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Letter to the Editor
Acute acalculous cholecystitis due to Q fever
Colecistitis aguda alitiásica por fiebre Q
Laura Rubio López
Corresponding author
lrubiol@salud.madrid.org

Corresponding author.
, Silvia Benito Barbero, Javier Páramo Zunzunegui
Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Móstoles, Móstoles, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Q fever &#40;QF&#41; is a worldwide zoonosis&#44; endemic in Spain&#44; caused by <span class="elsevierStyleItalic">Coxiella burnetti</span>&#46; Acute QF usually manifests as a febrile syndrome&#44; which can be associated with pneumonia and&#47;or hepatitis&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Acute acalculous cholecystitis is a rare clinical manifestation of QF&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> We report the case of a patient with fever of unknown origin&#44; associated with liver dysfunction&#44; who is diagnosed with acute acalculous cholecystitis due to QF&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 28-year-old male patient&#44; with no medical or surgical history of interest&#44; who came to the emergency department with a 4-day history of fever of up to 40&#160;&#176;C&#46; The patient reports travelling occasionally to rural areas in the south-west of the Iberian Peninsula&#46; Physical examination revealed mild abdominal pain on palpation in the right hypochondrium&#46; Laboratory tests showed elevated C-reactive protein &#40;170&#160;mgl&#41;&#44; plasma procalcitonin &#40;3&#46;31&#160;ng&#47;ml&#41; and elevated liver enzymes&#58; GPT &#40;352&#160;U&#47;l&#41;&#44; GOT &#40;426&#160;U&#47;l&#41;&#44; LDH &#40;665&#160;U&#47;l&#41;&#44; GGT &#40;93&#160;U&#47;l&#41; and AP &#40;121&#160;U&#47;l&#41;&#46; Chest X-ray&#44; electrocardiogram&#44; urine study and lumbar puncture&#44; without pathological findings&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was hospitalised and started on empirical antibiotic treatment with intravenous ceftriaxone&#44; with rapid improvement&#46; Given the abdominal symptoms and the laboratory pattern of hepatic cytolysis&#44; an abdominal ultrasound was performed&#44; showing a distended gallbladder with oedematous walls&#46; Lithiasis and biliary sludge are not visible&#46; The radiological findings were suggestive of acute acalculous cholecystitis&#46; The diagnosis was confirmed by abdominal computed tomography &#40;CT&#41;&#46; Given the good clinical and laboratory progress of the patient&#44; and while awaiting the microbiological results&#44; it was decided to maintain conservative antibiotic treatment with ceftriaxone&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The microbiological study was negative in urine&#44; stool&#44; blood&#44; cerebrospinal fluid&#44; and bone marrow cultures&#46; Polymerase chain reaction &#40;PCR&#41; for <span class="elsevierStyleItalic">Salmonella typhy</span> and <span class="elsevierStyleItalic">paratyphy</span> was negative&#46; Serologies for HIV as well as for hepatotropic viruses were negative&#46; Serological study using indirect immunofluorescence &#40;IIF&#41; for <span class="elsevierStyleItalic">C&#46; burnetti</span> showed elevated IgG against 1&#47;3200 phase II antigens&#46; The diagnosis of acute acalculous cholecystitis due to QF was established&#46; Antibiotic regimen with oral ciprofloxacin was completed on an outpatient basis for 14 days&#46; Currently&#44; one year after the onset of the disease&#44; the patient is asymptomatic and has no laboratory abnormalities&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Acute acalculous cholecystitis consists of inflammation of the gallbladder in the absence of stones&#46; Represents 5&#37;&#8211;10&#37; of all acute cholecystitis&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> It usually affects critically ill hospitalised patients&#59; however&#44; it can also be diagnosed in non-hospitalised patients without risk factors&#44; as in the case of the patient reported here&#46; In these cases&#44; the etiopathogenesis is usually related to a primary infection&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Few cases of QF associated with acute cholecystitis have been described in the literature&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;4</span></a> with Rolain et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> being the largest series published&#46; The gradual development of symptoms and their intensity differ from the form of presentation of cases with a calculous aetiology&#46; Therefore&#44; as reported by Gonz&#225;lez Delgado et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> cases of acalculous cholecystitis may have been missed in some cases of QF without apparent abdominal focality&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The diagnosis of acute cholecystitis is established by abdominal ultrasound&#44; in some cases in association with abdominal CT&#46; The diagnostic <span class="elsevierStyleItalic">gold standard</span> for QF is IIF and can also be established by PCR&#46; The serological diagnosis of acute QF is made by detecting phase II antigens&#44; which are detectable 7&#8211;15 days after the onset of the condition&#44; with significant IgG&#160;&#8805;&#160;1&#47;128 and IgM&#160;&#8805;&#160;1&#47;32 titers&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> IgG antibodies to phase II antigens&#160;&#62;&#160;1&#47;3200 were detected in our patient&#44; establishing the diagnosis of acute QF&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The treatment of choice for QF is doxycycline &#40;200&#160;mg&#47;day&#47;orally&#47;for 14 days&#41;&#46; Fluoroquinolones and macrolides have also shown efficacy&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> An excellent clinical response was observed in our patient with empirical broad-spectrum antibiotic therapy&#44; with intravenous ceftriaxone&#46; Therefore&#44; we agree with Reina-Serrano et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> although the treatment of acute cholecystitis is surgical&#44; when infection by <span class="elsevierStyleItalic">Coxiella burnetii</span> is suspected&#44; conservative management by antibiotic therapy can be applied&#44; and cholecystectomy should be indicated in case of failure&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion&#44; <span class="elsevierStyleItalic">C&#46; burnetii</span> infection should be considered in the etiological diagnosis of acute acalculous cholecystitis&#46;</p></span>"
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Article information
ISSN: 23870206
Original language: English
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es en pt

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