Acute acalculous cholecystitis due to Q fever

Rubio López, Laura; Benito Barbero, Silvia; Páramo Zunzunegui, Javier

doi:10.1016/j.medcle.2020.06.049

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Acute QF usually manifests as a febrile syndrome, which can be associated with pneumonia and/or hepatitis.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Acute acalculous cholecystitis is a rare clinical manifestation of QF.<a class="elsevierStyleCrossRefs" href="#bib0010">2–4</a> We report the case of a patient with fever of unknown origin, associated with liver dysfunction, who is diagnosed with acute acalculous cholecystitis due to QF.A 28-year-old male patient, with no medical or surgical history of interest, who came to the emergency department with a 4-day history of fever of up to 40 °C. The patient reports travelling occasionally to rural areas in the south-west of the Iberian Peninsula. Physical examination revealed mild abdominal pain on palpation in the right hypochondrium. Laboratory tests showed elevated C-reactive protein (170 mgl), plasma procalcitonin (3.31 ng/ml) and elevated liver enzymes: GPT (352 U/l), GOT (426 U/l), LDH (665 U/l), GGT (93 U/l) and AP (121 U/l). Chest X-ray, electrocardiogram, urine study and lumbar puncture, without pathological findings.The patient was hospitalised and started on empirical antibiotic treatment with intravenous ceftriaxone, with rapid improvement. Given the abdominal symptoms and the laboratory pattern of hepatic cytolysis, an abdominal ultrasound was performed, showing a distended gallbladder with oedematous walls. Lithiasis and biliary sludge are not visible. The radiological findings were suggestive of acute acalculous cholecystitis. The diagnosis was confirmed by abdominal computed tomography (CT). Given the good clinical and laboratory progress of the patient, and while awaiting the microbiological results, it was decided to maintain conservative antibiotic treatment with ceftriaxone.The microbiological study was negative in urine, stool, blood, cerebrospinal fluid, and bone marrow cultures. Polymerase chain reaction (PCR) for Salmonella typhy and paratyphy was negative. Serologies for HIV as well as for hepatotropic viruses were negative. Serological study using indirect immunofluorescence (IIF) for C. burnetti showed elevated IgG against 1/3200 phase II antigens. The diagnosis of acute acalculous cholecystitis due to QF was established. Antibiotic regimen with oral ciprofloxacin was completed on an outpatient basis for 14 days. Currently, one year after the onset of the disease, the patient is asymptomatic and has no laboratory abnormalities.Acute acalculous cholecystitis consists of inflammation of the gallbladder in the absence of stones. Represents 5%–10% of all acute cholecystitis.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> It usually affects critically ill hospitalised patients; however, it can also be diagnosed in non-hospitalised patients without risk factors, as in the case of the patient reported here. In these cases, the etiopathogenesis is usually related to a primary infection.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>Few cases of QF associated with acute cholecystitis have been described in the literature,<a class="elsevierStyleCrossRefs" href="#bib0010">2–4</a> with Rolain et al.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> being the largest series published. The gradual development of symptoms and their intensity differ from the form of presentation of cases with a calculous aetiology. Therefore, as reported by González Delgado et al.,<a class="elsevierStyleCrossRef" href="#bib0015">3</a> cases of acalculous cholecystitis may have been missed in some cases of QF without apparent abdominal focality.The diagnosis of acute cholecystitis is established by abdominal ultrasound, in some cases in association with abdominal CT. The diagnostic gold standard for QF is IIF and can also be established by PCR. The serological diagnosis of acute QF is made by detecting phase II antigens, which are detectable 7–15 days after the onset of the condition, with significant IgG ≥ 1/128 and IgM ≥ 1/32 titers.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> IgG antibodies to phase II antigens > 1/3200 were detected in our patient, establishing the diagnosis of acute QF.The treatment of choice for QF is doxycycline (200 mg/day/orally/for 14 days). Fluoroquinolones and macrolides have also shown efficacy.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> An excellent clinical response was observed in our patient with empirical broad-spectrum antibiotic therapy, with intravenous ceftriaxone. Therefore, we agree with Reina-Serrano et al.,<a class="elsevierStyleCrossRef" href="#bib0010">2</a> although the treatment of acute cholecystitis is surgical, when infection by Coxiella burnetii is suspected, conservative management by antibiotic therapy can be applied, and cholecystectomy should be indicated in case of failure.In conclusion, C. burnetii infection should be considered in the etiological diagnosis of acute acalculous cholecystitis." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Rubio López L, Benito Barbero S, Páramo Zunzunegui J. Colecistitis aguda alitiásica por fiebre Q. Med Clin (Barc). 2021;157:258–259." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "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:6 [ 0 => "C. Eldin" 1 => "C. Mélenotte" 2 => "O. Mediannikov" 3 => "E. Ghigo" 4 => "M. Million" 5 => "S. 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Venero-Gómez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S1473-3099(05)70274-7" "Revista" => array:6 [ "tituloSerie" => "Lancet Infect Dis" "fecha" => "2005" "volumen" => "5" "paginaInicial" => "734" "paginaFinal" => "735" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16310141" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Colecistitis alitiásica: una forma infrecuente de presentación de fiebre Q" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "L. González Delgado" 1 => "G. López Larramona" 2 => "S. Santolaria Piedrafita" 3 => "D. García Prats" 4 => "M. Ferrero Cancer" 5 => "M. Montoro Huguet" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1157/13073093" "Revista" => array:6 [ "tituloSerie" => "Gastroenterol Hepatol" "fecha" => "2005" "volumen" => "28" "paginaInicial" => "232" "paginaFinal" => "236" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15811266" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute acalculous cholecystitis associated with Q fever: report of seven cases and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.M. Rolain" 1 => "H. Lepidi" 2 => "J.R. Harlé" 3 => "T. Allegre" 4 => "E.D. Dorval" 5 => "Z. Khayat" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s10096-003-0899-1" "Revista" => array:6 [ "tituloSerie" => "Eur J Clin Microbiol Infect Dis" "fecha" => "2003" "volumen" => "22" "paginaInicial" => "222" "paginaFinal" => "227" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12687414" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "El papel de las infecciones y el microbioma en las enfermedades de la vesícula biliar" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "G.D. Eslick" 1 => "M.R. Cox" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:5 [ "editores" => "D.Eslick Guy" "titulo" => "Enfermedades gastrointestinales e infecciones asociadas" "paginaInicial" => "31" "paginaFinal" => "40" "serieFecha" => "2020" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015700000005/v1_202109171210/S2387020621004010/v1_202109171210/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015700000005/v1_202109171210/S2387020621004010/v1_202109171210/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020621004010?idApp=UINPBA00004N"]

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Vol. 157. Issue 5.

Pages 258-259 (September 2021)

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