Journal of Infection (2014) xx, 1e7
www.elsevierhealth.com/journals/jinf
Estimated prevalence of chronic Q fever among Coxiella burnetii seropositive patients with an abdominal aortic/iliac aneurysm or aorto-iliac reconstruction after a large Dutch Q fever outbreak*,** Julia C.J.P. Hagenaars a,*, Peter C. Wever b, ´ S. van Petersen c, Peter J. Lestrade d, Andre Monique G.L. de Jager-Leclercq e, Mirjam H.A. Hermans f, Frans L. Moll g, Olivier H.J. Koning a, Nicole H.M. Renders b a
Dept. of Surgery, Jeroen Bosch Hospital, ’s-Hertogenbosch, The Netherlands Dept. of Medical Microbiology and Infection Control, Jeroen Bosch Hospital, ’s-Hertogenbosch, The Netherlands c Dept. of Surgery, Bernhoven Hospital, Uden, The Netherlands d Dept. of Internal Medicine, Jeroen Bosch Hospital, ’s-Hertogenbosch, The Netherlands e Dept. of Internal Medicine, Bernhoven Hospital, Uden, The Netherlands f Molecular Diagnostics, Jeroen Bosch Hospital, ’s-Hertogenbosch, The Netherlands g Dept. of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands b
Accepted 4 March 2014 Available online - - -
KEYWORDS Chronic Q fever; Aneurysm; Vascular graft; Seroprevalence
Summary Objectives: The aim of this study was to estimate the seroprevalence of Q fever and prevalence of chronic Q fever in patients with abdominal aortic and/or iliac disease after the Q fever outbreak of 2007e2010 in the Netherlands. Methods: In November 2009, an ongoing screening program for Q fever was initiated. Patients with abdominal aortic and/or iliac disease were screened for presence of IgM and IgG antibodies to phase I and II antigens of Coxiella burnetii using immunofluorescence assay and
*
Presented to the Annual Meeting of the Dutch Society of Surgery, Veldhoven, The Netherlands, November 2011. Presented to the Interscience Conference on Antimicrobial Agents and Chemotherapy, Chicago, United States of America, September 2011. * Corresponding author. Department of Surgery, Jeroen Bosch Hospital, PO Box 90153, 5200 ME ’s-Hertogenbosch, The Netherlands. Tel.: þ31 (0) 735533652. E-mail address: [email protected] (J.C.J.P. Hagenaars).
**
0163-4453/$36 ª 2014 The British Infection Association. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jinf.2014.03.009 Please cite this article in press as: Hagenaars JCJP, et al., Estimated prevalence of chronic Q fever among Coxiella burnetii seropositive patients with an abdominal aortic/iliac aneurysm or aorto-iliac reconstruction after a large Dutch Q fever outbreak, J Infect (2014), http://dx.doi.org/10.1016/j.jinf.2014.03.009
2
J.C.J.P. Hagenaars et al. presence of C. burnetii DNA in sera and/or vascular wall tissue using polymerase chain reaction (PCR). Results: A total of 770 patients with abdominal aortic and/or iliac disease were screened. Antibodies against C. burnetii were detected in 130 patients (16.9%), of which 40 (30.8%) patients showed a serological profile of chronic Q fever. Three patients presented with acute Q fever, one of which developed to chronic Q fever over time. The number of aneurysm-related acute complications in patients with chronic Q fever was significantly higher compared to patients negative for Q fever (p Z 0.013); 9.0% (30/333) vs. 30.0% (6/20). Eight out of 46 patients with past resolved Q fever (8/46, 17.4%) presented with aneurysm-related acute complications (no significant difference). Conclusion: The prevalence of chronic Q fever in C. burnetii seropositive patients with abdominal aortic and/or iliac disease living in an epidemic area in the Netherlands is remarkably high (30.8%). Patients with an aneurysm and chronic Q fever present more often with an aneurysmrelated acute complication compared to patients without evidence of Q fever infection. ª 2014 The British Infection Association. Published by Elsevier Ltd. All rights reserved.
Introduction Q fever is a zoonotic disease caused by Coxiella burnetii (C. burnetii), a Gram-negative, aerobic intracellular bacterium. C. burnetii is omnipresent and its reservoir is found in various hosts such as goats, cattle, sheep and household pets. C. burnetii is highly infectious to humans, where the mode of transmission occurs mainly through inhalation of contaminated aerosols.1,2 Approximately 60% of all acute infections in humans are asymptomatic. In symptomatic patients, acute Q fever can manifest as a mild influenza-like illness, atypical pneumonia or hepatitis.1e4 Chronic Q fever will develop in 1e5% of all patients, generally several months to years after the acute infection.2,4,5 Chronic Q fever manifests itself mainly as endocarditis or, less commonly, as a vascular infection.2,5 Both (unoperated) aneurysms and vascular prostheses are independent risk factors for development of vascular chronic Q fever.6 Acute and chronic Q fever are traditionally diagnosed by detection of antibodies against the bacterium. Infection with C. burnetii is accompanied by antigenic phase variation.1 In general, during the primary infection, IgM and IgG antibodies against phase II antigens (phase II antibodies) are expressed first, followed by IgM and IgG antibodies against phase I antigens (phase I antibodies).2 In chronic infection, IgG phase I antibodies are predominant, and their level increases and persists over the course of infection.1,2,5,7,8 Chronic Q fever can also be diagnosed by detection of C. burnetii in blood or tissue samples using polymerase chain reaction (PCR) or culture.1,3,9 Q fever is an under-diagnosed disease, but nonetheless a noteworthy infection. Epidemics have been documented in several European countries, Australia and Canada.2 An outbreak of acute Q fever emerged in the Netherlands from 2007 until 2010. In 2009, a C. burnetii seroprevalence of 12.2% was demonstrated, which was much higher than before the outbreak (2.4%).10,11 The Jeroen Bosch Hospital and Bernhoven Hospital are located in the southern part of the Netherlands, the region most affected by the Q fever epidemic. Recent analysis indicated a high number of C. burnetii-infected persons in the catchment area of the Jeroen Bosch Hospital; 50e75 times higher than the number of notified patients.12 Consequently, a high number of patients are at risk for developing chronic Q fever in these
areas.12 Chronic Q fever in patients with abdominal aortic and/or iliac disease is a severe and life-threatening disease with reported mortality rates up to 25%.13 It has been recommended to initiate screening programs for chronic Q fever in patients with the mentioned risk factors living in epidemic areas.12,14e25 Here, we report on the outcome of such a screening program and estimate the seroprevalence of Q fever infection and the prevalence of chronic Q fever in patients with abdominal aortic and/or iliac disease after the Q fever outbreak of 2007e2010 in the Netherlands.
Patients and methods Patients From November 2009 to January 2012, all patients diagnosed with abdominal aortic and/or iliac disease at outpatient clinics, surgical wards and emergency departments (EDs) of the Jeroen Bosch Hospital and Bernhoven Hospital were screened for Q fever. Inclusion criteria were an abdominal aortic aneurysm (aorta 30 mm), an aneurysm of the common iliac artery (>12 mm) or an aorto-iliac reconstruction, such as an endovascular aneurysm repair (EVAR) or open aorto-iliac reconstruction. In addition, all patients who had undergone surgery between January 2005 and November 2009 for an aneurysm or stenoses in the abdominal aortic artery or common iliac artery were actively invited for screening. Two rounds of invitation letters were sent, while a third round consisted of active invitation by a telephone call for those that had not responded to previous invitations. All included patients were divided into three groups. The first group included all patients with a vascular prostheses who had undergone surgery before the outbreak started (
www.elsevierhealth.com/journals/jinf
Estimated prevalence of chronic Q fever among Coxiella burnetii seropositive patients with an abdominal aortic/iliac aneurysm or aorto-iliac reconstruction after a large Dutch Q fever outbreak*,** Julia C.J.P. Hagenaars a,*, Peter C. Wever b, ´ S. van Petersen c, Peter J. Lestrade d, Andre Monique G.L. de Jager-Leclercq e, Mirjam H.A. Hermans f, Frans L. Moll g, Olivier H.J. Koning a, Nicole H.M. Renders b a
Dept. of Surgery, Jeroen Bosch Hospital, ’s-Hertogenbosch, The Netherlands Dept. of Medical Microbiology and Infection Control, Jeroen Bosch Hospital, ’s-Hertogenbosch, The Netherlands c Dept. of Surgery, Bernhoven Hospital, Uden, The Netherlands d Dept. of Internal Medicine, Jeroen Bosch Hospital, ’s-Hertogenbosch, The Netherlands e Dept. of Internal Medicine, Bernhoven Hospital, Uden, The Netherlands f Molecular Diagnostics, Jeroen Bosch Hospital, ’s-Hertogenbosch, The Netherlands g Dept. of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands b
Accepted 4 March 2014 Available online - - -
KEYWORDS Chronic Q fever; Aneurysm; Vascular graft; Seroprevalence
Summary Objectives: The aim of this study was to estimate the seroprevalence of Q fever and prevalence of chronic Q fever in patients with abdominal aortic and/or iliac disease after the Q fever outbreak of 2007e2010 in the Netherlands. Methods: In November 2009, an ongoing screening program for Q fever was initiated. Patients with abdominal aortic and/or iliac disease were screened for presence of IgM and IgG antibodies to phase I and II antigens of Coxiella burnetii using immunofluorescence assay and
*
Presented to the Annual Meeting of the Dutch Society of Surgery, Veldhoven, The Netherlands, November 2011. Presented to the Interscience Conference on Antimicrobial Agents and Chemotherapy, Chicago, United States of America, September 2011. * Corresponding author. Department of Surgery, Jeroen Bosch Hospital, PO Box 90153, 5200 ME ’s-Hertogenbosch, The Netherlands. Tel.: þ31 (0) 735533652. E-mail address: [email protected] (J.C.J.P. Hagenaars).
**
0163-4453/$36 ª 2014 The British Infection Association. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jinf.2014.03.009 Please cite this article in press as: Hagenaars JCJP, et al., Estimated prevalence of chronic Q fever among Coxiella burnetii seropositive patients with an abdominal aortic/iliac aneurysm or aorto-iliac reconstruction after a large Dutch Q fever outbreak, J Infect (2014), http://dx.doi.org/10.1016/j.jinf.2014.03.009
2
J.C.J.P. Hagenaars et al. presence of C. burnetii DNA in sera and/or vascular wall tissue using polymerase chain reaction (PCR). Results: A total of 770 patients with abdominal aortic and/or iliac disease were screened. Antibodies against C. burnetii were detected in 130 patients (16.9%), of which 40 (30.8%) patients showed a serological profile of chronic Q fever. Three patients presented with acute Q fever, one of which developed to chronic Q fever over time. The number of aneurysm-related acute complications in patients with chronic Q fever was significantly higher compared to patients negative for Q fever (p Z 0.013); 9.0% (30/333) vs. 30.0% (6/20). Eight out of 46 patients with past resolved Q fever (8/46, 17.4%) presented with aneurysm-related acute complications (no significant difference). Conclusion: The prevalence of chronic Q fever in C. burnetii seropositive patients with abdominal aortic and/or iliac disease living in an epidemic area in the Netherlands is remarkably high (30.8%). Patients with an aneurysm and chronic Q fever present more often with an aneurysmrelated acute complication compared to patients without evidence of Q fever infection. ª 2014 The British Infection Association. Published by Elsevier Ltd. All rights reserved.
Introduction Q fever is a zoonotic disease caused by Coxiella burnetii (C. burnetii), a Gram-negative, aerobic intracellular bacterium. C. burnetii is omnipresent and its reservoir is found in various hosts such as goats, cattle, sheep and household pets. C. burnetii is highly infectious to humans, where the mode of transmission occurs mainly through inhalation of contaminated aerosols.1,2 Approximately 60% of all acute infections in humans are asymptomatic. In symptomatic patients, acute Q fever can manifest as a mild influenza-like illness, atypical pneumonia or hepatitis.1e4 Chronic Q fever will develop in 1e5% of all patients, generally several months to years after the acute infection.2,4,5 Chronic Q fever manifests itself mainly as endocarditis or, less commonly, as a vascular infection.2,5 Both (unoperated) aneurysms and vascular prostheses are independent risk factors for development of vascular chronic Q fever.6 Acute and chronic Q fever are traditionally diagnosed by detection of antibodies against the bacterium. Infection with C. burnetii is accompanied by antigenic phase variation.1 In general, during the primary infection, IgM and IgG antibodies against phase II antigens (phase II antibodies) are expressed first, followed by IgM and IgG antibodies against phase I antigens (phase I antibodies).2 In chronic infection, IgG phase I antibodies are predominant, and their level increases and persists over the course of infection.1,2,5,7,8 Chronic Q fever can also be diagnosed by detection of C. burnetii in blood or tissue samples using polymerase chain reaction (PCR) or culture.1,3,9 Q fever is an under-diagnosed disease, but nonetheless a noteworthy infection. Epidemics have been documented in several European countries, Australia and Canada.2 An outbreak of acute Q fever emerged in the Netherlands from 2007 until 2010. In 2009, a C. burnetii seroprevalence of 12.2% was demonstrated, which was much higher than before the outbreak (2.4%).10,11 The Jeroen Bosch Hospital and Bernhoven Hospital are located in the southern part of the Netherlands, the region most affected by the Q fever epidemic. Recent analysis indicated a high number of C. burnetii-infected persons in the catchment area of the Jeroen Bosch Hospital; 50e75 times higher than the number of notified patients.12 Consequently, a high number of patients are at risk for developing chronic Q fever in these
areas.12 Chronic Q fever in patients with abdominal aortic and/or iliac disease is a severe and life-threatening disease with reported mortality rates up to 25%.13 It has been recommended to initiate screening programs for chronic Q fever in patients with the mentioned risk factors living in epidemic areas.12,14e25 Here, we report on the outcome of such a screening program and estimate the seroprevalence of Q fever infection and the prevalence of chronic Q fever in patients with abdominal aortic and/or iliac disease after the Q fever outbreak of 2007e2010 in the Netherlands.
Patients and methods Patients From November 2009 to January 2012, all patients diagnosed with abdominal aortic and/or iliac disease at outpatient clinics, surgical wards and emergency departments (EDs) of the Jeroen Bosch Hospital and Bernhoven Hospital were screened for Q fever. Inclusion criteria were an abdominal aortic aneurysm (aorta 30 mm), an aneurysm of the common iliac artery (>12 mm) or an aorto-iliac reconstruction, such as an endovascular aneurysm repair (EVAR) or open aorto-iliac reconstruction. In addition, all patients who had undergone surgery between January 2005 and November 2009 for an aneurysm or stenoses in the abdominal aortic artery or common iliac artery were actively invited for screening. Two rounds of invitation letters were sent, while a third round consisted of active invitation by a telephone call for those that had not responded to previous invitations. All included patients were divided into three groups. The first group included all patients with a vascular prostheses who had undergone surgery before the outbreak started (
