Scientific letter
Coxiella burnetii-infected abdominal endovascular aortic stent graft in a kidney transplant recipient
Infección de stent endovascular aórtico-abdominal en un trasplantado renal por Coxiella burnetti
Justo Sandino Péreza,
, Francisco Lopez-Medranob, María Ruiz-Ruigómezb, Eduardo Gutiérrez Martineza
Corresponding author
a Department of Nephrology, Hospital Universitario “12 de Octubre”, Madrid, Spain
b Unit of Infectious Diseases, Hospital Universitario “12 de Octubre”, Instituto de Investigación Hospital 12 de Octubre (i+12), Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
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=> array:4 [ "autoresLista" => "Justo Sandino Pérez, Francisco Lopez-Medrano, María Ruiz-Ruigómez, Eduardo Gutiérrez Martinez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Justo" "apellidos" => "Sandino Pérez" "email" => array:1 [ 0 => "justosandino14@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Francisco" "apellidos" => "Lopez-Medrano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "María" "apellidos" => "Ruiz-Ruigómez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Eduardo" "apellidos" => "Gutiérrez Martinez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Nephrology, Hospital Universitario “12 de Octubre”, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unit of Infectious Diseases, Hospital Universitario “12 de Octubre”, Instituto de Investigación Hospital 12 de Octubre (i+12), Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Infección de stent endovascular aórtico-abdominal en un trasplantado renal por Coxiella burnetti" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 790 "Ancho" => 1750 "Tamanyo" => 160420 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">18F-FDG PET/CT showing: (A) Maximum intensity projection (MIP) and Axial-fused PET/CT images: two foci of high intensity FDG uptake in the aortic graft (SUVmax 17.79 and 9.46 respectively), consistent with infection of the graft (red arrows). (B) Same patient and same projections showing: significant decrease in FDG uptake after treatment (SUVmax 3.70 and 2.78 respectively) (blue arrows).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Q fever is caused by <span class="elsevierStyleItalic">Coxiella burnetii,</span> an intracellular Gram-negative bacterium that produces prolonged bacteriemia and represents great risk of persistent infections for patients with valve pathology or vascular defects.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> This infection may have serious consequences in renal transplant recipients, especially if cardiovascular abnormalities are present.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> We present the case of a renal transplant recipient with weight loss and malaise.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 65-year-old patient, with a kidney transplant from 2011 with baseline serum creatinine around 1.15<span class="elsevierStyleHsp" style=""></span>mg/dl. He was receiving tacrolimus (levels around 5–7<span class="elsevierStyleHsp" style=""></span>ng/ml) and mycophenolic acid (180<span class="elsevierStyleHsp" style=""></span>mg/d) as immunosupressive therapy. He also had an endo-vascular prosthesis for an abdominal aortic aneurysm from 2006 and referred several trips to Africa in the past 20 years. He was also the owner of a scrap dealing company in rural area of Castilla-La Mancha (Spain).</p><p id="par0015" class="elsevierStylePara elsevierViewall">Since June 2018, he endorsed gradual onset of non-specific symptoms (malaise, persistent low grade fever and weakness), and a 10<span class="elsevierStyleHsp" style=""></span>kg weight loss in one year. The patient consulted on August 2019: laboratory examinations of previous 3 months revealed increased value of liver enzymes and C reactive protein (CRP). Multiple blood cultures were negative for bacteria and fungi. A fluorine 18-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) was performed, showing aorto-iliac endovascular stent graft with heterogeneous content in aneurismatic sack and striation of the peri-aortic fat tissue, suggestive of peri-graft infectious process.</p><p id="par0020" class="elsevierStylePara elsevierViewall">IgG anti-phase I and phase II antibodies for <span class="elsevierStyleItalic">C. burnetii</span> were reactive at titers of 1:8192 and 1:16,384 respectively, with later detection of <span class="elsevierStyleItalic">Coxiella burnetii</span> DNA in blood sample by polymerase chain reaction (PCR).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Diagnosis of chronic Q fever was confirmed and the patient began treatment with doxycycline 200<span class="elsevierStyleHsp" style=""></span>mg/d and hydrochloroquine (400<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h because of gastrointestinal symptoms). No surgical intervention was performed due to high risk of aneurism rupture and compromise of vascularization of kidney allograft. After a three-month follow up period, patient was asymptomatic, had gained weight and in the last serological tests, IgG anti-phase I and phase II antibodies titers were 1:2048 and 1:8192 respectively. A follow up PET/TC performed three months after initiation of antibiotic therapy, showed an evident decrease in metabolic activity in the aneurismatic aortic sack (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Unfortunately, three months later the patient passed away due to an aggressive intrahepatic cholangiocarcinoma, precluding us from providing long-term follow up information about the infection.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Chronic Q fever is associated with high morbidity and mortality if left untreated and is more common in elderly subjects and those who are immunosuppressed.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Diagnosis of Q fever relies on serology and IFA (indirect immunofluorescence assay). In acute infection, the phase II antibody response appears first and is higher than the phase I antibody response. An IgG antibody titer of ≥1:800 to phase I antigens suggests chronic infection.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Usually the infection is treated for 18–24 months and first line treatment include doxycycline and hydrochloroquine or quinolones. Monitoring should be based on clinical, serological and imaging criteria (PET/TC). Surgical intervention is recommended and always should be associated with antibiotic therapy when vascular infection is confirmed.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Series of cases of <span class="elsevierStyleItalic">C. burnetii</span> infections on vascular grafts emphasize in the elevated mortality of <span class="elsevierStyleItalic">C. burnetii</span> vascular infections and recommend surgical intervention shortly after diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Few cases of Q fever in patients with renal transplant have been reported.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> In our case the patient bared an abdominal vascular graft stent, with radiologic signs of peri-prosthetic infection. Although surgery in these cases always should be proposed, medical therapy should be considered in a select group of patients in which surgery cannot be performed. In our case the patient presented an extremely high risk of kidney allograft loss and death during surgery, therefore, after careful evaluation by a multi-disciplinary team (nephrologists, infectious diseases specialists and vascular surgeons), surgery was discarded and prolonged antibiotic therapy was recommended.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Finally, the patient died of a liver tumor without finding a robust association between the tumor and the predisposition to this type of infrequent infection.</p><p id="par0055" class="elsevierStylePara elsevierViewall">We present a case of chronic <span class="elsevierStyleItalic">Coxiella burnetii</span> infection in a kidney transplant patient with endovascular infection. <span class="elsevierStyleItalic">C. burnetii</span> infection should be suspected in patients with immunosuppressive therapy and long-data constitutional syndrome, especially if they carry a vascular graft; also medical therapy should be considered in patients where surgery cannot be executed.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 790 "Ancho" => 1750 "Tamanyo" => 160420 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">18F-FDG PET/CT showing: (A) Maximum intensity projection (MIP) and Axial-fused PET/CT images: two foci of high intensity FDG uptake in the aortic graft (SUVmax 17.79 and 9.46 respectively), consistent with infection of the graft (red arrows). (B) Same patient and same projections showing: significant decrease in FDG uptake after treatment (SUVmax 3.70 and 2.78 respectively) (blue arrows).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Coxiella</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.R. Graves" 1 => "R.F. Massung" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:6 [ "editores" => "J.H.Jorgensen, M.A.Pfaller, K.C.Carroll" "titulo" => "Manual of clinical microbiology" "paginaInicial" => "1150" "paginaFinal" => "1158" "edicion" => "11th ed." "serieFecha" => "2015" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0060" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Infection in renal transplantation: a case of acute Q fever" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C.P. Larsen" 1 => "J.M. Bell" 2 => "B.L. Ketel" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/j.ajkd.2006.04.070" "Revista" => array:6 [ "tituloSerie" => "Am J Kidney Dis" "fecha" => "2006" "volumen" => "48" "paginaInicial" => "321" "paginaFinal" => "326" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16860200" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0065" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Q fever: a review and issues for the next century" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T.J. Marrie" 1 => "D. Raoult" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0924-8579(96)00369-x" "Revista" => array:7 [ "tituloSerie" => "Int J Antimicrob Agents" "fecha" => "1997" "volumen" => "8" "paginaInicial" => "145" "paginaFinal" => "161" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18611796" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0190962214014200" "estado" => "S300" "issn" => "01909622" ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0070" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Q fever 1985–1998: clinical and epidemiologic features of 1383 infections" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. Raoult" 1 => "H. Tissot-Dupont" 2 => "C. Foucault" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Medicine (Baltimore)" "fecha" => "2000" "volumen" => "79" "paginaInicial" => "109" "paginaFinal" => "123" "itemHostRev" => array:3 [ "pii" => "S0140673616006450" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0075" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Q fever" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Maurin" 1 => "D. Raoult" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Microbiol Rev" "fecha" => "1999" "volumen" => "12" "paginaInicial" => "518" "paginaFinal" => "553" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10515901" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0080" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chronic Q fever: review of the literature and a proposal of new diagnostic criteria" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.C.A. Wegdam-Blans" 1 => "L.M. Kampschreur" 2 => "C.E. Delsing" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Inf" "fecha" => "2012" "volumen" => "64" "paginaInicial" => "247" "paginaFinal" => "259" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0085" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "From Q fever to Coxiella burnetii infection: a paradigm change" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C. Eldin" 1 => "C. Mélenotte" 2 => "O. Mediannikov" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1128/CMR.00045-16" "Revista" => array:6 [ "tituloSerie" => "Clin Microbiol Rev" "fecha" => "2017" "volumen" => "30" "paginaInicial" => "115" "paginaFinal" => "190" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27856520" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0090" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Coxiella burnetii</span> infection of aortic aneurysms or vascular grafts: report of 30 new cases and evaluation of outcome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "E. Botelho-Nevers" 1 => "P.E. Fournier" 2 => "H. Richet" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Eur J Microbiol Infect Dis" "fecha" => "2007" "volumen" => "26" "paginaInicial" => "635" "paginaFinal" => "640" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0095" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment and prophylactic strategy for <span class="elsevierStyleItalic">Coxiella burnetii</span> infection of aneurysms and vascular grafts: a retrospective cohort study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C. Eldin" 1 => "M. Mailhe" 2 => "C. Lions" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Medicine (Baltimore)" "fecha" => "2016" "volumen" => "95" "paginaInicial" => "e2810" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0100" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chronic Q fever in a renal transplant recipient: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "I. Godinho" 1 => "E.L. Nogueira" 2 => "C.M. Santos" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Transplant ProcV 47" "fecha" => "2015" "paginaInicial" => "1045" "paginaFinal" => "1047" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/2529993X/0000003900000004/v1_202104030716/S2529993X21000617/v1_202104030716/en/main.assets" "Apartado" => array:4 [ "identificador" => "63562" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/2529993X/0000003900000004/v1_202104030716/S2529993X21000617/v1_202104030716/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529993X21000617?idApp=UINPBA00004N" ]
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| 2024 April | 8 | 27 | 35 |
| 2024 March | 15 | 9 | 24 |
| 2024 February | 9 | 6 | 15 |
| 2024 January | 15 | 4 | 19 |
| 2023 December | 18 | 3 | 21 |
| 2023 November | 7 | 5 | 12 |
| 2023 October | 16 | 6 | 22 |
| 2023 September | 18 | 3 | 21 |
| 2023 August | 14 | 5 | 19 |
| 2023 July | 11 | 4 | 15 |
| 2023 June | 13 | 0 | 13 |
| 2023 May | 6 | 2 | 8 |
| 2023 April | 13 | 1 | 14 |
| 2023 March | 18 | 7 | 25 |
| 2023 February | 12 | 4 | 16 |
| 2023 January | 10 | 3 | 13 |
| 2022 December | 11 | 4 | 15 |
| 2022 November | 18 | 8 | 26 |
| 2022 October | 83 | 11 | 94 |
| 2022 September | 29 | 4 | 33 |
| 2022 August | 21 | 10 | 31 |
| 2022 July | 8 | 10 | 18 |
| 2022 June | 10 | 6 | 16 |
| 2022 May | 11 | 10 | 21 |
| 2022 April | 14 | 10 | 24 |
| 2022 March | 12 | 9 | 21 |
| 2022 February | 18 | 4 | 22 |
| 2022 January | 50 | 8 | 58 |
| 2021 December | 28 | 9 | 37 |
| 2021 November | 17 | 10 | 27 |
| 2021 October | 18 | 7 | 25 |
| 2021 September | 1 | 0 | 1 |
Show all
