A 53-year-old male patient was referred to the ICU of Bach Mai hospital with a 2-week history of persistent high fever and acute hepatomegaly. There was no medical history. He lived in a rural area in Hai Phong city and had a cow. The patient had a high fever of about 39 C at the time of onset and took some antipyretics without symptoms alleviation. He was admitted to a local hospital after 3 days. The physical examination revealed hepatomegaly whilst laboratory investigation showed pancytopenia (WBC 2.7 G/L, PLT 129 G/L, RBC 3.52 T/L), elevated liver enzymes (GOT 110 U/L, GPT 70.7 U/L). After 10 days of treatment with Ceftazidim, the patient had no response, maintained fatigue, and high fever; he was referred to our hospital.
On admission, the patient was conscious with a body temperature of 39 C, pulse rate of 86 bpm, blood pressure of 110/70 mmHg, respiration rate of 26 bpm, hepatomegaly of 2 cm below the costal margin. Blood tests revealed pancytopenia (RBC 3.54 T/L, HGB 111 g/L, MCV 86.4 fL, MCH 31.4 pg, MCHC 360 g/L, PLT 63 G/L, WBC 0.57 G/L, NEU 17.5%, LYM 63.2%), elevated liver enzymes with normal bilirubin (GOT 208 U/L, GPT 369 U/L, total/ direct bilirubin 11.8/5.5 micromol/L), slightly increased Procalcitonin of 0.108 ng/mL. Other biochemical markers were in normal range, such as: Urea, creatinine, glucose, protein, albumin, electrolytes (Na, K, Cl), and urinalysis (10 parameters). Viral serologies including HIV, hepatitis A, B, C; EBV, CMV, dengue, and leptospira were negative. Blood and urine cultures were negative. Chest X-ray was normal, thoracic CT scan excluded lymphadenopathies. Both abdominal ultrasound and abdominal CT scan showed hepatomegaly. The transthoracic echocardiogram was normal. Other tests for tuberculosis, lupus, and autoimmune hepatitis were negative.
Bone marrow aspiration and biopsy were performed on day 2 after admission. The bone marrow aspiration smear was hypocellular but there was an increase in macrophages (Figure 1). On the bone marrow biopsy slide, many fibrin ring granulomas were seen (Figure 2), suggesting Q fever. Two daily 100 mg doses of Doxycycline were started after these bone marrow analysis results. 2 weeks later, the diagnosis of Coxiella burnetii was confirmed by PCR which was positive in the 16S primer sequence with primers 400 (Table 1). Doxycycline was continued for 14 days with clinical improvement with no fever. About laboratory test, CBC revealed HGB 121 g/L, PLT 154 G/L, WBC 3.2 G/L; and liver enzymes returned to normal range (GOT 36 U/L, GPT 43 U/L). The patient was discharged from the hospital after 20 days of treatment.