Case Presentation: A 39 year-old female from Sudan with no medical history presented with recurrent fevers. She had been discharged 3 days prior after a workup for the cause of her fevers was unfruitful. This workup had included blood and urine cultures, viral hepatitis serologies, anti-nuclear antibodies, rheumatoid factor, HIV antibodies, Quantiferon tuberculosis testing, stool culture, stool ova/parasite screen, Clostridium difficile PCR, Echinococcus serologies, and lower extremity venous dopplers. Abdominal CT showed liver cysts vs hemangiomas that were felt to be non-infectious based on appearance. She was empirically treated for 6 days with vancomycin and piperacillin-tazobactam and her fevers ceased. She was discharged home, only to return 3 days later with recurrent fevers.
She was readmitted, blood and urine cultures were obtained again, and she was restarted on empiric vancomycin/piperacillin-tazobactam. CT chest, abdomen, pelvis were unremarkable other than the previously visualized liver cysts. Broad infectious serologies for Bartonella, Rickettsia, Leptospira, Brucella, Aspergillus, Blastomyces, Coccidioides, Histoplasma, Toxoplasma, EBV, CMV, schistosomiasis, and malaria were all negative. While awaiting serologies, patient continued to fever multiple times per day. It was decided to stop broad spectrum antibiotics and start empiric doxycycline. With this, patient immediately defervesced and had no recurrent fevers.
Her serologic studies eventually returned positive for Coxiella burnetti. She subsequently underwent transesophageal echocardiography that did not reveal any valvular vegetations. She completed a 14-day course of doxycycline and had no further symptoms.
Discussion: Fever of unknown origin can be frustrating for both providers and patients. It has a large number of etiologies, many of them not commonly encountered in routine practice. It is classically defined as multiple fevers of at least 38.3° C, with a duration of at least 3 weeks, without a clear etiology after 1 week of hospitalization. The etiology typically lies in 1 of 3 categories: infection, malignancy, or connective tissue disorder. Q fever is a zoonotic infection caused by Coxiella burnetii, a strictly intracellular bacterium that does not grow in normal culture medium. It can present as an acute flu-like illness with variable lung and liver involvement, or present as a chronic infection involving a specific organ system, commonly the heart (endocarditis). Doxycycline for 14 days is the recommended treatment for uncomplicated, acute Q fever.
Conclusions: In this case, we suspected an infectious etiology of patient’s fevers (given her recent trip to Sudan), and specifically an atypical infection that we see less frequently in the United States. This suspicion proved correct. A known manifestation of Coxiella infection is hepatic involvement. This can manifest simply as hepatomegaly, but can also present with prolonged fevers with characteristic “doughnut-like” granulomas in the liver.