Abstract

A 32-year-old woman was admitted to our department with high fever, headache, myalgia, back pain and dry cough of three days' duration. Her past history was unremarkable. On physical examination, the patient was very ill, febrile to 39.5°C and with inspiratory coarse crackles at the base of the right lung. Admission laboratory findings included a WBC of 11,600/mm³ (86% polymorphonuclear cells), ESR: 82 mm/h and increased C-reactive protein (182 mg/L). Serum biochemistry, coagulation tests and urinalysis were normal. Chest x-ray showed dense consolidation in the right lower lobe (Fig.). Community-acquired pneumonia (CAP) was diagnosed and the patient was treated with clarithromycin plus cefuroxime. Despite the antibiotic therapy, on the following days, her symptoms showed no improvement. Blood cultures were negative. In addition, she had progressive worsening of her liver function tests. On the 5th day after admission, AST was 118 IU/L, ALT 262 IU/L, ALP 433 IU/L, and γGT was 154 ΙU/L). Although the latter were attributed to possible adverse reaction to antibiotics, further evaluation was decided. Serologic markers for hepatitis B and C, EBV, CMV, HSV, Mycoplasma pneumoniae, Legionella pneumophila, Leptospira and Toxoplasmawere all negative. However, immunofluorescence antibody revealed positive antibodies against C burnetii, compatible with acute infection (IgM 1/3200 and IgG 1/1920). The patient had a dog as a pet, but without recent parturition. Cefuroxime was substituted by oral doxycycline 100 mg b.i.d. The patient became afebrile two days later and she was discharged in good condition. The patient was followed up in the clinic, with normalization of her liver tests and positive conversion of IgG antibody (IgM 1/1600 and IgG 1/2840), 20 days after discharge.