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CME / ABIM MOC

Q Fever Osteoarticular Infection in Children

  • Authors: Halima Dabaja-Younis, MD; Michal Meir, MD; Anat Ilivizki, MD; Daniela Militianu, MD; Mark Eidelman, MD; Imad Kassis, MD; Yael Shachor-Meyouhas, MD
  • CME / ABIM MOC Released: 8/18/2020
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 8/18/2021
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Target Audience and Goal Statement

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.

Upon completion of this activity, participants will be able to:

  • Examine the laboratory evaluation of suspected Q fever osteoarticular infection among children
  • Analyze diagnostic criteria for Q fever osteoarticular infection among children
  • Distinguish joints affected by Q fever osteoarticular infection in the current study
  • Assess the management of Q fever osteoarticular infection among children


Disclosures

As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


Authors

  • Halima Dabaja-Younis, MD

    Ruth Rappaport Children's Hospital
    Rambam Health Care Campus and Bruce Rappaport Faculty of Medicine
    Haifa, Israel

    Disclosures

    Disclosure: Halima Dabaja-Younis, MD, has disclosed no relevant financial relationships.

  • Michal Meir, MD

    Ruth Rappaport Children's Hospital
    Rambam Health Care Campus and Bruce Rappaport Faculty of Medicine
    Haifa, Israel

    Disclosures

    Disclosure: Michal Meir, MD, has disclosed no relevant financial relationships.

  • Anat Ilivizki, MD

    Ruth Rappaport Children's Hospital
    Rambam Health Care Campus and Bruce Rappaport Faculty of Medicine
    Haifa, Israel

    Disclosures

    Disclosure: Anat Ilivizki, MD, has disclosed no relevant financial relationships.

  • Daniela Militianu, MD

    Ruth Rappaport Children's Hospital
    Rambam Health Care Campus and Bruce Rappaport Faculty of Medicine
    Haifa, Israel

    Disclosures

    Disclosure: Daniela Militianu, MD, has disclosed no relevant financial relationships.

  • Mark Eidelman, MD

    Ruth Rappaport Children's Hospital
    Rambam Health Care Campus and Bruce Rappaport Faculty of Medicine
    Haifa, Israel

    Disclosures

    Disclosure: Mark Eidelman, MD, has disclosed no relevant financial relationships.

  • Imad Kassis, MD

    Ruth Rappaport Children's Hospital
    Rambam Health Care Campus and Bruce Rappaport Faculty of Medicine
    Haifa, Israel

    Disclosures

    Disclosure: Imad Kassis, MD, has disclosed no relevant financial relationships.

  • Yael Shachor-Meyouhas, MD

    Ruth Rappaport Children's Hospital
    Rambam Health Care Campus and Bruce Rappaport Faculty of Medicine
    Haifa, Israel

    Disclosures

    Disclosure: Yael Shachor-Meyouhas, MD, has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine
    Irvine, California

    Disclosures

    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Johnson & Johnson Pharmaceutical Research & Development, L.L.C.; GlaxoSmithKline
    Served as a speaker or a member of a speakers bureau for: Genentech; GlaxoSmithKline

Editor

  • Dana C. Dolan, BS

    Copyeditor, Emerging Infectious Diseases

    Disclosures

    Disclosure: Dana C. Dolan, BS, has disclosed no relevant financial relationships.

CME/Content Reviewer

  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Disclosure: Stephanie Corder, ND, RN, CHCP, has disclosed no relevant financial relationships.

Medscape, LLC staff have disclosed that they have no relevant financial relationships.


Accreditation Statements



In support of improving patient care, this activity has been planned and implemented by Medscape, LLC and Emerging Infectious Diseases. Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

    For Physicians

  • Medscape, LLC designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.0 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

    Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]


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This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 75% on the post-test.

Follow these steps to earn CME/CE credit*:

  1. Read the target audience, learning objectives, and author disclosures.
  2. Study the educational content online or printed out.
  3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker.

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CME / ABIM MOC

Q Fever Osteoarticular Infection in Children

Authors: Halima Dabaja-Younis, MD; Michal Meir, MD; Anat Ilivizki, MD; Daniela Militianu, MD; Mark Eidelman, MD; Imad Kassis, MD; Yael Shachor-Meyouhas, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME / ABIM MOC Released: 8/18/2020

Valid for credit through: 8/18/2021

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Abstract and Introduction

Abstract

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.

Introduction

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.