• 1.

    Angelakis E, Raoult D, 2010. Review Q fever. Vet Microbiol 140: 297309.

  • 2.

    Eldin C, Mélenotte C, Mediannikov O, Ghigo E, Million M, Edouard S, Mege JL, Maurin M, Raoult D, 2017. From Q fever to Coxiella burnetii infection: a paradigm change. Clin Microbiol Rev 30: 115190.

    • Search Google Scholar
    • Export Citation
  • 3.

    Derrick EH, 1937. ‘Q’ fever, a new fever entity: clinical features, diagnosis and laboratory investigation. Med J Aust 11: 281299.

  • 4.

    Schneeberger PM, Wintenberger C, van der Hoek W, Stahl JP, 2014. Q fever in the Netherlands—2007–2010: what we learned from the largest outbreak ever. Med Mal Infect 44: 339353.

    • Search Google Scholar
    • Export Citation
  • 5.

    Epelboin L 2016. Q fever in French Guiana: tip of the iceberg or epidemiological exception? PLoS Negl Trop Dis 10: e0004598.

  • 6.

    Brandão H, Ribeiro do Valle LA, Christóvão DA, 1953. Investigações sobre a febre Q em São Paulo. 1. Estudo sorológico em operários de um frigorífico. Arq. Fac. Hig. Saúde Pública Univ São Paulo 7: 127134.

    • Search Google Scholar
    • Export Citation
  • 7.

    Mares-Guia MAMM, Rozental T, Guterres A, Ferreira MS, Botticini RG, Terra AK, Marrachi S, Bochner R, Lemos ERS, 2016. Molecular identification of Q fever in patients with a suspected diagnosis of dengue in Brazil in 2013–2014. Am J Trop Med Hyg 94: 10901094.

    • Search Google Scholar
    • Export Citation
  • 8.

    Rozental T, Mascarenhas LF, Rozenbaum R, Gomes R, Mattos GS, Magno CC, Almeida DN, Rossi MID, Favacho ARM, Lemos ERS, 2012. Coxiella burnetii, the agent of Q fever in Brazil: its hidden role in seronegative arthritis and the importance of molecular diagnosis based on the repetitive element IS1111 associated with the transposase gene. Mem Inst Oswaldo Cruz 107: 695697.

    • Search Google Scholar
    • Export Citation
  • 9.

    Shishido AA, Letiaia AG, Hartzell JD, 2016. Q fever. US Army Med Dep J Jan–Mar: 6870.

  • 10.

    Farris CM, Pho N, Myers TE, Richards AL, 2016. Seroconversions for Coxiella and rickettsial pathogens among US marines deployed to Afghanistan, 2001–2010. Emerg Infect Dis 22: 14911493.

    • Search Google Scholar
    • Export Citation
  • 11.

    Anderson AD, Smoak B, Shuping E, Ockenhouse C, Petruccelli B, 2005. Q fever and the US military. Emerg Infect Dis 11: 13201322.

 

 

 

 

 

Q Fever in Military Firefighters during Cadet Training in Brazil

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  • 1 Laboratório de Hantaviroses e Rickettsioses, Instituto Oswaldo Cruz, Fiocruz, Rio de Janeiro, Brazil;
  • 2 Hospital Central Aristarcho Pessoa–Corpo de Bombeiros Militar do Estado do Rio de Janeiro (CBMERJ), Rio de Janeiro, Brazil;
  • 3 Hospital São Francisco de Assis, Rio de Janeiro, Brazil;
  • 4 Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil;
  • 5 Hospital Municipal Jesus, Rio de Janeiro, Brazil;
  • 6 Laboratório Rocha e Fonseca, Rio de Janeiro, Brazil

We report five cases of Q fever among cadets during a training program for Military Firefighters Academy in the state of Rio de Janeiro, Brazil. This cluster confirms the significance of Coxiella burnetii as an infectious agent in Brazil, where the occurrence of this zoonosis is poorly documented and highlights the potential risk for Q fever transmission in rural areas or farms with infected animals.

Q fever is a zoonosis caused by Coxiella burnetii, an intracellular bacterium that infects several animals, including humans. After an incubation period of 14–37 days, most human infections are asymptomatic but can present as a flu-like illness, pneumonia, or hepatitis.1 Hepatitis and endocarditis or fatal cases depend on the patient’s risk factors and the virulence of the bacterial strain.1,2 The infection is transmitted to humans from infected animals through contact with and inhalation of secretions, particularly birth products from domestic ruminants.1

Coxiella burnetii was first reported in Australia in 1937 and has emerged in several regions of the world in the last decade.2,3 Thus, Q fever has become an important public health concern in the northern hemisphere, particularly in European countries, where cases have been reported in areas where Q fever was previously nonendemic, such as the Netherlands.4 Outbreaks and sporadic human cases are reported around the world, but there is little knowledge about Q fever in Africa and South America.5 In Brazil, the first serological evidence of C. burnetti infection was described in 1953. However, only recently, a few rare cases have been identified in the southeast region.58 Curiously, an annual incidence of 150 cases/100,000 people was observed in 2005 in French Guiana, which borders the northern region of Brazil.5 Thus, this disparity with Brazil suggests that the occurrence of Q fever may be underreported.

We describe a cluster of Q fever cases among cadets enrolled in a training program at the Pedro II Military Firefighters Academy (MFAPRJ) in Rio de Janeiro, Brazil.

In October 2016, five cadets with acute febrile illness were evaluated at the Central Hospital of MFAPRJ (Table 1). All patients were male, aged between 20 and 25 years, and had a history of camping during military survival training, with more than 42 cadets (total of 47) in the region of Ribeirão das Lajes (22°41′28″S 43°51′49″W) in the state of Rio de Janeiro from September 29 to October 13, 2016. They reported numerous tick bites, and 45 cadets participated directly in slaughtering animals for their own consumption (including a goat) under field survival conditions.

Table 1

Clinical and laboratorial findings of Q fever in cadets in Brazil, 2016

Case (age)Date of illness onsetClinical manifestationsIncubation periodHemogramThorax and abdominal computed tomographyIFA (serum samples–phase II IgG) (date of sample collection)PCRComments
1S2S3S4S5SBloodBAL
1 (20)October 17Fever (38°C), dry cough, myalgia, headache, and abdominal pain18142,000 leukocytesConsolidation in the left upper lobe, lingula, and right lower lobe with air bronchogram. Pleural effusion on the left side. Hepatosplenomegaly< 64 (October 27)128 (November 01)1,024 (November 07)2,048 (November 18)16,384 (November 30)NEGNANonhospitalized patient
467,000 platelets
2 (22)October 21Fever (38.4°C), dysuria, myalgia, dry cough, fatigue, headache, and dyspnea227,700 leukocytesConsolidation in the left lower lobe, with infiltrates “frosted glass” associated with air bronchogram. Hepatosplenomegaly< 64 (October 27)512 (November 01)4,096 (November 07)4,096 (November 16)16,384 (November 30)NEGNAHospitalized patient
178,000 platelets
3 (23)October 23Fever (38°C), myalgia, dry cough, and headache3110,400 leukocytesConsolidation in the right lung with air bronchogram.< 64 (October 27)128 (November 01)1,024 (November 07)256 (November 18)128 (November 30)NEGNAHospitalized patient
194,000 plateletsSplenomegaly
4 (21)October 23Fever (39°C), dry cough, headache, and acute respiratory failure248,700 leukocytesConsolidation in the left lung.< 64 (October 27)128 (November 01)1,024 (November 07)2,048 (November 18)16,384 (November 30)NEGPOSPatient hospitalized in intensive care
227,000 plateletsHepatosplenomegaly
5 (22)October 29Fever (38.1°C), nausea, vomit, abdominal pain, myalgia, dry cough, and headache307,900 leukocytesConsolidation in the left lung.< 64 (November 11)128 (November 16)1,024 (November 30)NANANEGNAHospitalized patient
193,000 plateletsHepatosplenomegaly

NA = not available; NEG = negative; IFA = indirect immunofluorescence test; PCR = polymerase chain reaction; POS = positive; S = sample. Normal ranges: leukocytes 4,000–11,000; platelets 150,000–450,000.

One of the cadets had severe pneumonia associated with respiratory failure. Laboratory findings and a chest radiograph were available from medical records and are reported in the table. Because of the possibility of diseases associated with ticks, 200 mg/day of doxycycline were administered after collecting blood samples from the patients and bronchoalveolar lavage (BAL) from the one patient who progressed to respiratory failure. All patients recovered and were discharged.

An indirect immunofluorescence assay (IFA) (Focus Diagnostics, Cypress, CA) for antibodies against C. burnetii was performed with a titer cutoff of 64. Sequential serum samples were collected from the patients, and in all cases, paired serum samples showed a > 4-fold increase of immunoglobulin G (phases II) specific to C. burnetii. Blood and BAL samples were analyzed using polymerase chain reaction (PCR) for a fragment of IS1111 gene—a transposon-like repetitive region, as reported previously.7,8 Coxiella burnetii DNA was detected in BAL from patient 4, and the sequence fragment revealed 99% sequence identity with the homologous gene fragment of the htpAB transposase gene from C. burnetii strains RSA 331, RSA 439, and RSA 443 (GenBank accession no. MF447442).

In December 2016, serum samples from the 42 healthy military cadets who participated in the training program were analyzed, and all were nonreactive. Considering that the probable source of infection was the goat, a field investigation was also carried out on a commercial shop where the cadets purchased the animal. Blood and anal swab samples collected from 12 goats were analyzed using IFA and PCR. The results revealed an absence of C. burnetii infection. Unfortunately, given the nature of most small ruminant markets in Brazil, it was not possible to identify the rural property that supplied the goat to the commercial place.

Previous studies have identified C. burnetii as one of the pathogens for outbreaks of influenza-like illness and pneumonia among military personnel. Military personnel are a high-risk occupational group that is often exposed to several infectious agents.911 This is the first report of a Q fever outbreak among military personnel in Brazil, where autochthonous cases have mainly been reported in the states of Rio de Janeiro and São Paulo.68

All five patients in this study had contact with the goat, and their estimated incubation periods ranged from 18 to 31 days. The estimated attack rate was 10.6% (5/47). However, cases 2 and 4 reported close contact with the ruminant and had more severe disease courses than the other patients. This confirms that the clinical severity also depends on the size of the inoculum. Outbreaks are being identified more frequently among military personnel around the world, and an increasing number of cases are being reported in Latin America. Together with the present data, these facts emphasize the need for further work to generate additional data on C. burnetii as an infectious agent in the general population and the significance of Q fever in the military in Brazil.

Acknowledgments:

We are grateful to the Sequencing Platform Network for bacterial genomic sequencing (Oswaldo Cruz Institute/Fiocruz); the Light Group Company and the staff members of the municipalities of Piraí, Resende, Rio Claro, Volta Redonda and Rio de Janeiro State Health Department for their assistance during field expeditions to Ribeirão das Lajes.

REFERENCES

  • 1.

    Angelakis E, Raoult D, 2010. Review Q fever. Vet Microbiol 140: 297309.

  • 2.

    Eldin C, Mélenotte C, Mediannikov O, Ghigo E, Million M, Edouard S, Mege JL, Maurin M, Raoult D, 2017. From Q fever to Coxiella burnetii infection: a paradigm change. Clin Microbiol Rev 30: 115190.

    • Search Google Scholar
    • Export Citation
  • 3.

    Derrick EH, 1937. ‘Q’ fever, a new fever entity: clinical features, diagnosis and laboratory investigation. Med J Aust 11: 281299.

  • 4.

    Schneeberger PM, Wintenberger C, van der Hoek W, Stahl JP, 2014. Q fever in the Netherlands—2007–2010: what we learned from the largest outbreak ever. Med Mal Infect 44: 339353.

    • Search Google Scholar
    • Export Citation
  • 5.

    Epelboin L 2016. Q fever in French Guiana: tip of the iceberg or epidemiological exception? PLoS Negl Trop Dis 10: e0004598.

  • 6.

    Brandão H, Ribeiro do Valle LA, Christóvão DA, 1953. Investigações sobre a febre Q em São Paulo. 1. Estudo sorológico em operários de um frigorífico. Arq. Fac. Hig. Saúde Pública Univ São Paulo 7: 127134.

    • Search Google Scholar
    • Export Citation
  • 7.

    Mares-Guia MAMM, Rozental T, Guterres A, Ferreira MS, Botticini RG, Terra AK, Marrachi S, Bochner R, Lemos ERS, 2016. Molecular identification of Q fever in patients with a suspected diagnosis of dengue in Brazil in 2013–2014. Am J Trop Med Hyg 94: 10901094.

    • Search Google Scholar
    • Export Citation
  • 8.

    Rozental T, Mascarenhas LF, Rozenbaum R, Gomes R, Mattos GS, Magno CC, Almeida DN, Rossi MID, Favacho ARM, Lemos ERS, 2012. Coxiella burnetii, the agent of Q fever in Brazil: its hidden role in seronegative arthritis and the importance of molecular diagnosis based on the repetitive element IS1111 associated with the transposase gene. Mem Inst Oswaldo Cruz 107: 695697.

    • Search Google Scholar
    • Export Citation
  • 9.

    Shishido AA, Letiaia AG, Hartzell JD, 2016. Q fever. US Army Med Dep J Jan–Mar: 6870.

  • 10.

    Farris CM, Pho N, Myers TE, Richards AL, 2016. Seroconversions for Coxiella and rickettsial pathogens among US marines deployed to Afghanistan, 2001–2010. Emerg Infect Dis 22: 14911493.

    • Search Google Scholar
    • Export Citation
  • 11.

    Anderson AD, Smoak B, Shuping E, Ockenhouse C, Petruccelli B, 2005. Q fever and the US military. Emerg Infect Dis 11: 13201322.

Author Notes

Address correspondence to Elba Regina Sampaio de Lemos, Laboratório de Hantaviroses e Rickettsioses, Fiocruz, Pavilhão Hélio e Peggy Pereira, Sala B115, Avenida Brasil 4365, Manguinhos, 21040-900 Rio de Janeiro, Brazil, E-mail: elemos@ioc.fiocruz.br or Tatiana Rozental, Laboratório de Hantaviroses e Rickettsioses, FIOCRUZ, Pavilhão Hélio e Peggy Pereira, Sala B116, Avenida Brasil 4365, Manguinhos, 21040-900 Rio de Janeiro, Brazil, E-mail: rozental@ioc.fiocruz.br.

Financial support: This study was supported by grants from Conselho Nacional para o Desenvolvimento Cientifico e Tecnológico (CNPq) Project 407664/2012 and Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ), Project E-26/010.001567/2014. This study was approved by the Ethics Committee of FIOCRUZ, under number CAAE 51398415.7.0000.5248.

Authors’ addresses: Elba Regina Sampaio de Lemos, Tatiana Rozental, Adonai Alvino Pessoa Júnior, Thays Euzebio Joaquim, and Raphael Gomes da Silva, Laboratório de Hantaviroses e Rickettsioses, Instituto Oswaldo Cruz, Fiocruz, Rio de Janeiro, Brazil, E-mails: elemos@ioc.fiocruz.br, rozental@ioc.fiocruz.br, adonai_pessoa@hotmail.com, thays.euzebio@ioc.fiocruz.br, and raphaelgomes@ioc.fiocruz.br. Bibiana Nogueira Siqueira, Hospital Central Aristarcho Pessoa–Corpo de Bombeiros Militar do Estado do Rio de Janeiro (CBMERJ), Rio de Janeiro, Brazil, and Hospital São Francisco de Assis, Rio de Janeiro, Brazil, E-mail: bibiveti@yahoo.com.br. Carolina de Andrade Leite, Hospital Central Aristarcho Pessoa–Corpo de Bombeiros Militar do Estado do Rio de Janeiro (CBMERJ), Rio de Janeiro, Brazil, and Hospital Universitário Pedro Ernesto, Rio de Janeiro, Brazil, E-mail: carol.leite.hemato@gmail.com. Adriana Alvarez Arantes, Hospital Municipal Jesus, Rio de Janeiro, Brazil, E-mail: adrianaalvarezarantes@hotmail.com. Marisângela Ferreira da Cunha, Laboratório Rocha e Fonseca, Rio de Janeiro, Brazil, E-mail: mari@laboratoriorochaefonseca.com. Danielle Provençano Borghi, Hospital Central Aristarcho Pessoa–Corpo de Bombeiros Militar do Estado do Rio de Janeiro (CBMERJ), Rio de Janeiro, Brazil, E-mail: danielle.borghi@uol.com.br.

These authors contributed equally to this work.

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