We read with great interest the case series of 20 patients with Q fever from a VA Medical Center in southern California by Akamine et al.1 We applaud the authors’ efforts to create greater awareness for an infection that is considered underreported in this region.
We identified 11 cases with Q fever at our community-based organization in southern California by a retrospective chart review from 2014 to 2019 (Table 1). On review, all of our patients presented with a febrile illness, and a vast majority of cases involved males (nine) with animal exposure, particularly to goats and cattle (seven). The geographic distribution of the cases favored urban areas (10) in Riverside and San Bernardino counties. In addition, six patients with acute Q fever presented with transaminitis (four), leukocytosis (three), and pneumonia (two). Complications of infection caused seven of our patients to be hospitalized. All patients were treated with oral doxycycline for 14 days, except for patient no. 2 who received a 1-year course of doxycycline and hydroxychloroquine sulfate for endocarditis. All of our cases received infectious diseases consultation and follow-up with subsequent complete recovery from infection.
Summary of demographic and clinical features of Q fever cases
|Patient no.||Age (years) and gender at diagnosis||Clinical presentation||Animal exposure||Date of symptoms||Date of first titer||Case classification|
|1||63, M||Febrile illness||Yes—goats||July 18, 2014||August 28, 2014||Acutec|
|2||59, M||Febrile illness with thrombocytopenia||Yes—goats||March 27, 2016||May 4, 2016||Chronicc|
|3||67, M||Febrile illness||Yes—cattle||March 25, 2018||March 28, 2018||Acutep|
|4||73, M||Febrile illness with transaminitis||Yes—goats||July 6, 2018||August 8, 2018||Acutec|
|5||43, M||Febrile illness with transaminitis and leukocytosis||No||August 18, 2018||August 30, 2018||Acutec|
|6||47, M||Febrile illness||Yes—goats/cattle||August 18, 2018||September 4, 2018||Acutep|
|7||30, M||Febrile illness||Yes—cats/dogs||August 22, 2018||September 17, 2018||Acutec|
|8||70, F||Febrile illness||No||November 19, 2018||January 7, 2019||Acutec|
|9||34, M||Febrile illness with pneumonia, transaminitis, and leukocytosis||No||January 22, 2019||January 27, 2019||Acutec|
|10||34, M||Febrile illness with transaminitis and leukocytosis||Yes—goats/cattle||February 22, 2019||March 11, 2019||Acutec|
|11||43, F||Febrile illness with pneumonia||Yes—goats/cattle||April 4, 2019||June 14, 2019||Acutep|
Acutec = acute infection, confirmed; Acutep = acute infection, probable; F = female; M = male.
Of significant interest, our findings revealed that a greater proportion of cases (nine) occurred between 2018 and 2019, which is of unclear etiology. Symptom onset was most frequent during the spring (three) and summer (five), with a peak in August (three). In addition, exposure to goats and cattle was the predominant risk factor for infection in our patients than exposure to rodents, dogs, cats, and sheep as reported in other studies in southern California.1,2 We identified two female patients with Q fever as compared with none by Akamine et al.1 Another distinctive finding from other studies is almost half of our patients were diabetic (five) and of Hispanic/Latino (five) descent.1,2
Our cases highlight that Q fever may be a bigger threat than previously thought in Riverside and San Bernardino counties of southern California. Our findings may also provide early evidence for an increasing trend of infection in this region. Health-care professionals should be vigilant in screening for infection in patients particularly presenting with a febrile illness associated with transaminitis, leukocytosis, pneumonia, and exposure to goats and cattle. We agree with the authors’ recommendation for early infectious diseases consultation to expedite diagnosis and treatment that may improve outcomes and potentially prevent complications of the infection. Further studies with larger cohorts involving multiple health-care institutions in southern California are warranted to confirm our observations for greater public health awareness.
Akamine CM, Perez ML, Lee JH, Ing MB, 2019. Q fever in southern California: a case series of 20 patients from a VA Medical Center. Am J Trop Med Hyg 101: 33–39.
Cone LA, Curry N, Shaver P, Brooks D, DeForge J, Potts BE, 2006. Q fever in the southern California desert: epidemiology, clinical presentation and treatment. Am J Trop Med Hyg 75: 29–32.