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Letter
Q Fever in Thailand
Yupin Suputtamongkol,* Jean-Marc Rolain,† Kitti Losuwanaruk,‡ Kanigar
Niwatayakul,§ Chuanpit Suttinont,¶Wirongrong Chierakul,* Kriangsak Pimda,#
and Didier Raoult†
*Mahidol University, Bangkok, Thailand; †Faculté de Médecine, Marseille,
France; ‡Banmai Chaiyapod Hospital, Bureerum Province, Thailand; §Maharat
Nakornrachasema Hospital, Nakornrachasema Province, Thailand; ¶Loei Hospital,
Loei Province, Thailand; and #Udornthani Hospital, Udornthani Province,
Thailand
Suggested citation
for this article:
Suputtamongkol Y, Rolain J-M, Losuwanaruk K, Niwatayakul K, Suthinont
C, Chierakul W, et al. Q fever in Thailand. Emerg Infect Dis [serial
online] 2003 Sept [date cited]. Available from: URL: http://www.cdc.gov/ncidod/EID/vol9no9/03-0086.htm
To the Editor: Coxiella burnetii, a strict intracellular
bacterium, is the etiologic agent of Q fever, a worldwide zoonosis. Humans
are infected by inhaling contaminated aerosols from amniotic fluid or
placenta or handling contaminated wool (1). The bacterium
is highly infectious by the aerosol route. Two forms of the disease are
typical: acute and chronic. Acute Q fever is the primary infection and
in specific hosts may become chronic (1,2). The major
clinical manifestations of acute Q fever are pneumonia and hepatitis.
Less common clinical manifestations are aseptic meningitis and/or encephalitis,
pancreatitis, lymphadenopathy that mimics lymphoma, erythrema nodosum,
bone marrow necrosis, hemolytic anemia, and splenic rupture (2).
The main clinical manifestation of the chronic form is culture-negative
endocarditis, but infection of vascular grafts or aneurysms, hepatitis,
osteomyelitis, and prolonged fever have also been described (1,2).
Fluoroquinolones, co-trimoxazole, and doxycycline are active against C.
burnetii in vitro, and ceftriaxone has been shown to have a bacteriostatic
effect and could be effective in the phagolysosome of C. burnetii–infected
cells (3). However, the treatment of choice for Q fever
is doxycycline.
The incidence of this disease is largely unknown, especially in Asia.
Q fever has been reported from Japan and China (1). Seroepidemiologic
surveys have shown that subclinical infection is common worldwide. Large
outbreaks of Q fever have also been reported in many countries in Europe
(4). A case series of acute Q fever was diagnosed in
a prospective study in patients with acute febrile illness who were admitted
to four hospitals in northeastern Thailand: Udornthani Hospital, Udornthani
Province; Maharat Nakhon Ratchasima Hospital, Nakornrachasema Province;
Loei Hospital, Loei Province; and Banmai Chaiyapod Hospital, Bureerum
Province. Two serum samples were taken from these patients, on admission
and at a 2- to 4-week outpatient follow-up visit, and stored at –20°C
until serologic tests were performed at the Faculty of Medicine Siriraj
Hospital, Mahidol University, and the National Research Institute of Health,
Public Health Ministry of Thailand. All serum samples were tested for
the serologic diagnosis of leptospirosis, scrub typhus, murine typhus,
and dengue infection as previously described (5,6). After
these serologic tests were performed, serum samples from patients with
unknown diagnosis were sent for the serologic test for Q fever at Unité
des Rickettsies, Faculté de Médecine, Marseille, France. The microimmunofluorescent
antibody test, using a panel antigen of C. burnetii, Rickettsial honei,
R. helvetica, R. japonica, R. felis, R. typhi, Bartonella henselae, B.
quintana, Anaplasma phagocytophila, and Orientia tsutsugamushi,
was used as described previously (6).
A total of 1,171 serum specimens from 678 patients were tested for Q
fever. Nine patients (1.3%, eight male and one female) fulfilled the diagnosis
of acute Q fever. The median age was 42 (range 15–62) years. All patients
were rice farmers, and their farm animals were chicken and cattle. The
median duration of fever was 3 (range 1–7) days before admission into
the hospital. When initially seen, all patients had acute febrile illness,
headache, and generalized myalgia (i.e., a flulike syndrome). Clinical
manifestations of acute Q fever in these patients ranged from this flulike
syndrome (three patients), pneumonitis (one patient), hepatitis (two patients),
pneumonitis and renal dysfunction (one patient), hepatitis and renal dysfunction
(one patient), to severe myocarditis and acute renal failure (one patient).
An epidemic of leptospirosis has been occurring in Thailand since 1996
(7). All patients in this study received a diagnosis
of either leptospirosis or acute fever of undefined cause; therefore,
empirical therapy, including penicillin G sodium, doxycycline, and cefotaxime
or ceftriaxone, was administered. The patient with hepatic and renal dysfunction
was treated with co-trimoxazole. The patient who had severe myocarditis
and acute renal failure was treated with a penicillin G sodium and doxycycline
combination. He also received a dopamine infusion and hemodialysis. The
median duration between admission and a reduction of fever was 3 days
(range 1–7) in this case series.
Results of several seroprevalence studies, using the complement fixation
test, conducted in both humans and animals suggest that C. burnetii
infection has been widespread in Thailand since 1966 (8).
The prevalence in asymptomatic persons varies from 0.4% to 2.6% (9),
and studies in domestic animals show that the highest prevalence of this
infection occurs in dogs (28.1%). The prevalence in goats, sheep, and
cattle varies from 2.3% to 6.1% (9). However, this clinical
case series of acute Q fever is the first diagnosed in this country. The
disease was diagnosed in patients in four hospitals, situated in various
parts of the northeastern region of Thailand. These data confirmed that
Q fever is widespread in this country. The disease had been unrecognized
previously because the specific serologic test was not widely available
in Thailand.
A self-limited course was suspected in four cases in this series. However,
severe cases, especially those with myocarditis, could be fatal. Therefore,
doxycycline should be an empirical therapy for patients with acute febrile
illness in areas where leptospirosis, scrub typhus, and acute Q fever
are suspected, such as in rural Thailand. Further studies to investigate
the epidemiology of Q fever in this country are needed.
This work was part
of research supported by grants from Thailand Research Fund, Thailand.
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