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.
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.
A: UTI, gynaecological infection, Barmah Forest virus, Ross River fever, Q fever, EBV, influenza, CMV, viral hepatitis.
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.
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.
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.
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.
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.
Reproduced by permission, NSW Health © 2019
