Limits...
Treatment and Prophylactic Strategy for Coxiella burnetii Infection of Aneurysms and Vascular Grafts

View Article: PubMed Central - PubMed

ABSTRACT

Coxiella burnetii vascular infections continue to be very severe diseases and no guidelines exist about their prevention. In terms of treatment, the benefit of the surgical removal of infected tissues has been suggested by 1 retrospective study.

We present a case of a C burnetii abdominal aortic graft infection for which we observed a dramatic clinical and biological recovery after surgery. We thus performed a retrospective cohort study to evaluate the impact of surgery on survival and serological outcome for patients with Q fever vascular infections diagnosed in our center.

Between 1986 and February 2015, 100 patients were diagnosed with Q fever vascular infections. The incidence of these infections has significantly increased over the past 5 years, in comparison with the mean annual incidence over the preceding 22 years (8.83 cases per year versus 3.14 cases per year, P = 0.001). A two-and-a-half-year follow-up was available for 66 patients, of whom 18.2% died. We observed 6.5% of deaths in the group of patients who were operated upon at 2 and a half years, in comparison with 28.6% in the group which were not operated upon (P = 0.02). Surgery was the only factor that had a positive impact on survival at 2 and a half years using univariate analysis [hazard ratio: 0.17 [95% CI]: [0.039–0.79]; P = 0.024]. Surgery was also associated with a good serological outcome (74.1% vs 57.1% of patients, P = 0.03). In the group of patients with vascular graft infections (n = 47), surgery had a positive impact on serological outcome at 2 and a half years (85.7% vs 42.9%, P < 0.001) [hazard ratio: 0.40 [95% CI]: [0.17–098]; P = 0.046] and tended to be associated with lower although not statistically significant mortality (11.1% vs 27.6% of deaths, P = 0.19).

Surgical treatment confers a benefit in terms of survival following C burnetii vascular infections. However, given the high mortality of these infections and their rising incidence, we propose a strategy that consists of screening for vascular graft and aneurysms in the context of primary Q fever, to decide when to start prophylactic treatment, similar to the strategy recommended for the prophylaxis of Q fever endocarditis.

No MeSH data available.


Serological and clinical outcome of the case patient before and after surgery.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC4998359&req=5

Figure 1: Serological and clinical outcome of the case patient before and after surgery.

Mentions: A 34-year-old Lebanese patient was transferred from the hospital in Beirut to the Timone Hospital in Marseilles, France, on January 23, 2008 for fever and polyarthralgia. His medical history included aortic prosthesis surgery in March 2001, due to a chronic traumatic aortic rupture. The CT scan revealed an eso-aneurysmal fistula with an associated aortic collection and a renal abscess. Q fever serology was performed in our laboratory and was found to be positive (IgG phase I: 6400 and IgG phase II: 12,800). Our patient had 2B criteria, that is definite diagnosis of Q fever vascular prosthesis infection according to the C burnetii vascular infection score (see Table, Supplemental Digital Content 1).1 As recommended in our center, treatment with doxycycline and hydroxychloroquine was initiated. We put this patient forward for surgical treatment. All surgeons refused to operate on him, considering the surgical risks to be too high. Twelve months later, he suffered from several deep abscesses (renal, splenic, and pulmonary) and bacteremia. Only 1 dilution decrease of IgG phase I was noted, suggesting a poor outcome. At 18 months, a new fistula on the prosthesis appeared with an endoluminal vegetation. On our advice (DR), the patient contacted a surgeon (HS) practicing in Liverpool, United Kingdom, who decided to perform surgery. He was finally operated on there for surgical debridement with graft replacement and fistulous tract repair. Antibiotherapy with doxycycline and hydroxychloroquine was continued. C burnetii was detected by qPCR on the graft biopsy. After the intervention, we observed a dramatic clinical improvement and a 5-fold decrease in Q fever serological titers 4 months later. (IgG phase I titer = 100 and IgG phase II titer = 200) (Figure 1). Doxycycline and hydroxychloroquine were continued for 16 months, that is 3 and a half years in total. At the time of publication, 4 years after the surgery, the patient is in good health, with no clinical or serological relapses.


Treatment and Prophylactic Strategy for Coxiella burnetii Infection of Aneurysms and Vascular Grafts
Serological and clinical outcome of the case patient before and after surgery.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4998359&req=5

Figure 1: Serological and clinical outcome of the case patient before and after surgery.
Mentions: A 34-year-old Lebanese patient was transferred from the hospital in Beirut to the Timone Hospital in Marseilles, France, on January 23, 2008 for fever and polyarthralgia. His medical history included aortic prosthesis surgery in March 2001, due to a chronic traumatic aortic rupture. The CT scan revealed an eso-aneurysmal fistula with an associated aortic collection and a renal abscess. Q fever serology was performed in our laboratory and was found to be positive (IgG phase I: 6400 and IgG phase II: 12,800). Our patient had 2B criteria, that is definite diagnosis of Q fever vascular prosthesis infection according to the C burnetii vascular infection score (see Table, Supplemental Digital Content 1).1 As recommended in our center, treatment with doxycycline and hydroxychloroquine was initiated. We put this patient forward for surgical treatment. All surgeons refused to operate on him, considering the surgical risks to be too high. Twelve months later, he suffered from several deep abscesses (renal, splenic, and pulmonary) and bacteremia. Only 1 dilution decrease of IgG phase I was noted, suggesting a poor outcome. At 18 months, a new fistula on the prosthesis appeared with an endoluminal vegetation. On our advice (DR), the patient contacted a surgeon (HS) practicing in Liverpool, United Kingdom, who decided to perform surgery. He was finally operated on there for surgical debridement with graft replacement and fistulous tract repair. Antibiotherapy with doxycycline and hydroxychloroquine was continued. C burnetii was detected by qPCR on the graft biopsy. After the intervention, we observed a dramatic clinical improvement and a 5-fold decrease in Q fever serological titers 4 months later. (IgG phase I titer = 100 and IgG phase II titer = 200) (Figure 1). Doxycycline and hydroxychloroquine were continued for 16 months, that is 3 and a half years in total. At the time of publication, 4 years after the surgery, the patient is in good health, with no clinical or serological relapses.

View Article: PubMed Central - PubMed

ABSTRACT

Coxiella burnetii vascular infections continue to be very severe diseases and no guidelines exist about their prevention. In terms of treatment, the benefit of the surgical removal of infected tissues has been suggested by 1 retrospective study.

We present a case of a C burnetii abdominal aortic graft infection for which we observed a dramatic clinical and biological recovery after surgery. We thus performed a retrospective cohort study to evaluate the impact of surgery on survival and serological outcome for patients with Q fever vascular infections diagnosed in our center.

Between 1986 and February 2015, 100 patients were diagnosed with Q fever vascular infections. The incidence of these infections has significantly increased over the past 5 years, in comparison with the mean annual incidence over the preceding 22 years (8.83 cases per year versus 3.14 cases per year, P = 0.001). A two-and-a-half-year follow-up was available for 66 patients, of whom 18.2% died. We observed 6.5% of deaths in the group of patients who were operated upon at 2 and a half years, in comparison with 28.6% in the group which were not operated upon (P = 0.02). Surgery was the only factor that had a positive impact on survival at 2 and a half years using univariate analysis [hazard ratio: 0.17 [95% CI]: [0.039–0.79]; P = 0.024]. Surgery was also associated with a good serological outcome (74.1% vs 57.1% of patients, P = 0.03). In the group of patients with vascular graft infections (n = 47), surgery had a positive impact on serological outcome at 2 and a half years (85.7% vs 42.9%, P < 0.001) [hazard ratio: 0.40 [95% CI]: [0.17–098]; P = 0.046] and tended to be associated with lower although not statistically significant mortality (11.1% vs 27.6% of deaths, P = 0.19).

Surgical treatment confers a benefit in terms of survival following C burnetii vascular infections. However, given the high mortality of these infections and their rising incidence, we propose a strategy that consists of screening for vascular graft and aneurysms in the context of primary Q fever, to decide when to start prophylactic treatment, similar to the strategy recommended for the prophylaxis of Q fever endocarditis.

No MeSH data available.