A “Q”uizzical Cause of Abnormal LFTs

Abstract

Introduction: Q fever is a rare cause of abnormal liver function tests (LFT) in an urban population. The disease is characterized by sudden onset of fevers, chills, headaches, myalgia, and pneumonitis or hepatitis. In North America, acute Q fever usually presents as atypical pneumonia. We present a case of Q fever in a patient who presented with jaundice, anorexia, and intermittent fevers. Case Report: A 62-year-old Nepalese man with past medical history of diabetes presented with fatigue and 3 weeks of fevers. On admission, he was febrile to 102°F and found to have ALT 81U/L, AST 103U/L, alkaline phosphatase 298U/L, and total bilirubin 7.7mg/dL with direct component 6.1mg/dL. Synthetic function was preserved with INR 1.2 and platelets of 246THOU/uL. Albumin of 2.8g/dL and pre-albumin of 3mg/dL signified severe malnutrition. The patient denied abdominal pain or change in bowel pattern, but reported nausea and vomiting for 2 days. He denied recent foreign travel, sick contacts, or new medications. Imaging studies revealed fatty liver with an edematous gallbladder and splenomegaly, but no pancreatic mass or biliary obstruction. Urine drug test, acetaminophen, alcohol, and salicylate levels were normal. Viral hepatitis panel was negative, including HIV, CMV, EBV, and HSV. Autoimmune work-up was unremarkable, and he was previously treated for latent TB. There was no leukocytosis, but his fevers persisted despite negative infectious work-up, including brucellosis. Subsequently, the patient underwent liver biopsy, which revealed non-necrotizing granulomas in the background of mild steatohepatitis. Special stains were negative for iron, copper, acid-fast bacilli, and fungal organisms. Finally, after a prolonged hospitalization, the patient was found to have positive Coxiella burnetti serologies confirmed by PCR. He was started on doxycycline, and his fevers and LFT improved. Upon further review, the family admitted to recently consuming freshly slaughtered and skinned goat meat from their local goat farm. Discussion: Acute Q fever is a worldwide zoonosis caused by a Gram-negative bacterium Coxiella burnetti, and is spread by inhalation of bacteria from air contaminated by cattle, sheep, or goat feces, urine, or placenta. It is endemic in the Netherlands and Middle East, and less commonly seen in the United States. Given the nonspecific nature of clinical manifestations of acute Q fever, its diagnosis requires a high index of suspicion. It is usually self-limited, and in most cases, diagnosed retrospectively. Treatment with doxycycline of symptomatic patients has been shown to shorten illness and reduce risk of progression to chronic disease.