Case Presentation: A 52-year-old man with a past medical history of hypertension, hyperlipidemia, and type 2 diabetes mellitus presented to the emergency department (ED) with complaints of two weeks of nausea, vomiting, abdominal fullness and distension, full-body fatigue, and myalgias. He was also noted to be febrile and jaundiced. Abdominal ultrasound findings were consistent with acute cholecystitis and empiric antibiotic therapy with ceftriaxone and metronidazole was initiated. Upon evaluation the following morning, he was no longer febrile. Physical exam was notable for jaundice, a distended abdomen, and right upper quadrant pain with deep palpation, but a negative Murphy’s sign. Further evaluation of the patient’s liver injury was pursued given his presentation was not entirely consistent with acute cholecystitis and initial laboratory values, including elevated AST, ALT, and INR, suggested a degree of hepatic involvement beyond that expected for acute cholecystitis. Additional imaging including MRCP and CT abdomen/pelvis ruled out acute cholecystitis but did reveal significant hepatomegaly. An infectious workup including HIV, CMV, EBV, and hepatitis A, B, and C was negative. Autoimmune etiologies were unremarkable. A thorough history of potential infectious exposures was taken, and the patient denied exposure to farm animals, intravenous drug use, recent travel, recent blood transfusions, or new sexual partners. Ceftriaxone and metronidazole were continued for empiric treatment, but the patient repeatedly fevered overnight. Surgery, hepatology, gastroenterology, and infectious disease were consulted, and it was ultimately recommended to broaden the infectious workup to include coxiellosis, malaria, rickettsiosis, brucellosis, and leptospirosis, among others. Intravenous doxycycline was initiated on hospital day five and fevers resolved shortly thereafter. The patient’s other symptoms also began resolving rapidly and he was discharged on hospital day seven after being transitioned to oral doxycycline. It was not until several days after discharge that serology for C. burnetii returned positive. He ultimately required four weeks of treatment to achieve complete resolution of his elevated transaminase levels but otherwise had no complications.
Discussion: Q fever is a unique bacterial infection caused by Coxiella burnetii that is often challenging to diagnose due to its variability in presentation. Hepatic Q fever is a relatively uncommon manifestation of the disease and is particularly difficult to identify as symptoms are nonspecific and similar to those of other hepatobiliary pathologies. This case illustrates the diagnostic challenge presented by hepatic Q fever and how a broad infectious workup is often required to achieve diagnosis. Although initial imaging was consistent with acute cholecystitis and there was no history of exposures classic for C. burnetii infection, a thorough investigation uncovered hepatic Q fever as the underlying cause of this puzzling hepatobiliary injury.
Conclusions: Hepatic Q fever should be considered in patients presenting with fever and nonspecific abdominal symptoms, even if initial imaging is consistent with another diagnosis. Treatment with doxycycline should be initiated as early as possible and should especially be considered in patients fevering through empiric antibiotic therapy.