Q fever endocarditis
- Didier Raoult, MD, PhD
Didier Raoult, MD, PhD
- Faculté de Médecine
- Aix Marseille Université
Q fever results from infection with Coxiella burnetii, a Proteobacteria that is mostly spread through aerosol transmission from infected animals and is found in most countries throughout the world. Q fever can present as an acute or more chronic disease.
Persistent localized infections (eg, endocarditis, infection of aneurysms or vascular grafts, bone and joint infections) can develop in a patient after symptomatic acute Q fever or following asymptomatic infection. Endocarditis, which is the most common manifestation among those with persistent infection, can be severe and even fatal. However, diagnosing Q fever endocarditis is difficult and primarily relies upon nonspecific cardiac findings, the presence of peripheral manifestations (eg, liver, kidney, and splenic involvement), the results of serologic or molecular tests, and/or the findings on imaging studies.
This topic reviews the diagnosis and treatment of patients with endocarditis associated with persistent Q fever infection. Discussions of the clinical manifestations, diagnosis, and treatment of acute Q fever (including endocarditis associated with acute infection), as well as an overview of culture-negative endocarditis, are found elsewhere. (See "Clinical manifestations and diagnosis of Q fever" and "Treatment and prevention of Q fever" and "Epidemiology, microbiology, and diagnosis of culture-negative endocarditis".)
Most cases of subacute or chronic endocarditis secondary to C. burnetii develop between two months and two years following acute Q fever. However, only 20 to 40 percent of patients who develop endocarditis have symptoms of acute infection. (See "Clinical manifestations and diagnosis of Q fever", section on 'Acute infection'.)
Q fever endocarditis occurs primarily in men over the age of 40, and in those who are immunocompromised, pregnant, and/or have underlying valvular damage [1-6]. This was illustrated in a retrospective study of 302 patients diagnosed with acute Q fever, which noted the following :
- Raoult D, Marrie T. Q fever. Clin Infect Dis 1995; 20:489.
- Fenollar F, Fournier PE, Carrieri MP, et al. Risks factors and prevention of Q fever endocarditis. Clin Infect Dis 2001; 33:312.
- Maurin M, Raoult D. Q fever. Clin Microbiol Rev 1999; 12:518.
- Stein A, Raoult D. Q fever endocarditis. Eur Heart J 1995; 16 Suppl B:19.
- Million M, Walter G, Thuny F, et al. Evolution from acute Q fever to endocarditis is associated with underlying valvulopathy and age and can be prevented by prolonged antibiotic treatment. Clin Infect Dis 2013; 57:836.
- Anderson A, Bijlmer H, Fournier PE, et al. Diagnosis and management of Q fever--United States, 2013: recommendations from CDC and the Q Fever Working Group. MMWR Recomm Rep 2013; 62:1.
- Houpikian P, Habib G, Mesana T, Raoult D. Changing clinical presentation of Q fever endocarditis. Clin Infect Dis 2002; 34:E28.
- Million M, Thuny F, Richet H, Raoult D. Long-term outcome of Q fever endocarditis: a 26-year personal survey. Lancet Infect Dis 2010; 10:527.
- Raoult D, Etienne J, Massip P, et al. Q fever endocarditis in the south of France. J Infect Dis 1987; 155:570.
- Brouqui P, Dupont HT, Drancourt M, et al. Chronic Q fever. Ninety-two cases from France, including 27 cases without endocarditis. Arch Intern Med 1993; 153:642.
- Levy P, Raoult D, Razongles JJ. Q-fever and autoimmunity. Eur J Epidemiol 1989; 5:447.
- Million M, Walter G, Bardin N, et al. Immunoglobulin G anticardiolipin antibodies and progression to Q fever endocarditis. Clin Infect Dis 2013; 57:57.
- Lepidi H, Houpikian P, Liang Z, Raoult D. Cardiac valves in patients with Q fever endocarditis: microbiological, molecular, and histologic studies. J Infect Dis 2003; 187:1097.
- Barten DG, Delsing CE, Keijmel SP, et al. Localizing chronic Q fever: a challenging query. BMC Infect Dis 2013; 13:413.
- Wang SX, Zhang XC, Wang SY, et al. (18)F-FDG PET/CT localized valvular infection in chronic Q fever endocarditis. J Nucl Cardiol 2015; 22:1320.
- Chieng D, Janssen J, Benson S, et al. 18-FDG PET/ CT Scan in the Diagnosis and Follow-up of Chronic Q fever Aortic Valve Endocarditis. Heart Lung Circ 2016; 25:e17.
- Raoult D, Tissot-Dupont H, Foucault C, et al. Q fever 1985-1998. Clinical and epidemiologic features of 1,383 infections. Medicine (Baltimore) 2000; 79:109.
- Raoult D. Chronic Q fever: expert opinion versus literature analysis and consensus. J Infect 2012; 65:102.
- Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis 2000; 30:633.
- Fournier PE, Casalta JP, Habib G, et al. Modification of the diagnostic criteria proposed by the Duke Endocarditis Service to permit improved diagnosis of Q fever endocarditis. Am J Med 1996; 100:629.
- Edouard S, Million M, Lepidi H, et al. Persistence of DNA in a cured patient and positive culture in cases with low antibody levels bring into question diagnosis of Q fever endocarditis. J Clin Microbiol 2013; 51:3012.
- Rolain JM, Mallet MN, Raoult D. Correlation between serum doxycycline concentrations and serologic evolution in patients with Coxiella burnetii endocarditis. J Infect Dis 2003; 188:1322.
- Mühlemann K, Matter L, Meyer B, Schopfer K. Isolation of Coxiella burnetii from heart valves of patients treated for Q fever endocarditis. J Clin Microbiol 1995; 33:428.
- Brouqui P, Dumler JS, Raoult D. Immunohistologic demonstration of Coxiella burnetii in the valves of patients with Q fever endocarditis. Am J Med 1994; 97:451.
- Hoen B, Selton-Suty C, Lacassin F, et al. Infective endocarditis in patients with negative blood cultures: analysis of 88 cases from a one-year nationwide survey in France. Clin Infect Dis 1995; 20:501.
- Houpikian P, Raoult D. Blood culture-negative endocarditis in a reference center: etiologic diagnosis of 348 cases. Medicine (Baltimore) 2005; 84:162.
- Raoult D, Houpikian P, Tissot Dupont H, et al. Treatment of Q fever endocarditis: comparison of 2 regimens containing doxycycline and ofloxacin or hydroxychloroquine. Arch Intern Med 1999; 159:167.
- Rolain JM, Boulos A, Mallet MN, Raoult D. Correlation between ratio of serum doxycycline concentration to MIC and rapid decline of antibody levels during treatment of Q fever endocarditis. Antimicrob Agents Chemother 2005; 49:2673.
- Fournier PE, Marrie TJ, Raoult D. Diagnosis of Q fever. J Clin Microbiol 1998; 36:1823.
- Raoult D. Treatment of Q fever. Antimicrob Agents Chemother 1993; 37:1733.
- Million M, Thuny F, Bardin N, et al. Antiphospholipid Antibody Syndrome With Valvular Vegetations in Acute Q Fever. Clin Infect Dis 2016; 62:537.
- Million M, Raoult D. The pathogenesis of the antiphospholipid syndrome. N Engl J Med 2013; 368:2335.
- RISK FACTORS
- CLINICAL FEATURES
- Constitutional symptoms
- Cardiac findings
- Non-cardiac manifestations
- LABORATORY DATA
- ECHOCARDIOGRAPHIC FINDINGS
- RADIOGRAPHIC IMAGING
- EVALUATION AND DIAGNOSIS
- - Our criteria
- - Duke criteria
- Testing for C. burnetii
- - Serology
- - Polymerase chain reaction
- - Culture
- - Other methods for isolating the organism
- DIFFERENTIAL DIAGNOSIS
- Drug regimens
- Antibiotic resistance
- Monitoring treatment
- - Drug levels
- - Toxicity
- - Clinical response
- - Serologic response
- Duration of therapy
- Surgical valve replacement
- PREVENTIVE THERAPY
- ENDOCARDITIS DURING ACUTE Q FEVER
- SUMMARY AND RECOMMENDATIONS