Vascular complications of Q-fever infections

Coxiella burnetii is a strict intracellular pathogen causing Q fever, a worldwide zoonosis with an extensive animal reservoir. Chronic Q fever infections are frequently associated with cardiovascular complications, mainly endocarditis, and also aortic aneurysms and vascular-graft infection. We present four cases of chronic Q fever infections and associated vascular complications, and review the literature to identify major symptoms and assess the prevalence, treatment and outcome in these challenging patients.

The demographic and clinical data of four patients presenting at our unit were analysed. PubMed was searched to identify articles describing patients with chronic Q-fever-associated vascular complications.

Combining our own with the published experience, 58 cases (49 male) of chronic Q-fever-associated vascular complications were identified. The average age of the patients was 64 years (range: 30-83 years). As many as 26 patients had vascular graft infections (25 Dacron/polytetrafluoroethylene (PTFE), one homograft) and 32 had infected aneurysms. The majority of these patients presented with fever (n = 40) and/or pain (n = 43). Weight loss and fatigue were seen in 25 and 14 patients, respectively. Aneurysm rupture, aorto-enteric fistulae and lower-limb embolisation were seen in nine, four and four patients, respectively. Concurrent endocarditis was seen in two patients, whereas, for 15 cases, this information was not available. Patients were treated with antibiotics for an average of 23 months (range 1-54 months). Treatment of infected vascular segments was described in 50 patients. Ten patients were treated conservatively whilst 40 underwent resection of the infected vessel and reconstruction with a graft. Major surgical complications (graft infection, n = 3;aorto-enteric fistula, n = 2; bleeding, n = 1; anastomotic leakage, n = 1; aortic dissection, n = 1; vertebral osteomyelitis, n = 3; graft thrombosis, n = 1; renal failure, n = 2; and pneumonia, n = 1) were reported in 11 cases (21%) and were not specified in 13. The overall mortality was 24% (14/58). Seven (18%) surgically treated patients died. Six of them died within 6 months of surgery and one patient at 3 years' follow-up. Seven out of 10 of the conservatively treated patients died within 3 years of diagnosis.

Aneurysms associated with Q-fever infections tend to be complicated, requiring challenging surgical corrections, and long-term antibiotic treatment. Major complications and mortality rates are significant, especially in conservatively treated patients.