Poster Presentations Q.1. Clinical Conundrums in the Management of Q fever. The many remaining Queries in Query Fever 8/9/2012

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1 Clinical Conundrums in the Management of Q fever Poster Presentations The many remaining Queries in Query Fever Associate Professor Anthony Allworth, Director of Infectious Diseases, Royal Brisbane & Women s Hospital, QLD Dr William Pratt, Staff Specialist Physician, Shoalhaven Hospital, South East Sydney and Illawarra Area Health Service, NSW Associate Professor Clare Nourse, Director Paediatric Infection Management Service, Mater Health Services, QLD Dr Jenny Robson, Sullivan Nicolaides Pathology Taringa Brisbane Cooke, R The Derrick Legacy Q fever an Australian Discovery Q.1 What is your recommended follow up of acute cases of Q fever timing & frequency of examinations duration of serological follow Female 60 years 12 day h/o Mild sore throat, headaches, myalgias, abdominal pain, fevers, rigors, minimal cough Past history: Multiple pregnancies, 5 children, 2 LSCS, hysterectomy for menorrhagia, psoriasis Progress Progressive thrombocytopenia nadir 16, anaemia nadir 105 Probable haemophagocytosis Progressive jaundice peak bilirubin 90 Peripheral & sacral oedema S4, bilateral pleural effusions, non-cardiogenic pulmonary oedema Thin, pale, jaundice, tender hepatomegaly Hb 120, Neut 3.8, Lymph 0.58, Ptl 139 GGT 111, ALT 110, AST 251 1

2 Acute Q fever diagnosis: Clinical history & examination Esp heart disease, murmurs, prosthetic vascular material βhcg Serology from lab that will follow-up 6 weeks Clinical history and examination Explanation & reassurance (fatigue 6 months, 6 months+ Clinical history & examination Serology if c/w past infection NFA Serological testing Landaiset al From acute Q fever to Endocarditis: serological Follow up strategy CID 2007:44; Q.2 Phase 2 IgG can persist at high levels for > 12 m(43%) Phase I 1024 at 3 months (14%) majority <1024 at 12 m Phase I 1024 at 6 months best sensitivity & PPV In Netherlands - routine ECHO 59% abnormalities Stratify by risk factors: Risk factors: 3,6,12 m employ risk factors & clinical signs, imaging, pathology in decision making Acute cases without risk factors -9 months only CID 2011;52: A major dilemma is the validity of serological profiles as predictors of chronic Q fever. What are your comments regarding a 45 year old male with non specific symptoms and a serological profile as shown? Do you apply any particular serological cut off values? 2

3 Male aged 45 years Lab Q1 G IFA Q1 M IFA Q1 A IFA Q2G IFA Q2 M IFA Q2 A IFA < < < < >1280 <25 >1280 >1280 < < < CFT phase 1 = 256 CFT phase 2 = 256 Different serological results in 3 countries (France, Australia, UK) Concordance in result interpretation 35%. Question validity of using serological criteria alone as a means of diagnosing Chronic Q fever Affects the interpretation of epidemiological studies All results interpreted - clinical picture Healy et al CID Serological Markers of Chronic Disease 200 patients -classified PCR, serology, clinical, imaging, pathology Proven, -93 (46.5%) 65% PCR pos Probable 51 (25.5%) Possible 56 (28.0%) PPV Sensitivity 1: % : % : % : % 60.2 Increasing current diagnostic cut-off > 1:1024 not recommended 3 patients proven Chronic Q fever phase I 512 Not diagnostic on their own and should be interpreted with clinical parameters Positive association between height of phase I IgGand likelihood of a positive PCR 66% of proven cases were PCR positive however this was included as part of the definition. Phase I CFT 200 abandoned by all but us Phase I IgAIFA 25 (gone by the wayside) Phase I IgGIFA 800 (Dupont1994; major Dukes Criteria 2000) Phase I IgGIFA 1600 (Frankel 2011 French) Phase I IgGIFA 1280 (Wegdam-Blands Dutch) CVI 2012 ; 19: Q.2 contd J of Infection 2012;64: J of Infection: Available on line June 2012 What is the role of PCR in the diagnosis of Q fever? chronic disease: tissue (up to 100%) more sensitive than blood (22.9%, 66% in consensus article 47% and 23%) Role of FDG-PET-CT in diagnostic workup? Sensitivity 90% v 64% CT Specificity 90% if adopt clear criteria Focal, homogenous, abnormal uptake 3

4 Q.3 In cases of confirmed Q fever endocarditis or vascular lesions resulting in chronic Q fever what do you regard as optimum treatment; how long should treatment be given and how do you monitor response to therapy? Q.4 Q fever is said to be uncommon in children. Could you summarise the complicated cases of Q fever in children that you have managed and describe their presentation and management? Year Age Clinical Treatment Outcome Geographical Ongoing multifocal Bactrim + Clarithromycin, Booral, QLD R foot, chest wall, vertebral recurrences despite Doxycycline + body, R and L navicular therapy for some Hydroxychloroquine years Rural QLD Bactrim + Doxycycline, 18 month symptom Tibia, radius, shoulder Rifampicin, Ciprofloxacin free Rural QLD Distal L radius Rifampicin + Ciprofloxacin Resolution Recurrent lesions on therapy but resolution St. George, QLD Multiple cutaneous lesions Doxycycline + Rifampicin after 9 months (14m total therapy) Croftby OM sternum and tibia Doxycycline + 1 month therapy only (Toowoomba) Concurrent ATM infection hip Hydroxychloroquine so far QLD Nil after 4 months Bingara, NSW OM calcaneus, tibia, femur Ciprofloxacin + rifampicin therapy Q.5 Australia is the only country in the world that has a licensed human vaccine for Q fever. Currently it is licensed for over 16 year olds. Do you have any recommendations for vaccination of children at high risk? Others what is the role of vaccination in control of this disease? What is the future of vaccination in Australia? Milaa, Milaa Cairns QLD Recurrent osteomyelitis femur, talus, tibia Doxycycline + Hydroxychloroquine Ongoing lesions on therapy (2 months) Q fever Vaccination Prevaccination Screening Humoral phase 2 IgG CMI Skin test Adverse Effects Severe Local reactions Severe systemic side effects + Fever Q fever Register 1 st non-statutory health register in Australia Total individuals on the Register: 88,178 No. of participating organisations: 422 Q fever Register Total individuals on the Register: 88,178 No. of participating organisations:

5 Q.6 Farmer contracted Q fever agricultural show 2006 patient has chronic polyarthropathy with fatigue since 2006 Mr JR Dob: 04/10/55 Sex: Date 20/04/06 29/05/12 12/06/12 25/06/12 QF phase 2 EIA IgG Negative Positive Positive Positive QF phase 2 EIA IgM Positive Positive Positive Positive QF phase 2 CFT Negative QF phase 1 CFT Negative Q fever Fatigue Syndrome what are your thoughts? Would you support a work cover claim? Q.7 A woman 12 weeks pregnant contracts acute Q fever. What are the risks to her pregnancy? How would you manage her treatment and delivery? What will you advice for subsequent pregnancies? Is there a role for screening? Q.8 In adults, prior valvulopathy, endothelial lesions or immunosuppression are thought to predispose to chronicity. What is known about predisposition in children? 5