A 23-year-old primigravida presented to the emergency department with reports of headache. On examination, her blood pressure was found to be 190/140 mm Hg. Her laboratory results were notable for proteinuria, deranged liver function and low platelets. She was diagnosed with HELLP syndrome and was delivered via caesarean section. She noticed diminution of vision 2 days after delivery. Fundus examination revealed bilateral serous retinal detachment involving the maculae. She was managed conservatively and had complete recovery of her vision by 3 weeks postpartum.

A woman in her 80s was brought to the emergency department for acute onset of generalised weakness, lethargy and altered mental state. The emergency medical service found her to have symptomatic bradycardia, and transcutaneous pacing was done. Medical history was notable for hypertension, hyperlipidaemia, type 2 diabetes, and a recently diagnosed SARS-CoV-2 (COVID-19) infection for which she was prescribed ritonavir-boosted nirmatrelvir (Paxlovid) two days before the presentation. On arrival at the hospital, she was found to have marked bradycardia with widened QRS, hyperglycaemia and metabolic acidosis. Transvenous pacing along with pressor support and insulin were initiated, and she was admitted to the intensive care unit. Drug interaction between ritonavir-boosted nirmatrelvir and verapamil leading to verapamil toxicity was suspected of causing her symptoms, and both drugs were withheld. She reverted to sinus rhythm on the fourth day, and the pacemaker was discontinued.

Q fever is an endemic zoonotic infection in Australia cause by Coxiella burnetii. It has been recognised in other parts of the world, especially among livestock rearing occupations, stock yard and abattoir workers. Majority (65%) of patients infected with C.burnetti are asymptomatic while symptoms similar to those of respiratory and hepatitis are the most common making diagnosis difficult in the early stages. We report a case of a young man who was exposed to and infected with Q fever as an occupational hazard. He presented in an unusual way with the predominant initial symptoms of abdominal pain, fever, hepatitis and sterile peritonitis necessitating an emergency surgical procedure to explore a suspected surgical abdomen. Respiratory involvement ensued only several days later. The diagnosis of Q fever was confirmed with positive convalescent serology phase II IgM and IgG antibodies to Coxiella burnetii. A marked clinical response to doxycycline pending serological confirmation was supportive of this highly suspected diagnosis in an at-risk patient.