaise and interstitial pneumonitis. Caused by Coxiella Burnettii

Distribution - is worldwide, maintained as an apparent infection in domestic animals – sheep, cattle, goats , are the main reservoirs for human infection.

The organism persists in faeces, urine, milk and tissues ( esp Placenta )

And spreads by areoles easily .

Cases occur amongst workers exposed to above. ie abattoir workers, farmers, but also include tanning and Taxidermy.

Incubation Period 9-28 days

Presents – as in our cases with fever (up to 40 degrees), severe headaches ( abrupt) chills, malaise, myalgia, chest pain. No rash .

a non productive cough,

X –Ray evidence of pneumonitis

mortality <1% in untreated patients , lower if treated .

In Fatal Q Fever – lobar consolidation gives appearance of pneumonia but histology resembles psittacosis and viral pneumonia – interstitial infiltrate

Hepatitis in 1/3 of patients

Several forms of Chronic Q fever can affect liver ( chronic Hepatitis) and Myocardium – Endocarditits

Organisms can also be maintained in ‘animal – tick cycle’. ie it can involve various arthropods , rodents, other mammals, birds.

A large outbreak in SA was from dust at a sale yards.

Diagnosis

made on clinical suspicion and Phase I antibodies in Plasma Serum Q Fever stimulates many infections – ie flu , other viral infections, Salmonellosis, Malaria, Hepatitis,

Bronchiolitis, pneumonias In Case 2, I tested for PCR master, Chlamyd Pneum, legionella master, Blood Culture, Resp Master, Hep/

HIV Mycoplasma Pneumonia and Q fever all Negetive Contact with animals, animal products and ticks is a clue regarding diagnosis.

Vaccination is recommended Blood test for Q Fever pre vaccination along with Skin test using Qvax Skin Test. 7/7 later - read skin test. a Positive test is any induration at skin test site, this is used in conjunction with

-Blood test result • If either test is positive patient is considered immune and is not immunised • if both skin prick and blood test are negative then a sub cutaneous immunisation with Q Vax Australian Q Fever Register via www.qfever.org has further information and training

Q Fever Testing at the local Abattoir has been irregular and Spasmodic.

The abattoir – for various reasons has high staff turnover. Most workers have low health literacy, and the management has not enforced testing and vaccination prior to work . Workers are paid as casuals, low wages, If a worker insists on Q fever screening, they may be asked to get another job.

There was an episode of 3-5 cases of Q Fever in 2013. Most of these presentations were at Metro surgeries. With Health Department Notification, it was traced back to our local Abattoir.

Local Public Health Unit and Local Shire Health Inspector worked closely with the Abattoir to prevent further outbreak, by immunisation and screening. This has been difficult, with poor employee and employer compliance.

Public Health Physicians have tried to raise concerns with Work Safe. At the time of presentation of Case 1 and 2 there was a further 3 other cases, 1 being a hospital admission in

Mandurah. We managed to immunise a further 20 people at this time. Some positive blood tests were noted , on further examination patients stated that they had a temperature or had felt unwell at the time .

There have also been a few farmers who have tested positive in a non acute setting. All up 9 have tested positive in my practice for Q Fever (1000 active patients).

Late in 2016 I came across a 38 year old man with history of previous Q Fever who had a prosthetic heart valve, presenting for INR testing. It had taken 18 months for him to be diagnosed with Q Fever, and the delay caused complications of valvular disease. He was from the cluster of 2013.

Management of all cases has involved Public Health Worksafe Infectious Disease in Tertiary Hospital.

Summary – these cases highlight the importance of occupation, in the clinical history, and a team approach

Q fever can have a very high morbidity and requires early diagnosis and management

Role of the work place screening is very important to ensure immunity to Q Fever and reduce acute episodes / complications.

These cases also highlight the combined work of GP/Registered Nurse, Environmental Health Officer, Public Health Physicians, Occupational Health Physicians, and Work Safe in overall management .