A 77-year-old man with hypertension, hyperlipidemia, and prior infrarenal aortic aneurysm repair presented with several months of worsening lower abdominal pain and a weight loss of 20 pounds (9 kilograms). The endovascular repair of his aortic aneurysm occurred two years prior and was prompted by expansion to 4.4 cm in diameter. He denied any fever or chills. He lived in the rural southeastern United States (Georgia), where he hunted deer and had exposure to livestock on a nearby farm. On exam, he was cachectic and had a temperature of 100.4 F (38 C). Abdominal exam showed tenderness to deep palpation in the epigastrium and bilateral lower quadrants. His white blood cell count was normal at 8.0 x 109/L (reference 4-11 x 109/L), hemoglobin 11.3 g/dL (reference 11.4-14.4 g/dL), and platelet count of 345 x 109/L (reference 150-400 x 109/L). Serum sodium, renal function, and aminotransferases were normal. The erythrocyte sedimentation rate and C-reactive protein were elevated at 100 mm/hr (reference 0-20 mm/hr) and 111.8 mg/dL (reference 0-7.5 mg/dL), respectively. A chest radiograph was unremarkable, and computed tomography (CT) scan of his abdomen and pelvis detected large (up to 2.6 cm x 2 cm) necrotic periaortic lymph nodes with normal appearance of the liver. CT-guided retroperitoneal lymph node biopsies were performed, and pathology was negative for malignancy but noted chronic inflammation and non-necrotizing granulomas. Lymph node aerobic and anaerobic Gram stain and cultures, acid fast bacillus (AFB) smear and culture, and fungal stain and cultures were negative. Aerobic and anaerobic blood cultures, AFB blood smear and culture, serum cryptococcal antigen, HIV antigen/antibody, purified protein derivative for tuberculosis exposure, and rapid plasma reagin (RPR) for syphilis were all negative. Positron emission tomography (PET) CT imaging was pursued for further evaluation of the intra-abdominal lymphadenopathy and revealed increased radiotracer activity and soft tissue stranding at the bifurcation of the aortoiliac stent, indicative of increased metabolic activity (Figure 1).
Prior to hospital discharge, the patient's Coxiella burnetii titers were pending as well as the psoas fluid aspirate polymerase chain reaction (PCR) and culture. The psoas fluid aspirate was sent to the Centers for Disease Control and Prevention given negative infectious workup until this point. After discharge, his Coxiella burnetii (Q fever) titers resulted as follows: IgM Phase I: 1 : 64, IgG Phase I: 1 : 131,072, IgM Phase II: 1 : 16, IgG Phase II: 1 : 65,536. Polymerase chain reaction (PCR) testing of the psoas fluid aspirate was pursued, and aspirate PCR and cultures were positive for Coxiella burnetii. During outpatient infectious diseases management, the patient was started on therapy with hydroxychloroquine and doxycycline. Despite therapy, he had progressive decline in his functional and nutritional status, which limited monitoring of titers and drug levels. On a subsequent admission two months later, he was noted to have developed psoas abscesses bilaterally (left 1.9 x 1.8 x 4 cm and right 1.9 x 2.5 x 6 cm) (Figure 2) with aortitis of the posterior aspect of the aorta at the level of L2 and osteomyelitis of L2 and L3 vertebral bodies (Figure 3). The patient declined despite therapy with doxycycline and hydroxychloroquine and fluoroscopy-guided drainage (with drain placement) of the psoas abscesses. The patient was deemed high-risk given need for revision of aneurysm repair, progression to bedbound status, failure to thrive, and poor nutritional status. After discussions with the patient, family, and the medical and surgical teams, it was decided to forego potential surgical interventions, such as removal of the infected graft, due to the high risk of intraoperative mortality. The patient and his family elected hospice care. He died at home five months after the diagnosis of chronic Q fever and four years after his abdominal pain began. The exact timing of his exposure to C. burnetii is uncertain, but he did recall that several years prior to the onset of symptoms, he assisted his neighbor with the difficult birth of a calf.