Case

Presentation
Elaborated by : Masmoudi
Abderrahmen
Supervisor
: Dr Koubaa
Makram

 Ms C.B , 45 years old , was

admitted for investigation because
of high fever , deterioration of the
general condition and a weight
loss with anorexia.

History of presenting complaint

Back one month ,the patient had
several episodes of fever ( resolved
without medical help) and a weight
loss of 5 kg with anorexia .
She precised that 6 monthes ago she
spent several weeks living in a village
in Sidi Bouzid where she had been
helping with charity work and was in
close contact with newborn cows.

Past history

Surgery for prosthetic aortic

valve replacement in January
2012 ( now under AVK)

Clinical examination
Temp 38.9 C , Pulse 120 , BP 11/50 , Respiratory
Rate 16
Cardiovascular system review: systolic aortic murmur
Splenomegaly
Petechial purpura of the two lower limbs with
paresthesia of the right foot .

laboratory tests
Blood cell count
Leucocytes :
13500/mm3
Hg : 10 g/l
Platelets : 120 109 /L
VS : 30 mm in 1 Hour
CRP : 250 mg/l

 What is your Clinical

Diagnosis ?

 In front of

1) The deterioration of the general

condition
2) The aortic systolic murmur
3) History of valve replacement
4)Inflammatory syndrome:
leukocytosis, increased CRP and VS
5) Petechial purpura

The most likely diagnostic is :

Infective
endocarditis

2 additional tests you ask

for ,to confirm your
diagnosis ?

 Blood cultures
Transthoracic
echocardiography
(TTE)

 The blood cultures came back

negative
The TTE showed aortic vegetations
that protrude into the left ventricular
outflow tract .

What agent(s) suspected ,

in relation with the
history of animal
contact ? How do you
confirm your diagnosis ?

In front of
-Previous contact with new born
cows(6 months ago )
-Infectious endocarditis with
negative blood cultures
- Valvular replacement history
the suspected agent is
Coxiella Burnetii : Chronic Q Fever
agent

 Bartonella can be reponsable of Infectious

endocarditis BUT :
- The last animal contact
is 6 months ago ( no cats )
- no animal scratches or
bites
- no lymphadenopathy

We complete with
Serology ( IIF ) , looking for IgG and
IgA antibodies to phase I Coxiella burnetii
( PCR or Culture can confirm diagnosis to )

 serological tests revealed elevated

levels of IgG (titer 1:6400) and
IgA (titer 1:6400) antibodies to
phase I Coxiella burnetii consistent
with the chronic Q fever diagnosis.
IgM titers were low confirming
the chronic type of infection.

What would be your

therapeutic attitude

 Doxycycline 200mg/day +
chloroquine ( Plaquenil)
600mg/day
during 18 monthes

Thank you