Table of Contents
Credits
Host(s): Sara Dong
Guests: Raghad Al-abdwani, Zaid Al Hinai, Badriya Al Adawi
Writing: Zaid Al Hinai
Edited and Produced by Sara Dong with support from the Infectious Diseases Society of America (IDSA)
Our Guests
Dr. Zaid Al Hinai
Dr Zaid Al Hinai serves currently as the head of the Pediatric ID unit at the Child Health Department, College of Medicine and Health Sciences, Sultan Qaboos University, in Muscat, Oman. He earned his MD degree from Tufts University in 2010, completed his residency training at Children’s Hospital of Michigan/Wayne State University, and fellowship at Hasbro Children’s Hospital/Brown University in the United States. His research interests include osteoarticular infections and respiratory viruses in children.
Dr. Raghad Al-abdwani
Dr. Raghad Al-Abdwani is a Senior Consultant and is the Head of the Pediatric Intensive Care Unit (PICU) at Sultan Qaboos University Hospital (SQUH), University Medical City, Oman. She completed her pediatric residency followed by pediatric critical care fellowship at The Hospital for Sick Children in Toronto. After that, she moved back to her home country and joined PICU at Sultan Qaboos Univeristy Hospital and has been instrumental in elevating the quality of care and pioneering the establishment of the High Dependency Unit at the hospital.
Dr. Al-Abdwani is a passionate advocate for medical education and healthcare improvement. She is the Associate Program Director and also the Chairperson of the Simulation Committee for the Pediatric Residency Program, Oman Specialty Medical Board. She also serves as the Chairperson of the Examination Committee for the Pediatric Critical Care Fellowship Program in Oman.
Dr. Al-Abdwani is actively involved in various national and international initiatives. She is a member of the WFPICCS Physician Education Committee and the National Organ Transplant Committee, as well as the National Task Force for Brain Death. A dedicated educator, Dr. Al-Abdwani is also a certified instructor in Pediatric Advanced Life Support (PALS) and Pediatric Fundamental Critical Care Support (PFCCS) through the Society of Critical Care Medicine (SCCM), equipping healthcare professionals with the skills needed to excel in high-stakes environments.
Raghad has a particular passion for hiking and aspires to hike in as many countries and mountains as possible.
Dr. Badriya Al Adawi
Dr. Badriya Al Adawi is a medical microbiologist at Sultan Qaboos University Hospital, Muscat, Oman. She obtained her MD degree from Sultan Qaboos University, Oman, and completed training in medical microbiology in Glasgow, UK, culminating in the award of Fellowship of the Royal College of Pathologists (FRCPath).
Culture
Raghad has a particular interest in hiking, trekking, and abseiling. She has done several international routes but also noted the beautiful mountains and canyons in Oman
Badriya shared a recent trip with her children to the Fort of Nizwa
Zaid enjoys cooking and trying out ancient recipes, such as musakhan which he mentioned on the episode
Consult Notes
Case Summary
4 year old child with sickle cell disease with septic shock and fulminant hepatic failure secondary to Q fever
Key Points
Check out the case report from our authors and colleagues
Introduction to Q Fever!
- Q fever is a zoonotic disease caused by the intracellular bacterium Coxiella burnetii
- Farm animals / livestock (such as cattle, sheep, goats) are the main reservoirs
- Transmissions to humans occurs mainly from the inhalation of contaminated aerosols from infected animals
- Organisms can contaminate the environment due to shedding from infected animals
- Consider sources including birth products (eg, placenta), urine, feces, and milk
- The bug is also resistant to desiccation —> after drying it can remain viable in soil and standing water, which can later be aerosolized
- Worldwide distribution although incidence is higher in Middle East compared to North America and Europe
Diagnosis of Q fever
- Serology is typically used, with the indirect fluorescent antibody (IFA) test being the most common antibody test
- IFA tests can quantify phase I and phase II antibodies
- Phase I antibodies
- Often used for diagnosis of chronic Q fever
- Phase I IgG that is very high is common result used to diagnose chronic Q fever (these antibodies appear about a month after symptom onset)
- Phase I IgM has a limited role, IgG phase I Ab have higher specificity than IgM
- Phase II antibodies
- Used primarily for diagnosis of acute infection
- Phase II IgG in patients with acute Q fever, typically develops about 5 days after symptom onset
- Acute and convalescent phase II IgG titers are the gold-standard for acute Q fever
- Blood samples in first 4 days of illness are often negative —> repeat sample 2-10 weeks later confirms diagnosis with seroconversion
- Phase II IgM may be detectable at similar time; IgG and IgM phase II antibodies frequently overlaps and IgM positivity in absence of IgG should be interpreted with caution (as false-positive IgM are not uncommon and can persist for prolonged periods of time)
- Phase I antibodies
- PCR testing is available and can be used to confirm diagnosis of Q fever
- PCR is particularly useful for early diagnosis of acute Q fever before serologic tests become positive
- For chronic Q fever, PCR testing has lower sensitivity
- Culture: C.burnetii doesn’t grow in routine blood cultures
Clinical manifestations of acute Q fever
- Clinical presentations may vary significantly
- Approximately half will develop symptoms, while the other half develop asymptomatic seroconversion
- Acute Q fever clinical syndromes may include:
- Flu-like illness
- Pneumonia
- Hepatitis
- Other less common symptoms such as rash, neurologic, cardiac, and others
- Q fever in children usually is asymptomatic or a self-limited febrile illness but rare cases with severe infection or death have been reported
- Interestingly, clinical manifestations may depend on geographic location, likely due to different genotypes of the bacterium in certain areas and/or genetic variations in patients with infection
Treatment of acute Q fever
- Although acute Q fever is self-limited, treatment is suggested with symptomatic infection
- Treatment has been shown to shorten the duration of symptoms and if given early, reduces hospitalization
- Preferred treatment is doxycycline!
- Alternative options include potential use of TMP-SMX, moxifloxacin, clarithromycin
Acute sickle hepatopathies
- Acute sickle hepatopathies (a term used to describe overlapping causes of liver dysfunction in patients with sickle cell disease) occur in ~10% of patients presenting with vaso-occlusive crises
- Estimated mortality rates range 11-14% in adults but thought to be lower in children
- These are categorized into various entities such as:
- Hepatic crisis (fever, jaundice, tender hepatomegaly, severe anemia, direct hyperbilirubinemia, mildly elevated transaminases)
- Intrahepatic cholestasis (fever, tender hepatomegaly, extreme direct hyperbilirubinemia, marked elevation in transaminases, and progressive liver failure)
- In this podcast episode and case report (see link above), the patient presented in septic shock with findings suggestive of both hepatic sequestration and intrahepatic cholestasis
Infographics
Goal
Listeners will be able to describe the epidemiology, diagnosis, and management of Q fever
Learning Objectives
After listening to this episode, listeners will be able to:
- Discuss the epidemiology of Coxiella burnetii
- Compare the available diagnostics for diagnosis of acute Q fever
- Describe potential clinical presentations of acute Q fever in a child
Disclosures
Our guests as well as Febrile podcast and hosts report no relevant financial disclosures
Citation
Alhinai, Z., Al Adawi, B., Al-Abdwani, R., Dong, S. “#125: A Critical Query”. Febrile: A Cultured Podcast. https://player.captivate.fm/episode/1d0620d3-a25b-490b-ac55-20b5c1c5547d/