Case Report
Q-Fever Can Simulate a Lupus Flare
La fiebre Q puede simular un brote lúpico
José Ángel Hernández Beriain
, Sergio Machín García, Francisco Javier Novoa Medina, Daniel Batista Perdomo, Antonio Rosas Romero, Eduardo Girona Quesada
Corresponding author
Servicio de Reumatología, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
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Francisco Javier Novoa Medina, Daniel Batista Perdomo, Antonio Rosas Romero, Eduardo Girona Quesada" "autores" => array:6 [ 0 => array:4 [ "nombre" => "José Ángel" "apellidos" => "Hernández Beriain" "email" => array:1 [ 0 => "hernandezberiain@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Sergio" "apellidos" => "Machín García" ] 2 => array:2 [ "nombre" => "Francisco Javier" "apellidos" => "Novoa Medina" ] 3 => array:2 [ "nombre" => "Daniel" "apellidos" => "Batista Perdomo" ] 4 => array:2 [ "nombre" => "Antonio" "apellidos" => "Rosas Romero" ] 5 => array:2 [ "nombre" => "Eduardo" "apellidos" => "Girona Quesada" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Reumatología, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La fiebre Q puede simular un brote lúpico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1006 "Ancho" => 1554 "Tamanyo" => 84726 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Progressive normalization of acute phase reactants.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The presence of fever in a patient with SLE is a diagnostic challenge as the two main causes of it, the reactivation of the disease or infection, require very different<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> therapeutic actions.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Q fever is an infectious disease of worldwide distribution, caused by <span class="elsevierStyleItalic">Coxiella burnetii</span> (<span class="elsevierStyleItalic">C. burnetii</span>).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The usual clinical manifestations of the acute form include fever, headache, asthenia, sweating, chills and frequent musculoskeletal pain and gastrointestinal symptoms, all common in lupus outbreaks. We describe a patient with SLE, who was diagnosed with Q fever in what appeared to be a lupus flare.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Clinical Observation</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 176-year-old woman was first seen by the rheumatology consultation in September 2008 in connection to thrombocytopenia and positive antinuclear antibodies (ANA). In November 2009, the diagnosis of SLE due to the presence of polyarthritis, leukopenia, and anti-DNA antibodies (titer of 1/80) was made. She was treated with deflazacort (6<span class="elsevierStyleHsp" style=""></span>mg/day) and presented significant improvement of the arthritis and, later, treatment was begun with hydroxychloroquine (300<span class="elsevierStyleHsp" style=""></span>mg/day) and nonsteroidal antiinflammatory drugs in varying doses and she remained virtually asymptomatic in the following months. She remained in remission until the end of May 2010, but developed fever of up to 39<span class="elsevierStyleHsp" style=""></span>°C, with no clear chronological pattern, musculoskeletal pain and stiffness with doubtful signs of arthritis, loss of appetite, malaise and sore throat. Physical examination was normal except for some pharyngeal hyperemia, but cardiopulmonary examination was normal and the abdomen was soft and without organ enlargement. In the initial analysis we carried out, she had a hemoglobin of 10.5<span class="elsevierStyleHsp" style=""></span>g/dl and 3700 leukocytes. The ESR was 41 and CRP 4.33<span class="elsevierStyleHsp" style=""></span>mg/dl, complement fractions C3 46<span class="elsevierStyleHsp" style=""></span>mg/dl (NV: 90–180) and C4 of 3<span class="elsevierStyleHsp" style=""></span>mg/dl (NV: 10–40). The urinary sediment presented 1–5 cells/field without proteinuria and transaminases were normal. The chest X-ray was normal. Based on clinical and laboratory data and waiting for the other microbiological data requested, deflazacort was substituted by prednisone (30<span class="elsevierStyleHsp" style=""></span>mg/day), due to the suspicion of a lupus flare. In the next 7 days we observed a slight reduction of fever and improvement of musculoskeletal pain, but in later days these symptoms were reactivated. The results of microbiological studies were negative for major viral infections (including hepatotropic virus, Epstein-Barr virus, cytomegalovirus and human immunodeficiency virus) and positive for <span class="elsevierStyleItalic">C. burnetii</span> phase II IgG 1/16384 (titers above 1/256 show active or recent infection) and IgM 1/64 (titles showing active infection are at or above 1/32), at which point we started doxycycline 100<span class="elsevierStyleHsp" style=""></span>mg. Every 12<span class="elsevierStyleHsp" style=""></span>h for 14 days, which began about 3 weeks after the process’ onset, and led to complete relief of the symptoms, with the patient being virtually asymptomatic after 5 days of antibiotic and with progressive normalization of acute phase reactants, as shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. The serological testing performed at 3 weeks showed a negative result for IgM and a significant reduction of IgG (1/2048). Given the good outcome, no echocardiogram was performed and treatment was continued with hydroxychloroquine (300<span class="elsevierStyleHsp" style=""></span>mg/day) and prednisone (5<span class="elsevierStyleHsp" style=""></span>mg/day).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">In patients with SLE, fever is a common symptom and distinguishing between an infection or lupus flare is sometimes a challenge. It has been suggested that elevated CRP levels (above 6<span class="elsevierStyleHsp" style=""></span>mg/dl) are highly suggestive of infection and may be of help,<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> and typical data of SLE activity, such as complement decrease or increased activity of SLE measured by the SLEDAI1 index, may be absent. On the other hand, the use of high doses of steroids in lupus patients with infection might be fatal, hence the importance of differentiating both. As previously described by Ohguchi et al.,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> the existence of Q fever might present with clinical and even biological SLE data and has an excellent response to antibiotic treatment and no further testing is needed to confirm SLE. In our case, we had a previous diagnosis of SLE, defined on the basis of clinical and laboratory data and, later, the patient developed nonspecific clinical signs and symptoms that could respond to both infection or a reactivation of SLE. Q fever is a universal zoonosis and infected animals excrete the organism in the feces, urine and milk. The usual route of human infection is inhalation of pseudoespores. It is asymptomatic in many patients (up to 50% in some series) and most cases occur as an acute process,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> which presents with fever and general symptoms such as pneumonia or liver disease, although in our case these complications did not occur. The differential diagnosis is broad, given the nonspecific symptoms, and the use of diagnostic criteria is aimed at the recognition of Q fever-associated endocarditis. The microbiological diagnosis by culture can be direct, but its sensitivity is very low, so one commonly resorts to indirect techniques, among them one of the most widely used is indirect immunofluorescence, which shows a 97% sensitivity and specificity of 100% for phase II IgG in some studies.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In acute infection, it is common to find elevated antibody titers to phase II antigens, while those directed to phase I antigens are more characteristic of chronic infection. Test results can be misleading in the presence of rheumatoid factor, which was not present in our patient. Cross reactions with other microorganisms, such as <span class="elsevierStyleItalic">Legionella</span>, <span class="elsevierStyleItalic">Bartonella</span> and <span class="elsevierStyleItalic">Ehrlichia</span>, can be seen, although these seem more common in chronic forms of Q fever. The clinical differences and regional distribution can help in the differential diagnosis.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0020" class="elsevierStylePara elsevierViewall">The main interest of this case is to consider Q fever as a causal factor of fever and other symptoms that are similar to a lupus outbreak in a patient with SLE, especially in endemic areas where the infection is common, and where an appropriate therapeutic intervention is crucial.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Disclosures</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors have no disclosures to make.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres125769" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec113057" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres125770" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec113056" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical Observation" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Disclosures" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-04-15" "fechaAceptado" => "2011-07-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec113057" "palabras" => array:3 [ 0 => "Systemic lupus erythematosus" 1 => "Q fever" 2 => "Infection" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec113056" "palabras" => array:3 [ 0 => "Lupus eritematoso sistémico" 1 => "Fiebre Q" 2 => "Infección" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Fever is a diagnostic challenge in the patient with lupus. Infections can mimic a lupus flare which further complicates the diagnostic approach. Moreover, immunosuppressive treatment of SLE may promote the development of infections and poor outcome. We report the case of a patient with SLE with an initial diagnosis of lupus flare, who was found to have Q fever showing an excellent response to treatment with doxycycline.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La fiebre constituye un reto diagnóstico en el paciente lúpico. Algunas infecciones pueden imitar un brote de la enfermedad, lo que complica aún más la orientación diagnóstica. Por otra parte, el tratamiento inmunodepresor del lupus eritematoso sistémico (LES) puede favorecer la aparición de infecciones y su mala evolución. Presentamos el caso de una paciente con LES en tratamiento con antipalúdicos y dosis bajas de esteroides, cuyo diagnóstico inicial fue de brote lúpico y que resultó tener fiebre Q, presentando una respuesta excelente al tratamiento con doxiciclina.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Hernández Beriain JÁ, et al. La fiebre Q puede simular un brote lúpico. Reumatol Clin. 2012;<span class="elsevierStyleBold">8</span>:143–4.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1006 "Ancho" => 1554 "Tamanyo" => 84726 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Progressive normalization of acute phase reactants.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The causes and clinical significance of fever in systemic lupus erythematosus: a retrospective study of 487 hospitalised patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "W.J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 16 | 25 |
| 2024 October | 51 | 57 | 108 |
| 2024 September | 68 | 62 | 130 |
| 2024 August | 76 | 75 | 151 |
| 2024 July | 61 | 48 | 109 |
| 2024 June | 86 | 48 | 134 |
| 2024 May | 69 | 35 | 104 |
| 2024 April | 61 | 33 | 94 |
| 2024 March | 69 | 51 | 120 |
| 2024 February | 58 | 37 | 95 |
| 2024 January | 52 | 29 | 81 |
| 2023 December | 47 | 27 | 74 |
| 2023 November | 71 | 34 | 105 |
| 2023 October | 42 | 35 | 77 |
| 2023 September | 86 | 45 | 131 |
| 2023 August | 82 | 27 | 109 |
| 2023 July | 43 | 22 | 65 |
| 2023 June | 62 | 28 | 90 |
| 2023 May | 50 | 24 | 74 |
| 2023 April | 22 | 22 | 44 |
| 2023 March | 59 | 33 | 92 |
| 2023 February | 49 | 30 | 79 |
| 2023 January | 42 | 19 | 61 |
| 2022 December | 56 | 39 | 95 |
| 2022 November | 52 | 41 | 93 |
| 2022 October | 70 | 49 | 119 |
| 2022 September | 46 | 32 | 78 |
| 2022 August | 47 | 41 | 88 |
| 2022 July | 52 | 46 | 98 |
| 2022 June | 45 | 27 | 72 |
| 2022 May | 60 | 60 | 120 |
| 2022 April | 79 | 51 | 130 |
| 2022 March | 106 | 52 | 158 |
| 2022 February | 113 | 27 | 140 |
| 2022 January | 74 | 39 | 113 |
| 2021 December | 52 | 48 | 100 |
| 2021 November | 81 | 45 | 126 |
| 2021 October | 90 | 59 | 149 |
| 2021 September | 74 | 43 | 117 |
| 2021 August | 36 | 37 | 73 |
| 2021 July | 249 | 35 | 284 |
| 2021 June | 341 | 48 | 389 |
| 2021 May | 304 | 59 | 363 |
| 2021 April | 184 | 125 | 309 |
| 2021 March | 109 | 41 | 150 |
| 2021 February | 61 | 36 | 97 |
| 2021 January | 52 | 27 | 79 |
| 2020 December | 74 | 33 | 107 |
| 2020 November | 75 | 30 | 105 |
| 2020 October | 61 | 18 | 79 |
| 2020 September | 43 | 31 | 74 |
| 2020 August | 35 | 21 | 56 |
| 2020 July | 41 | 23 | 64 |
| 2020 June | 52 | 28 | 80 |
| 2020 May | 49 | 23 | 72 |
| 2020 April | 42 | 15 | 57 |
| 2020 March | 21 | 11 | 32 |
| 2020 February | 1 | 0 | 1 |
| 2020 January | 4 | 0 | 4 |
| 2019 September | 4 | 0 | 4 |
| 2019 June | 1 | 0 | 1 |
| 2019 March | 1 | 0 | 1 |
| 2019 January | 1 | 0 | 1 |
| 2018 May | 4 | 1 | 5 |
| 2018 April | 82 | 16 | 98 |
| 2018 March | 125 | 18 | 143 |
| 2018 February | 49 | 1 | 50 |
| 2018 January | 63 | 4 | 67 |
| 2017 December | 47 | 10 | 57 |
| 2017 November | 40 | 5 | 45 |
| 2017 October | 34 | 6 | 40 |
| 2017 September | 24 | 6 | 30 |
| 2017 August | 39 | 9 | 48 |
| 2017 July | 34 | 19 | 53 |
| 2017 June | 65 | 9 | 74 |
| 2017 May | 50 | 6 | 56 |
| 2017 April | 47 | 12 | 59 |
| 2017 March | 47 | 26 | 73 |
| 2017 February | 35 | 6 | 41 |
| 2017 January | 36 | 5 | 41 |
| 2016 December | 57 | 25 | 82 |
| 2016 November | 69 | 8 | 77 |
| 2016 October | 104 | 9 | 113 |
| 2016 September | 75 | 6 | 81 |
| 2016 August | 65 | 8 | 73 |
| 2016 July | 42 | 20 | 62 |
| 2016 April | 1 | 0 | 1 |
| 2015 December | 2 | 0 | 2 |
| 2015 September | 2 | 0 | 2 |
| 2015 August | 2 | 0 | 2 |
| 2015 July | 29 | 5 | 34 |
| 2015 June | 52 | 8 | 60 |
| 2015 May | 148 | 18 | 166 |
| 2015 April | 65 | 12 | 77 |
| 2015 March | 36 | 11 | 47 |
| 2015 February | 32 | 6 | 38 |
| 2015 January | 50 | 15 | 65 |
| 2014 December | 48 | 12 | 60 |
| 2014 November | 24 | 10 | 34 |
| 2014 October | 40 | 11 | 51 |
| 2014 September | 34 | 9 | 43 |
| 2014 August | 36 | 5 | 41 |
| 2014 July | 49 | 9 | 58 |
| 2014 June | 53 | 8 | 61 |
| 2014 May | 47 | 12 | 59 |
| 2014 April | 42 | 10 | 52 |
| 2014 March | 44 | 16 | 60 |
| 2014 February | 35 | 10 | 45 |
| 2014 January | 47 | 8 | 55 |
| 2013 December | 30 | 8 | 38 |
| 2013 November | 50 | 12 | 62 |
| 2013 October | 63 | 10 | 73 |
| 2013 September | 55 | 12 | 67 |
| 2013 August | 53 | 16 | 69 |
| 2013 July | 52 | 8 | 60 |
| 2013 June | 46 | 9 | 55 |
| 2013 May | 32 | 12 | 44 |
| 2013 April | 42 | 10 | 52 |
| 2013 March | 46 | 13 | 59 |
| 2013 February | 38 | 9 | 47 |
| 2013 January | 32 | 5 | 37 |
| 2012 December | 33 | 5 | 38 |
| 2012 November | 21 | 10 | 31 |
| 2012 October | 27 | 11 | 38 |
| 2012 September | 8 | 4 | 12 |
| 2012 July | 5 | 0 | 5 |
| 2012 June | 13 | 0 | 13 |
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