Geoff, chronic Q fever and post Q fever fatigue syndrome sufferer
Geoff is a process control systems engineer who lives on a property at White Rock near Bathurst in NSW.
He was brought up on the land in rural NSW. His parents bred blue ribbon sheep and won awards for the quality of their wool, in fact, topping the wool price in the 1952/’53 season.
Geoff attended Farrer Memorial Agricultural College in Tamworth and went on to study electronics engineering. Despite not carrying on the family business of breeding sheep, his passion has always been farming. The lure of the land drew Geoff in, and having purchased a property near Bathurst, he decided he’d breed Boer goats to sell as meat to the ‘White Tablecloth’ end of the fine dining restaurant market.
It was in December 2007 when Geoff first realised he may have contracted Q fever.
On his property, does were experiencing problems giving birth and many kids were stillborn. One doe was in labour for 24 hours and Geoff knew that if he didn’t lend a hand, he’d lose both mother and baby.
“So on the vet’s advice, we went in after the kid… my wife at the front and me at the business end. Without going into the gruesome details, I pulled out the stillborn kid. Unknowingly our doe must have been infected with the bacteria that causes Q fever.”
“I didn’t know about it until three weeks later when I was in Tumbarumba on a contract engineering job. That’s when the fever first hit. Although it was summer, I’d spend two hours shivering like a Chihuahua in bed with the electric blanket on high and then have to turn the air con up to full just to cool down. The fever lasted a full 10 days and it presented itself in other ways too, with a red raw Achilles tendon that made it very painful to walk.”
“ I’d never even heard of Q fever, despite being brought up on a sheep farm. A colleague at work suggested I may indeed have Q fever – he’d experienced abattoir workers that had contracted it. So I had blood tests done and the diagnosis of Q fever was confirmed.”
Unfortunately, Geoff continued to have ongoing symptoms that were undiagnosed. In 2016, he was referred to a specialist and subsequently diagnosed with Chronic Q fever.
“Every summer, like clockwork, it comes back”, he said. “The fever is nowhere near as bad as it was back in 2007, but my Achilles still goes red raw and hurts incredibly and now the pain spreads to other joints – mainly my knees and elbows. When it hits, I’m just totally exhausted all the time, yet find it really hard to sleep. Medication helps, but nothing works for long.”
“It’s an insidious thing and I wouldn’t wish the suffering on anybody. Anyone working with animals needs to be made more aware of Q fever.”
To this day, Geoff can’t work a full week; 32 hours a week is his limit. He still works in engineering and is back breeding, but no longer goats.
“Amazingly, I’m back to sheep… breeding superfine merinos. Life has come full circle I guess. I can’t just sit around doing nothing… it’s part of my psyche that I have to be doing something and this is what I know.”
Jason, acute Q fever sufferer
Jason is a specialist refrigeration and air conditioning mechanic. He specialises in industrial size cool rooms and freezers that use ammonia as a refrigerant.
Jason and his family live in Cessnock, in the Hunter Valley region of NSW. Jason contracted Q fever in 2016 during a brief stint working at an abattoir in Victoria. It was his first job in the beef industry and he’d never heard of the illness.
He had been advised by his employer to get vaccinated when he first started the job, but chose not to, as he figured that he would never be in contact with the high-risk environments within the abattoir. After all, his workplace was a room in which he was surrounded by machinery – not animals.
“I’d never experienced anything like it”, said Jason. “It started with what seemed like typical ‘flu symptoms, but it quickly got much worse.”
“I’d be freezing cold for hours, then I’d get so hot I’d sweat profusely. This continued non-stop for two weeks and somehow I kept turning up for work each day.”
“I’d get home and just couldn’t move. I’d need three or four layers of clothing on and when I got into bed, I’d have up to four doonas over me just to try and stop the shivering. I knew it had to be more than a case of the flu.”
“I didn’t want to eat and lost something like 10kg in those two weeks. My body was just so sore. Every muscle was aching beyond anything I’d ever felt. It was like I’d done a dozen workouts at the gym, back to back to back. Except I couldn’t do a thing! One weekend, I was only out of bed for one hour over the entire two days. I was completely useless!”
Jason made a full recovery and hasn’t experienced any recurring symptoms since his initial episode of Q fever. Jason trains five days a week and considers himself “pretty fit”. He doesn’t work much in refrigeration any more, instead providing security at weddings and other functions in Cessnock and surrounding areas.
But he still looks back on those two weeks of suffering from an acute case of Q fever with a shudder.
Q Fever Case Study: Glen
Glen is a cattle farmer on a property just outside of Tamworth. He rarely visits the doctor but has booked an appointment to see you (his GP) as his wife has been urging him to be vaccinated against Q fever. After ascertaining that he has not been vaccinated or had Q fever in the past you explain the need for pre-vaccination testing. Glen asks if he can just get the vaccine anyway while he is here. He has never been sick before. It is difficult for him to leave the farm he is not able to come back next week.
Q: What should you explain to Glen?
A: You advise Glen that he may experience a serious reaction if you get the vaccine when you have already been exposed to the bacteria. It is quite possible that he may have been exposed to Q fever but not experienced any symptoms. He is at high risk of Q fever infection as a cattle farmer and may become very unwell if infected with Q fever. It is important that he is vaccinated as early as possible if he found to be nonimmune.
Glen remains unconvinced. He wants to know why he needs to have both the skin test and the blood test. He is unable to return for at least a fortnight as he will be busy branding cattle.
Q: What would you say to Glen?
A: It is important to test for both humoral and cell mediated immunity. Detectable antibodies may decline at a quicker rate than cell mediated immunity. You explain to him that the skin test and the blood test are both needed because immunity can wane over time. The skin test and the blood test are looking at different types of immunity. One test may be positive and the other negative. Glen cannot be vaccinated if either test is positive. You advise him that if he was to become infected with Q fever he may be forced to take some time off work. Some people with Q fever require extended time periods (months) of work. This would have a significant impact on his life and that of his family. Glen should reschedule another appointment the earliest he can make the 2 appointments.
You are working as a GP in Bathurst, NSW (a regional city about 200km north west of Sydney). Karen is a 32-year-old female from Bathurst who presents to you in September complaining of flu-like symptoms including sweats and a fever that has been on and off for the last couple of days. You are unable to identify any signs of focal infection. You advise her to rest, take paracetamol and plenty of fluids and ask her to return if she isn’t better in the next couple of days.
Q: What clinical signs and symptoms would suggest to you that Karen may have more than just a virus?
A: Severe symptoms, drenching night sweats, prolonged fever, headache, abdominal pain, febrile illness without usual respiratory symptoms that occur with flu (dry flu), extreme nausea, very dehydrated, negative on a urine dipstick test.
Karen returns a few days later feeling worse. Her fever and sweats have continued and she is now also experiencing nausea and abdominal pain. She cannot remember ever feeling this unwell.
Q: What are some possible causes of her illness?
A: UTI, gynaecological infection, Barmah Forest virus, Ross River fever, Q fever, EBV, influenza, CMV, viral hepatitis.
Q: Do you consider Karen is at risk of Q fever?
A: You are not yet able to decide. You will need to ask more questions about her recent contact with animals or animal products or possible environmental exposure to Q fever.
You ask Karen where she lives and works. She runs a café in the Bathurst town centre and lives with her husband and 2 children in town.
Q: This does not suggest to you that she is at risk of Q fever. Is there anything else you would ask before you exclude Q fever as a possibility?
A: While Karen’s work does not put her at risk of Q fever she may well still be at risk outside of work. You should ask her about occupations of other household members and contact with animals in the previous 6 weeks.
Karen reports that her brother has a cattle farm outside of town and the family went to visit the property a couple of weeks ago so her children could see the calves that were born last month. She and the children had been out in the field for several hours with the newborn calves.
You decide it could be Q fever based on her clinical symptoms and recent animal exposure. On assessment Karen’s chest is clear, no pharyngitis. She has no signs or symptoms of genitourinary infection and her abdomen is soft and non-tender.
Q: Should you exclude any other diagnoses prior to commencing treatment for Q fever?
A: You should ensure that she is not pregnant or allergic to doxycycline. Consider STI screen, blood and urine cultures. Request LFTs, EUC, FBC and serology to exclude EBV. Abdominal ultrasound may be useful.
Karen’s results are negative for EBV and UTI. LFTs show mildly raised transaminases. Abdominal ultrasound shows mildly enlarged liver with no enlargement of the gall bladder or bile ducts, and no focal changes. Karen is not pregnant. She is not on any other medication and has no history of adverse reactions to doxycycline or tetracyclines.
Based on Karen’s clinical symptoms and recent contact with cattle, you recommend a 14-day course of doxycycline and request Q fever PCR and serology (request Phase I and Phase II IgG and IgM serology and titres).
You inquire about other illness in the family. Her husband and daughter are well but her 8-year-old son has been off school with fevers, malaise and anorexia.
Q: Could the son have Q fever?
A: While less common than adults, children can get Q fever.
You recommend that she brings the son in for an appointment as soon as possible.
Q: Karen asks if her husband or brother and his family should take antibiotics to stop them getting sick. What do you advise?
A: There is no evidence to support antibiotic prophylaxis. People who work or live on a cattle farm are a high risk of Q fever infection. You give her some factsheets including “Q fever”, “Q fever vaccination” and “Q fever prevention on farms” to give to her brother and advise them to seek medical attention early if he or his family develop any symptoms of Q fever. You also inform her that vaccination is available and her brother should speak to his GP about how to protect himself and his family.
You are working as a GP in Dubbo, NSW (city about 300km northwest of Sydney). Tom is a 29-year-old male who lives by himself outside of Dubbo. He presents to you in January feeling very unwell with a fever and cough. He has had no recent travel. He reports no gastrointestinal or UTI symptoms.
Q: What other signs and symptoms would you ask Tom about?
A: chills, profuse sweats, severe headache (especially behind the eyes), photophobia, weakness, anorexia, myalgia and arthralgia, abdominal pain, weight loss, nausea, and fatigue. Tom also reports having a headache, sweats, chills, myalgia and fatigue. He hasn’t been able to work since the fever started 3 days ago.
Q: What are the more common possible causes of Tom’s illness?
A: Influenza (albeit unlikely in January without overseas travel), Ross River or Barmah Forest fever (less likely in Dubbo), psittacosis, other community acquired pneumonias, EBV or HIV.
Q: What would you look for on objective examination?
hepatosplenomegaly, jaundice, cholecystitis
On objective examination Tom has a fever of 38.5°C. You can palpate his liver and spleen 1 cm below the costal margin, his heart rate is 100. He has no skin rashes or lymphadenopathy. There are a few crackles in left lower lung.
Q: What tests would you order at this stage?
A: FBC, EUC, LFTs, blood cultures, CRP, urinalysis, CXR, serology for chlamydiosis, mycoplasma and EBV.
Q: Outline the specific questions you could ask Tom to determine his risk of Q fever?
A: You want to find out about Tom’s contact with animals or animal products (especially cattle, sheep and goats) in the past 6 weeks. This contact could occur while at work or outside of work.
Tom is a sheep shearer and has been shearing sheep in the 6 weeks before his symptoms started. He has mainly stayed in the western region and hasn’t travelled to parts of the state with floods, nor has he gone pig hunting. He reports no risk\ factors for HIV.
Q: Before you consider Q fever as a diagnosis what would you ask Tom?
A: Have you ever had Q fever before or been vaccinated for Q fever?
If Tom has been vaccinated or has had Q fever in the past he is likely to be immune. Tom has not heard of Q fever before and is pretty sure he has never been vaccinated.
Q: Do you think Tom could have Q fever? Why or why not?
A: Yes. Based on Tom’s symptoms and work as a shearer in the incubation period you suspect Q fever.
Q: What treatment would you recommend?
A: You know early treatment is beneficial. Tom is not on any other medications and has no history of adverse reactions to doxycycline or tetracyclines so you start him on doxycycline (100mg po bd) and test for Q fever. You tell him it is important to complete the antibiotic course even if he is feeling better.
Given it is less than a week since his symptom onset you request a Q fever PCR as well as baseline serology (request Phase I and Phase II IgG and IgM serology and titres) in addition to tests for Psittacosis, Mycoplasma pneumonia, EBV and chlamydiosis. You also request liver function tests as they usually show raised transaminases if it’s acute Q fever.
Q: When would you ask Tom to come back for another appointment?
A: In 1 week, whether he is better or not, sooner if he is getting worse. In a week, if he is better, you can organise repeat serology for one week’s time.
Tom cancels his appointment because he is feeling better now and needs to be back at work. His Q fever PCR test was negative. He tested negative for psittacosis, Mycoplasma pneumonia and EBV.
Q: Does Tom need to come back if he is well?
A: It is important that Tom returns as he needs to have convalescent serology 2 – 3 weeks after first collection to confirm his diagnosis. If Q fever is confirmed on serology he will need to be monitored as acute Q fever can progress to chronic Q fever. He should be assessed for his chronic Q fever risk.