Subarachnoid Hemorrhage, CNS Vasculitis and Stroke as a Sequela of Q Fever Infection

A 64-year-old female with a history of Subarachnoid Hemorrhage (SAH) of non-aneurysmal origin underwent 4 cerebral Digital Subtraction Angiography (cDSA) studies to investigate the cause of the SAH. All angiograms were unrevealing. Two years and 3 months following her SAH, she presented to the emergency department with ataxia and aphasia. Magnetic Resonance Imaging (MRI) of the brain without contrast showed a right posterior parietal lobe stroke with a watershed appearance and a chronic right cerebellar infarct with encephalomalacia. Repeat cDSA showed stenosis in the right A3 of the Anterior Cerebral Artery (ACA) and right M2 of the Middle Cerebral Artery (MCA) suggesting CNS vasculitis. Known reversible and secondary causes of CNS vasculitis were tested and found to be negative. However, Indirect Immunofluorescence Assay (IFA) testing revealed a high titer of IgG phase II Coxiella indicating acute Q fever. CDC lab findings from 10 years earlier also showed a high titer IgG phase II Coxiella, indicating untreated Q fever prior to the SAH event. A whole-body Positron Emission Tomography (PET) scan was negative for systemic or CNS vasculitis. The patient was treated for Q fever and CNS vasculitis with 1 year of doxycycline and hydroxychloroquine. There was no recurrence of symptoms 15 months after treatment. We conclude that Q fever can present with SAH in addition to CNS vasculitis and stroke.