Saturday, June 10, 2023
This activity is intended for primary care physicians, pediatricians, infectious disease specialists, orthopedists, and other physicians who care for children who may have Q fever.
The goal of this activity is to assess the diagnosis and management of Q fever osteoarticular infection among children.
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CME / ABIM MOC Released: 8/18/2020
Valid for credit through: 8/18/2021
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Q fever osteoarticular infection in children is an under- estimated disease. We report 3 cases of Q fever osteomyelitis in children and review all cases reported in the literature through March 2018. A high index of suspicion is encouraged in cases of an unusual manifestation, prolonged course, relapsing symptoms, nonresolving or slowly resolving osteomyelitis, culture-negative osteomyelitis, or bone histopathology demonstrating granulomatous changes. Urban residence or lack of direct exposure to animals does not rule out infection. Diagnosis usually requires use of newer diagnostic modalities. Optimal antimicrobial therapy has not been well established; some case-patients may improve spontaneously or during treatment with a β-lactam. The etiology of treatment failure and relapse is not well understood, and tools for follow-up are lacking. Clinicians should be aware of these infections in children to guide optimal treatment, including choice of antimicrobial drugs, duration of therapy, and methods of monitoring response to treatment.
Qfever is a zoonotic disease caused by the intracellular bacterium Coxiella burnetii. Persistent focalized Q fever infection in adults mainly manifests as endocarditis or as an endovascular infection. Cases of osteoarticular infection (OAI) have been scantly reported in the literature rarely in children [1,2]. Disease severity varies, similar to the clinical variations reported in adult patients [1].
C. burnetii infections are endemic to Israel. Because diagnosis requires a high level of suspicion, an increase in diagnoses over time may be partly related to physician awareness of the disease rather than true higher incidence [3]. An observational study of 2,434 cases of C. burnetii infection in France [4] reported 58 pediatric cases, among which 22 (38%) were OAIs. This large study described the clinical characteristics of Q fever, the less common manifestations of Q fever such as lymphadenitis and lymphoma, and identified risk factors and screening tools predicting complications and death.
Because C. burnetii bacteria do not grow in standard laboratory cultures, serology is the first-line diagnostic method for C. burnetii infection. Phase II antibodies are predominant during primary infection and Phase I antibodies in persistent infection. Cutoffs of titers considered positive are debated and vary in different countries [5,6]. Immunofluorescence assay (IFA) remains the preferred serology test because of its simplicity and accuracy. Complement fixation test (CFT) is more widely used despite its lower sensitivity [1,2,5]. Immunohistochemistry and quantitative PCR of C. burnetii–infected tissues are also available [5,6].
Diagnosis may be aided by clinical criteria. One definite criterion, 2 major criteria, or 1 major and 3 minor criteria are needed for definitive diagnosis of persistent Q fever. Definite criteria include a positive result on culture, PCR, or immunochemistry of bone, synovial biopsy, or joint aspirate. Major criteria include positive blood culture or PCR, phase I IgG antibodies >800, evidence of bone or joint involvement by computed tomography scan, ultrasonography, magnetic resonance imaging (MRI), or abnormal positron emission tomography scan or indium leukocyte scan. Minor criteria include phase I IgG titer of 400–800 mg/dL, temperature >38°C, and monoor polyarthralgia. These last diagnostic criteria have been proposed to enable diagnosis of C. burnetii persistent infection in cases in which titers are below the serologic cutoff [5]. Other studies use a higher serology cutoff of phase I IgG >1,024 [6].
Optimal antimicrobial treatment for chronic Q fever OAI has not been well established. Pediatric treatment recommendations in Q fever OAI are based on treatment of Q fever endocarditis in adults [7]. We describe 3 cases of Q fever osteomyelitis in children in Israel and a review of the related literature.
