Querying Q Fever

The hazards of police work are many. There are uncooperative bad guys with guns and knives, high-speed car chases, and physical assaults. Sometimes the crime scene itself presents physical dangers in the form of backyard bomb factories and trailer park meth labs. But who would suspect that a dirty house could assault and disable a healthy investigating officer? That’s what happened to a California cop who was investigating a murder inside a filthy, rodent-infested house. After repeated visits to the crime scene, the officer began to develop flulike symptoms and a spiking fever. Severe body aches and vomiting began. His vision and hearing began to erode, along with his mental awareness. It took several trips to the hospital before a doctor finally realized he had Q fever and started antibiotic treatments. Full recovery would take more than two years. Q fever is almost as mysterious today as it was 70 years ago when the first cases were described in Australian slaughterhouse workers. No one knew what the men had so the name Q fever—for query—was concocted as a handy diagnostic label. Probably it sounded more reassuring than, “we don’t know what you have.” A few years later the agent of Q fever was identified as a small bacterium and was named Coxillea burnetii. It was discovered by Sir MacFarlane-Burnet so he got to name it after himself, but for some reason no one bothered to rename Q fever. Q fever is primarily a disease of goats, sheep and cattle, but rodents also are an important source of infection. Animals tend to pass the infection through milk, urine and feces. Among sheep, the Q fever bacteria may reach high concentrations in the placenta, fetal membranes and amniotic fluid, thereby providing a means of easy exposure to herders and veterinarians.

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Most people—including that California policeman—become infected by inhaling aerosols of the bacteria from contaminated environments. Amazingly, it only takes a single cell of Coxiella burnetii to start an infection. That makes it one of the most infectious agents known. To make matters worse, Coxiella is extremely resistant to desiccation, heat, sunlight and disinfectants so it tends to persist in the environment waiting for someone to come along. Once inhaled, the bacteria begin to replicate and roughly two weeks later flu-like symptoms begin to appear. Surprisingly, about half of acute Q fever infections are asymptomatic: meaning you are not even aware of the infection because your immune system eventually suppresses it. Overt signs of illness, however, may require medical attention, and lead to complications. These include atypical pneumonia and hepatitis. Even more serious is endocarditis (a heart infection), which can occur years after the initial infection. Undetected and untreated, about seven percent of infected individuals will develop endocarditis and possible heart failure. The mortality rate for endocarditis may be in the range of 30-60 percent. Coxiella burnetii may cause brief illnesses, but it also has the ability to persist silently in the body for months or years, thus making recovery a slow and frustrating process. It may also cause a form of chronic fatigue. In the 1990’s physicians in Australia identified such a syndrome among slaughterhouse workers. Symptoms included sweating, breathlessness, blurred vision and general fatigue. (The authors of the study noted that research on this chronic fatigue syndrome was complicated by “the adversarial process involved in gaining maintenance and financial compensation.” That’s a diplomatic way of saying lawyers got involved.)

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Q fever complications arise in part because the infection is difficult to distinguish from the symptoms of many others diseases and infections. Thus, a delay in diagnosis usually means a delay in treatment. Diagnosis is based on serology: looking for antibodies to Coxiella in the blood of suspected patients. Once a diagnosis is made tetracycline antibiotics are given for 7-14 days. Combinations of antibiotics, plus an anti-malarial drug, are used to treat endocarditis, but relapse is not uncommon. Even after years of treatment, the bacteria often can be isolated from patients’ heart valves. There is an effective vaccine in Australia, but it is not licensed for use in the U.S. Because Coxiella can be transmitted by aerosol, persists in the environment for long periods, and is difficult to diagnose and treat, it is considered a possible bioterrorism agent. In reality, Q fever probably will continue to be a rare infection among veterinarians, livestock and slaughterhouse workers, and the occasional cop. Maryland has had only one case since 2000. A man in Texas caught Q fever earlier this summer. No is sure how he got it, but it probably has more to do with local cows than foreign terrorists. For more information, see Maryland’s Epidemiology and Disease Control Program at http://edcp.org/vet_med/q_fever.html.

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