415 TRANSACTIONS OF THE ROYAL. SOCIETY OF TROPICAL ~UCDICINB MD HYGIENE, VOL. 73, No. 4, 1979
Investigation
of Coxiella burneti infection as a possible cause of chronic liver disease in man A. J. SPICER Queen EIizabeth Military Hospital,
Summary The possible role of Coxiella burneti as a cause of chronic liver disease in man was investigated in Cyprus. Serology, using the complement fixation test and phase 1 and phase 2 antigens, was performed on 16 patients with cryptogenic cirrhosis and two patients with chronic active hepatitis. Antibody studies were also done on 106 adult Cypriot villagers and on 13 shepherds from flocks infected with C. burneti, to provide a base line for comparative purposes. No evidence was found to implicate the organism as a cause of chronic liver disease. As the number of patients investigated was small it was not possible to exclude C. burneti as an occasional pathogen, and guiding principles were formulated for future investigations. Introduction Subclinical hepatitis commonly occurs in acute Q fever (CLARK et al., 1951; POWELL, 1961; DUPONT et al.. 1971: SPICER et al.. 1977). An American 1971) drew attention to the (i&ON., Editorial disparity between the minor abnormalities of liver function tests and extensive abnormalities seen on bioosv, and also observed that histological changes may persist beyond the symptomaticstage. There have been two reports associating long-term liver damage with C. burneti infection. DELANEY & ROBERTS(1975) gave the first account of chronic liver disease in a patient with Q fever endocarditis. Liver function tests were only slightly abnormal but a needle biopsy of the liver showed scattered areas of hepatocyte necrosis, occasional lobular eranulomata and a diffuse infiltration of the portal &acts. The patient apparently recovered after prolonged treatment with-tetracycline. TIJRCK et al. (1976) reuorted 16 cases of chronic Q fever, all with evidence of liver involvement. Two of these patients, with minor degrees of heart valve disease, but no evidence of subacute endocarditis, presented primarily as chronic active hepatitis. Liver biopsy showed a patchy focal necrosis of parenchymal cells, a mononuclear infiltration of the portal tracts and an abnormal prominence of the sinusoidal Kupffer cells. A second biopsy from one of these patients 16.5 months later had almost identical features. Phase 1 complement fixing antibody titres on admission to- hospital were 1:4,096 and 1: 1,024. Both natients recovered after prolonged treatment with a combination of lincomycin and tetracycline. Another patient with C. burneti endocarditis showed a histological progres\
II
London
sion from intrahepatic granulomata to a wellestablished micronodular cirrhosis over the course of 10 months, and he died in hepatic coma 24 months after diagnosis. Liver biopsy of a further patient with subacute endocarditis revealed early fibrosis of the portal tracts. He was reported to be well after a prolonged course of lincomycin and tetracycline, but follow-up histology was not performed. Because of the possibility that chronic C. burneti infection may cause long-term liver damage, and because of the potential for effective treatment, a serological survey was performed to find out if the organism can be a significant pathogen in this respect. Cyprus appeared ideal for the study as Q fever is endemic in both the human and animal populations (KELLY, 1974; KAPLAN & BERTAGNA, 1955) and there is a close association between rural Cypriot families and their livestock, Also, human and animal epidemics had occurred in the south-east region two years before the study (SPICER et al., 1977). A phase 1 antibody titre in excess of 1:200 was accepted as the serological criterion for diagnosing chronic C. burneti infection, as recommended by a WHO study group in 1963. Patients and Methods The complement fixation test using phase 1 and phase 2 antigens was performed on a random sample of adults in the south-east region of Cyprus, a group of shepherds from flocks known to be infected with C. burneti, and a number of patients suffering from cirrhosis and chronic active hepatitis. Blood was taken from 106 consecutive Cypriot villagers who entered the British military hospital compound over the course of two days. They comprised a mixed group of patients, visitors and hospital staff. This was done to provide a base line against which the patients with chronic liver disease could be assessed. The 13 shepherds were from 10 flocks affected by the abortion epidemic in the Eastern Sovereign Base Area. This group was chosen to show the antibody response in persons constantly or recurrently exposed to C. burneti infection, again to provide base line information. Five of the cirrhotics were kindly referred by Dr. V. Kalbian, consultant physician, Nicosia General Hospital. The remainder were patients of mine at Dhekelia Military Hospital. Thalassaemics and persons known, or suspected, to be suffering from alcoholism were excluded from the study. Both cases of chronic active hepatitis were negative for anti-HB and HB antigen. The cirrhotics were
416
c.
Table I-Distribution 106 Cypriot villagers
bumf?ti
AS POSSIBLE
of complement king and 13 shepherds*
Titre Antibody Villagers Shepherds -
CAUSE OF CHRONIC
LIVER
DISEASE
phase 1 and phase 2 Coxiella burneti antibody
titres in
Neg
1 :lO
1:20
140
Phase 1 Phase 2
Phase 1 Phase 2
Phase 1 Phase 2
Phase 1 Phase 2
106
92
10
2
11 2
4
3 1
6
1
Table II-Complement fixing phase 1 and phase 2 CoxieZZa burneti antibody titres in 16 patients with cirrhosis and 2 patients with chronic active hepatitis*
Hepatic disorder Cirrhosis ,, J, J> ,> >9 ,, >, >9 * >> * ,3 * ,9 >> >, >3 Chr%ric active hepatitis ,,
z
Titre
Duration (years)
4s (years)
3” 1 l/2 7
41 52
; 2
:; 2::
z 2 4 2 11 3 :
52 49 54 62 49 79 54 49 7
7
32
z
Phase 1
Phase 2
1:lO 1 :lO 1 :lO 1:20 1:160 1:20
* Diagnosis confirmed by liver biopsy not tested for evidence of hepatitis B infection. The diagnosis in the two patients with chronic active hepatitis and three patients with cirrhosis had been previously confirmed by percutaneous liver biopsy. Serum iron was estimated on all casesas a screening test for haemochromatosis. In no instance did it exceed 32 pmol/litre. The complement fixation test was performed at the Royal Army Medical College, London, by a & technique adapted from that of BRADSTREET TAYLOR (1962). Phase 1 and phase 2 antigens were kindly supplied by Dr. C. M. P. Bradstreet of the Standards Laboratory for Serological Reagents, Colindale, London. Results Of the 106 Cypriot villagers, 14 had evidence of recent acute C. burneti infection with phase 2 antibody titres of 1: 10 to 1:20. None had demonstrable phase 1 antibodies. 11 of the 13 shepherds had phase 2 antibodies with titres ranging from 1:lO to 1:40. Three shepherds had phase 1 titres of 1 :lO to 1:20. The results for the population sample and shepherds are given in Table I.
Six of 18 patients with chronic liver disease had phase 2 antibodies with titres ranging from 1 :lO to 1:160, but none had phase 1 antibodies. The results are given in Table II. Discussion The results of the Cypriot survey show that whilst acute Q fever is common in the south-east region, chronic Q fever, if it exists there at all, is rare. That 11 of the 13 shepherds had serological evidence of recent infection reflects the high degree of occupational exposure, but only three had phase 1 antibodies and at low titres. It is unlikely that the latter resulted from chronic infection, as they were in good health, had no abnormality on examination, and could not recall any relevant symptoms. The evidence from the patients shows that C. burneti is not a significant cause of chronic liver disease in Cyprus, but because the number studied was small it can not be excluded as an occasional pathogen in this respect. Some of the casesof cirrhosis and chronic active hepatitis may have been the end result of viral hepatitis, although this is not a common disease in
417
A.J. SPICER
Cyprus. No reliable civilian statistics were available, but in 1974 the incidence among soldiers in the ESBA was only 1.51 per thousand and in 1975 it was 0 -73 per thousand. None of the cases were hepatitis B. It can be reasonably assumed that most of the cases of cirrhosis studied were of the cryptogenie type, and it is in such a group that other infective aetiologies are most likely to be found. This appears to be the first study of its kind, and from the experience gained certain principles can be formulated for guidance in future investigations. In assessing the significance of serological surveys to determine the prevalence of chronic C. burneri infection three factors must be considered. Firstly, whilst a phase 1 antibody titre of more than 1:200 is a good indication of active chronic Q fever (WHO, 1963), the correlation between lower titres and past chronic infection is uncertain, as the persistence of phase 1 antibodies has not been ascertained. Secondly, chronic Q fever can occur with titres less than 1:200 as in two patients of TURCK et al. (1976) who had titres of -1:128 and 1: 160. Thirdlv. nhase 1 antibodies can arise after acute Q fever-as-shown in POWELL & STALLMAN'S (1962) series. Therefore, the significance of phase 1 antibodies should only be interpreted in conjunction with a carefully taken medical history, for in the light of current knowledge it seems unlikely that chronic Q fever often occurs as an entirely inapparent infection. Biochemical liver function tests, and perhaps percutaneous biopsy of the liver, may be needed to clarify the serological and historical findings, References Anon. (1971). Q fever and hepatitis. (Editorial). Journal of the American Medical Association, 55, 1004. Bradstreet, C. M. P. & Taylor, C. E. D. (1962). Technique of complement fixation test applicable
to the diagnosis of virus disease. Monthly Bulletin of the Ministry of Health Laboratory Service, 21, 96-104. Clark, W. H., Lennette, E. H., Railsback, 0. C. & Romer, M. S. (1951). Q fever in California. American Journal of Hygiene, 54, 319-330. Delaney, J. C. & Roberts, H. L. (1975). Q fever endocarditis and chronic liver involvement. Practitioner, 214, 243-245. Duoont. H. L.. Hornick. R. B. & Levin. H. S. (i971j. Q fever hepatitis. Annals of Internal Medicine, 74, 198-206. Kaplan, M. M. & Bertagna, I’. (1955). The geographical incidence of Q fever. Bulletin of the World Health Organization, 13, 829-860. Kelly, H. B. (1974). Q fever in Cyprus: report of cases and a survey of United Nations personnel. International Journal of Epidemiology, 3, 47-53. Powell, 0. W. (1961). Liver involvement in Q fever. Australian Annals of Internal Medicine, 10, 52-58. Powell, 0. & Stallman, N. D. (1962). The incidence and significance of phase 1 complement fixing antibody in Q fever. Journal of Hygiene, 60, 359364. Spicer, A. J., Crowther, R. W., Vella, E. E., Bengtsson, E., Miles, R. & Pitzolis, G. (1977). Q fever and animal abortion in Cyprus. Transactions of the Royal Society of Tropical Medicine and Hygiene, 71, 16-20. Turck, W. P. G., Howitt, G., Turnberg, L. A., Fox, H., Longson, M., Matthews, M. B. & Des Gupta, R. (1976). Chronic Q fever. Quarterly Journal of Medicine, 45, 193-217. World Health Organization (1963). Report to Director General; Meeting of Scientific Group on Rickettsial Disease in Man, Geneva, July 1963, pp. 21-63.
Accepted for publication
28th November, 1978.
Investigation
of Coxiella burneti infection as a possible cause of chronic liver disease in man A. J. SPICER Queen EIizabeth Military Hospital,
Summary The possible role of Coxiella burneti as a cause of chronic liver disease in man was investigated in Cyprus. Serology, using the complement fixation test and phase 1 and phase 2 antigens, was performed on 16 patients with cryptogenic cirrhosis and two patients with chronic active hepatitis. Antibody studies were also done on 106 adult Cypriot villagers and on 13 shepherds from flocks infected with C. burneti, to provide a base line for comparative purposes. No evidence was found to implicate the organism as a cause of chronic liver disease. As the number of patients investigated was small it was not possible to exclude C. burneti as an occasional pathogen, and guiding principles were formulated for future investigations. Introduction Subclinical hepatitis commonly occurs in acute Q fever (CLARK et al., 1951; POWELL, 1961; DUPONT et al.. 1971: SPICER et al.. 1977). An American 1971) drew attention to the (i&ON., Editorial disparity between the minor abnormalities of liver function tests and extensive abnormalities seen on bioosv, and also observed that histological changes may persist beyond the symptomaticstage. There have been two reports associating long-term liver damage with C. burneti infection. DELANEY & ROBERTS(1975) gave the first account of chronic liver disease in a patient with Q fever endocarditis. Liver function tests were only slightly abnormal but a needle biopsy of the liver showed scattered areas of hepatocyte necrosis, occasional lobular eranulomata and a diffuse infiltration of the portal &acts. The patient apparently recovered after prolonged treatment with-tetracycline. TIJRCK et al. (1976) reuorted 16 cases of chronic Q fever, all with evidence of liver involvement. Two of these patients, with minor degrees of heart valve disease, but no evidence of subacute endocarditis, presented primarily as chronic active hepatitis. Liver biopsy showed a patchy focal necrosis of parenchymal cells, a mononuclear infiltration of the portal tracts and an abnormal prominence of the sinusoidal Kupffer cells. A second biopsy from one of these patients 16.5 months later had almost identical features. Phase 1 complement fixing antibody titres on admission to- hospital were 1:4,096 and 1: 1,024. Both natients recovered after prolonged treatment with a combination of lincomycin and tetracycline. Another patient with C. burneti endocarditis showed a histological progres\
II
London
sion from intrahepatic granulomata to a wellestablished micronodular cirrhosis over the course of 10 months, and he died in hepatic coma 24 months after diagnosis. Liver biopsy of a further patient with subacute endocarditis revealed early fibrosis of the portal tracts. He was reported to be well after a prolonged course of lincomycin and tetracycline, but follow-up histology was not performed. Because of the possibility that chronic C. burneti infection may cause long-term liver damage, and because of the potential for effective treatment, a serological survey was performed to find out if the organism can be a significant pathogen in this respect. Cyprus appeared ideal for the study as Q fever is endemic in both the human and animal populations (KELLY, 1974; KAPLAN & BERTAGNA, 1955) and there is a close association between rural Cypriot families and their livestock, Also, human and animal epidemics had occurred in the south-east region two years before the study (SPICER et al., 1977). A phase 1 antibody titre in excess of 1:200 was accepted as the serological criterion for diagnosing chronic C. burneti infection, as recommended by a WHO study group in 1963. Patients and Methods The complement fixation test using phase 1 and phase 2 antigens was performed on a random sample of adults in the south-east region of Cyprus, a group of shepherds from flocks known to be infected with C. burneti, and a number of patients suffering from cirrhosis and chronic active hepatitis. Blood was taken from 106 consecutive Cypriot villagers who entered the British military hospital compound over the course of two days. They comprised a mixed group of patients, visitors and hospital staff. This was done to provide a base line against which the patients with chronic liver disease could be assessed. The 13 shepherds were from 10 flocks affected by the abortion epidemic in the Eastern Sovereign Base Area. This group was chosen to show the antibody response in persons constantly or recurrently exposed to C. burneti infection, again to provide base line information. Five of the cirrhotics were kindly referred by Dr. V. Kalbian, consultant physician, Nicosia General Hospital. The remainder were patients of mine at Dhekelia Military Hospital. Thalassaemics and persons known, or suspected, to be suffering from alcoholism were excluded from the study. Both cases of chronic active hepatitis were negative for anti-HB and HB antigen. The cirrhotics were
416
c.
Table I-Distribution 106 Cypriot villagers
bumf?ti
AS POSSIBLE
of complement king and 13 shepherds*
Titre Antibody Villagers Shepherds -
CAUSE OF CHRONIC
LIVER
DISEASE
phase 1 and phase 2 Coxiella burneti antibody
titres in
Neg
1 :lO
1:20
140
Phase 1 Phase 2
Phase 1 Phase 2
Phase 1 Phase 2
Phase 1 Phase 2
106
92
10
2
11 2
4
3 1
6
1
Table II-Complement fixing phase 1 and phase 2 CoxieZZa burneti antibody titres in 16 patients with cirrhosis and 2 patients with chronic active hepatitis*
Hepatic disorder Cirrhosis ,, J, J> ,> >9 ,, >, >9 * >> * ,3 * ,9 >> >, >3 Chr%ric active hepatitis ,,
z
Titre
Duration (years)
4s (years)
3” 1 l/2 7
41 52
; 2
:; 2::
z 2 4 2 11 3 :
52 49 54 62 49 79 54 49 7
7
32
z
Phase 1
Phase 2
1:lO 1 :lO 1 :lO 1:20 1:160 1:20
* Diagnosis confirmed by liver biopsy not tested for evidence of hepatitis B infection. The diagnosis in the two patients with chronic active hepatitis and three patients with cirrhosis had been previously confirmed by percutaneous liver biopsy. Serum iron was estimated on all casesas a screening test for haemochromatosis. In no instance did it exceed 32 pmol/litre. The complement fixation test was performed at the Royal Army Medical College, London, by a & technique adapted from that of BRADSTREET TAYLOR (1962). Phase 1 and phase 2 antigens were kindly supplied by Dr. C. M. P. Bradstreet of the Standards Laboratory for Serological Reagents, Colindale, London. Results Of the 106 Cypriot villagers, 14 had evidence of recent acute C. burneti infection with phase 2 antibody titres of 1: 10 to 1:20. None had demonstrable phase 1 antibodies. 11 of the 13 shepherds had phase 2 antibodies with titres ranging from 1:lO to 1:40. Three shepherds had phase 1 titres of 1 :lO to 1:20. The results for the population sample and shepherds are given in Table I.
Six of 18 patients with chronic liver disease had phase 2 antibodies with titres ranging from 1 :lO to 1:160, but none had phase 1 antibodies. The results are given in Table II. Discussion The results of the Cypriot survey show that whilst acute Q fever is common in the south-east region, chronic Q fever, if it exists there at all, is rare. That 11 of the 13 shepherds had serological evidence of recent infection reflects the high degree of occupational exposure, but only three had phase 1 antibodies and at low titres. It is unlikely that the latter resulted from chronic infection, as they were in good health, had no abnormality on examination, and could not recall any relevant symptoms. The evidence from the patients shows that C. burneti is not a significant cause of chronic liver disease in Cyprus, but because the number studied was small it can not be excluded as an occasional pathogen in this respect. Some of the casesof cirrhosis and chronic active hepatitis may have been the end result of viral hepatitis, although this is not a common disease in
417
A.J. SPICER
Cyprus. No reliable civilian statistics were available, but in 1974 the incidence among soldiers in the ESBA was only 1.51 per thousand and in 1975 it was 0 -73 per thousand. None of the cases were hepatitis B. It can be reasonably assumed that most of the cases of cirrhosis studied were of the cryptogenie type, and it is in such a group that other infective aetiologies are most likely to be found. This appears to be the first study of its kind, and from the experience gained certain principles can be formulated for guidance in future investigations. In assessing the significance of serological surveys to determine the prevalence of chronic C. burneri infection three factors must be considered. Firstly, whilst a phase 1 antibody titre of more than 1:200 is a good indication of active chronic Q fever (WHO, 1963), the correlation between lower titres and past chronic infection is uncertain, as the persistence of phase 1 antibodies has not been ascertained. Secondly, chronic Q fever can occur with titres less than 1:200 as in two patients of TURCK et al. (1976) who had titres of -1:128 and 1: 160. Thirdlv. nhase 1 antibodies can arise after acute Q fever-as-shown in POWELL & STALLMAN'S (1962) series. Therefore, the significance of phase 1 antibodies should only be interpreted in conjunction with a carefully taken medical history, for in the light of current knowledge it seems unlikely that chronic Q fever often occurs as an entirely inapparent infection. Biochemical liver function tests, and perhaps percutaneous biopsy of the liver, may be needed to clarify the serological and historical findings, References Anon. (1971). Q fever and hepatitis. (Editorial). Journal of the American Medical Association, 55, 1004. Bradstreet, C. M. P. & Taylor, C. E. D. (1962). Technique of complement fixation test applicable
to the diagnosis of virus disease. Monthly Bulletin of the Ministry of Health Laboratory Service, 21, 96-104. Clark, W. H., Lennette, E. H., Railsback, 0. C. & Romer, M. S. (1951). Q fever in California. American Journal of Hygiene, 54, 319-330. Delaney, J. C. & Roberts, H. L. (1975). Q fever endocarditis and chronic liver involvement. Practitioner, 214, 243-245. Duoont. H. L.. Hornick. R. B. & Levin. H. S. (i971j. Q fever hepatitis. Annals of Internal Medicine, 74, 198-206. Kaplan, M. M. & Bertagna, I’. (1955). The geographical incidence of Q fever. Bulletin of the World Health Organization, 13, 829-860. Kelly, H. B. (1974). Q fever in Cyprus: report of cases and a survey of United Nations personnel. International Journal of Epidemiology, 3, 47-53. Powell, 0. W. (1961). Liver involvement in Q fever. Australian Annals of Internal Medicine, 10, 52-58. Powell, 0. & Stallman, N. D. (1962). The incidence and significance of phase 1 complement fixing antibody in Q fever. Journal of Hygiene, 60, 359364. Spicer, A. J., Crowther, R. W., Vella, E. E., Bengtsson, E., Miles, R. & Pitzolis, G. (1977). Q fever and animal abortion in Cyprus. Transactions of the Royal Society of Tropical Medicine and Hygiene, 71, 16-20. Turck, W. P. G., Howitt, G., Turnberg, L. A., Fox, H., Longson, M., Matthews, M. B. & Des Gupta, R. (1976). Chronic Q fever. Quarterly Journal of Medicine, 45, 193-217. World Health Organization (1963). Report to Director General; Meeting of Scientific Group on Rickettsial Disease in Man, Geneva, July 1963, pp. 21-63.
Accepted for publication
28th November, 1978.
