Q fever endocarditis masquerading as Mixed cryoglobulinemia type II. A case report and review of the literature

Abstract

BackgroundThe clinical manifestations of Q fever endocarditis are protean in nature. Mixed cryoglobulinemia type II is rarely a facet of the presenting clinical manifestations of Q fever endocarditis.Case presentationWe report a case of a 65-year-old pensioner with such an association and review the literature. As transesophageal echocardiograms are usually normal and blood cultures are usually negative in Q fever endocarditis, many of the manifestations (fever, rash, glomerulonephritis/evidence of renal disease, low serum C4 complement component, presence of mixed type II cryoglobulin, constitutional symptoms as arthralgias and fatigue) can be attributed to Mixed cryoglobulinemia type II per se. The use of Classic Duke Endocarditis Service criteria does not always suffice for the diagnosis of Q fever.ConclusionThe application of the modified criteria proposed by Fournier et al for the improvement of the diagnosis of Q fever endocarditis will help to reach the diagnosis earlier and thus reduce the high mortality of the disease. We would like to stress the importance of ruling out the diagnosis of Q fever endocarditis in cases of mixed type II cryoglobulinemia.

From Q Fever to Coxiella burnetii Infection: a Paradigm Change

“…This suggests that most clinical features of the antiphospholipid syndrome can be found in acute Q fever with laboratory classification criteria for the antiphospholipid syndrome (lupus anticoagulant and anticardiolipin antibody of IgG and/or IgM isotype) ( (295). Rare cases of Q fever associated with amyloidosis (533) or mixed cryoglobulinemia (531,534) are reported in the literature. Two case of Jarisch-Herxheimer reactions following the treatment of a C. burnetii pneumonia or endocarditis have been reported (535,536).…”

Resolution of Q Fever–Associated Cryoglobulinemia With Anti-CD20 Monoclonal Antibody Treatment

“… 7 In contrast to the patient described above, the 6 other case reports of Q fever endocarditis associated with mixed cryoglobulinemia had prosthetic valves. 7 To our knowledge, our patient is the first to have Q fever endocarditis of a native valve associated with mixed cryoglobulin disease. Type II mixed cryoglobulinemia causes vasculitis by deposition of circulating immune-complexes, specifically cryoglobulins that contain a polyclonal IgG and a monoclonal IgM with RF activity.…”

“…6 Both type II mixed cryoglobulinemia and Q fever endocarditis can manifest with fever, rash, low C4, and glomerulonephritis. 7 In contrast to the patient described above, the 6 other case reports of Q fever endocarditis associated with mixed cryoglobulinemia had prosthetic valves. 7 To our knowledge, our patient is the first to have Q fever endocarditis of a native valve associated with mixed cryoglobulin disease.…”

Infective Endocarditis Observed With Cryoglobulinemic Vasculitis

“…In a case published in 2017, a patient presented with a non-blanching purpuric rash on her lower extremities, anemia, and blood and trace protein on urine dipstick [ 8 ]. Another case was described in 2006 in which a patient with cryoglobulinemic vasculitis secondary to Coxiella burnetii endocarditis [ 9 ]. This patient also presented with lower extremity purpura and renal disease, and additionally had normal blood cultures and no vegetations or valvular dysfunction was seen on transesophageal echocardiograph.…”