Raoult, Didier

AbstractTo the best of our knowledge, we report the first case of pre‐transplant unrecognized disseminated Coxiella burnetii infection, unmasked in the post‐transplant period leading to both heart and kidney allograft dysfunction. A 59 year old man with a history of simultaneous heart‐kidney transplantation due to end stage heart failure from severe aortic regurgitation (AR) and cryoglobulinemic immune complex mediated concentric necrotizing glomerulonephritis (GN), presents with a history of intermittent fevers and fatigue. Prior to transplantation he was treated for multiple episodes of culture negative endocarditis requiring bio‐prosthetic valve replacement. Evaluation of fever included a transesophageal echocardiogram (TEE) that revealed a large hyperechoic mass on the anterior mitral leaflet with perforation, severe mitral regurgitation and moderate AR. Blood cultures were negative at that time. Owing to development of allograft mitral and aortic valve insufficiency, he underwent allograft bio‐prosthetic mitral valve (MV) replacement and aortic valvuloplasty 2 years following his transplantation. Pathologic examination of the allograft mitral valve demonstrated fibrinopurulent exudate with degenerating bacterial organisms, consistent with vegetation and myxoid degenerative changes. Due to a high suspicion for native heart C. burnetii prosthetic valve endocarditis prior to transplantation, we re‐evaluated the native explanted heart histopathology, as well as the explanted allograft MV. Cardiac allograft and native MV were positive for C. burnetii by real‐time PCR. C. burnetii serology was consistent with persistent infection as well.

Abstract Background Chronic Coxiella burnetii infections such as vertebral osteomyelitis caused by contiguous spread from an infected abdominal aortic graft or aneurysm have been rarely reported and are associated with significant morbidity and mortality. Methods We present the first four reported US acquired cases of Coxiella burnetii vertebral osteomyelitis caused by contiguous spread from an infected abdominal aortic graft or aneurysm. Results Presenting symptoms included progressive back pain, malaise, and weight loss with recent or remote animal exposure. Typical imaging findings demonstrated a peri-aortic collection with extension to the paraspinal muscles and vertebrae. Antibiotic regimens included doxycycline with either hydroxychloroquine or a quinolone for at least 2 years or as chronic suppression. Conclusions C. burnetii vertebral osteomyelitis is rare and can occur by contiguous spread from an abdominal aneurysm or vascular graft infection. It should be suspected in patients where pre-antibiotic cultures are negative with animal/farming exposure.

ABSTRACT We present the first published case of Coxiella burnetii prosthetic joint infection. Diagnosis was established with PCR and culture of periprosthetic tissue and synovial fluid (and serology). A novel PCR assay is described herein. Q fever should be considered in patients with prosthetic joint infection without an identified pathogen.