Letter to the Editor – Brief Case Reports
Resistant anaemia and mixed cryoglobulinaemia in a patient on haemodialysis in the context of Q fever
Anemia resistente y crioglobulinemia mixta en paciente en hemodiálisis en contexto de fiebre Q
Natalia Allende Burgos
, Jordi Calls Ginesta
Corresponding author
Servicio de Nefrología, Hospital de Manacor, Manacor, Palma de Mallorca, Spain
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Nearly 1–5% of infected patients develop a chronic form, which can take place months or years after an acute infection. The most common manifestation is endocarditis, especially in immunocompromised patients or in patients with valvular heart disease. Mixed cryoglobulinaemia is rare<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> and can be diagnosed using an immunoassay. Seroconversion is usually detected 7–15 days after the onset of symptoms. Titres of anti-phase II antigens IgG greater than 200 or Titres of anti-phase II antigens IgM greater than 50 are indicative of a recent infection, whereas titres of anti-phase I antigens IgG greater than 800 are suggestive of chronic infection. Mild forms are commonly self-limiting. Doxycycline is the drug of choice if treatment is needed. Hydroxychloroquine and doxycycline are recommended for at least 18 months for the treatment of chronic forms of endocarditis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Our patient is a 64-year-old man from Germany who has been living in Mallorca since 2011.</p><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">History</span>: HTN, ischaemic cardiomyopathy that underwent revascularisation (3 stents). Atrial fibrillation treated with anticoagulation. Moderate alcoholism. End-stage chronic renal disease (ESCRD) receiving haemodialysis with vascular graft access.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In April 2013, the patient started with fever, elevated transaminases (GPT 124, GOT 114, and GGT 100), and positive CMV IgM. Following 2 weeks of treatment with ganciclovir, the fever abated but the inflammatory parameters remained high (CRP 9.24 and PCT 12.48). Fever recurred subsequently and neutropenia (up to 1150<span class="elsevierStyleHsp" style=""></span>mcl), anaemia refractory to erythropoiesis-stimulating agents (ESA) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), and thrombocytopenia were associated. Ganciclovir was administered for 3 weeks with <span class="elsevierStyleItalic">Rickettsia</span>- and <span class="elsevierStyleItalic">Coxiella</span>-positive serologies (IgG using IIF).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Although the patient denied any animal or tick bites, treatment with doxycycline (100<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h) was initiated due to a suspected <span class="elsevierStyleItalic">Coxiella/Rickettsia</span> infection and after ruling out endocarditis using a transthoracic echocardiogram.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient still had fever and neutropenia seven days after treatment began. A CT scan of the abdomen and chest revealed liver cirrhosis and splenomegaly. HCV and HBV serologies were negative. Finally, <span class="elsevierStyleItalic">Serratia marcescens</span> was isolated in a sputum culture, and fever subsided following 5 days of treatment with ceftazidime. The patient remained without fever after 2 weeks of treatment with ceftazidime and doxycycline.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Fever recurred one month later (June 2013). The sputum culture and haemocultures were negative, while <span class="elsevierStyleItalic">Rickettsia</span> and <span class="elsevierStyleItalic">Coxiella</span> serologies remained positive (phase 1 IgM and IgG and phase 2 IgM and IgG [1/512; 1/2056, respectively]). Hypergammaglobulinaemia was observed with an IgG kappa monoclonal component, and serologies were read as false positives in the context of hypergammaglobulinaemia, which is why patient was not treated. The patient developed apparent purpura in the lower limbs soon after and cryoglobulins containing polyclonal Ig and monoclonal IgG kappa (essential mixed cryoglobulinaemia) were positive. After ruling out haematological neoplasia (a bone marrow biopsy revealed no signs of multiple myeloma) and HBV/HCV as potential causes, serology tests for <span class="elsevierStyleItalic">Coxiella</span> were requested, and the results – IgG (phase 2)<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>1/4092, IgM (phase 1)<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>1/64, IgG (phase 1)<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>1/4092 – were consistent with chronic Q fever. Endocarditis was ruled out and treatment with doxycycline 100<span class="elsevierStyleHsp" style=""></span>mg/day and hydroxychloroquine 200<span class="elsevierStyleHsp" style=""></span>mg/day was initiated. The fever abated and the patient had a favourable outcome.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Symptomatic Q fever is common among adult male patients such as ours. Despite the sudden onset of fever without a focus, which is typical of acute forms, recurrence of symptoms following withdrawal of doxycycline was rather suggestive of chronic Q fever.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Endocarditis is the most common presentation, particularly among immunocompromised patients or patients with valvular heart disease. And yet, surprisingly, endocarditis was ruled out in our patient, who was immunocompromised as a result of his baseline comorbidity (ESCRD undergoing haemodialysis) and neutropenia.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Hepatitis and cirrhosis are also common. In our patient, who had a history of moderate alcoholism, transaminasaemia had remained normal before he developed his condition. Liver cirrhosis and splenomegaly were observed in the CT scan, and Q fever may have been a contributing factor.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Anaemia and thrombocytopenia may also occur. Our patient already had nephropathy-related anaemia which was initially refractory to EEAs, probably as a result of Q fever.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Finally, the diagnosis of Q fever was reinforced by the finding of type II cryoglobulinaemia (mono-polyclonal) in the absence of the hepatitis C virus or haematologic neoplasia, as it is one of its potential manifestations.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Our patient started treatment with doxycycline and hydroxychloroquine and so far, after 18 months of treatment, the fever has not recurred and the anaemia has resolved, even without EEAs.</p><p id="par0070" class="elsevierStylePara elsevierViewall">In conclusion, the patient described here is a case of chronic Q fever with blood, liver, and skin involvement, together with secondary cryoglobulinaemia.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Allende Burgos N, Calls Ginesta J. Anemia resistente y crioglobulinemia mixta en paciente en hemodiálisis en contexto de fiebre Q. Nefrología. 2015;35:586–587.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 876 "Ancho" => 1612 "Tamanyo" => 114694 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythropoietin resistance rate.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Q fever: epidemiology, diagnosis, and treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.D. Hartzell" 1 => "R.N. Wood-Morris" 2 => "L.J. Martínez" 3 => "R.F. Trotta" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4065/83.5.574" "Revista" => array:6 [ "tituloSerie" => "Mayo Clin Proc" "fecha" => "2008" "volumen" => "83" "paginaInicial" => "574" "paginaFinal" => "579" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18452690" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Q fever" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D. Raoult" 1 => "T. Marrie" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "1995" "volumen" => "20" "paginaInicial" => "489" "paginaFinal" => "495" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7756465" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Q fever a review and issues for the next century" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T.J. Marrie" 1 => "D. Raoult" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Int J Antimicrob Agents" "fecha" => "1997" "volumen" => "8" "paginaInicial" => "145" "paginaFinal" => "161" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18611796" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mixed cryoglobulinemia associated with chronic Q fever" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.J. Enzenauer" 1 => "W.P. Arend" 2 => "J. Woodruff Emlen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Rheumatol" "fecha" => "1991" "volumen" => "18" "paginaInicial" => "76" "paginaFinal" => "78" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2023203" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Q fever endocarditis masquerading as mixed cryoglobulinemia type II. A case report and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P.I. Rafailidis" 1 => "S.P. Dourakis" 2 => "C.A. Fourlas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1471-2334-6-32" "Revista" => array:5 [ "tituloSerie" => "BMC Infect Dis" "fecha" => "2006" "volumen" => "6" "paginaInicial" => "32" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16504099" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003500000006/v2_201703220324/S2013251415001224/v2_201703220324/en/main.assets" "Apartado" => array:4 [ "identificador" => "42662" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor - Brief comments on case reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003500000006/v2_201703220324/S2013251415001224/v2_201703220324/en/main.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2013251415001224?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 7 | 10 |
| 2024 October | 49 | 46 | 95 |
| 2024 September | 44 | 27 | 71 |
| 2024 August | 42 | 64 | 106 |
| 2024 July | 42 | 46 | 88 |
| 2024 June | 55 | 34 | 89 |
| 2024 May | 56 | 27 | 83 |
| 2024 April | 49 | 30 | 79 |
| 2024 March | 38 | 22 | 60 |
| 2024 February | 38 | 37 | 75 |
| 2024 January | 28 | 24 | 52 |
| 2023 December | 19 | 23 | 42 |
| 2023 November | 26 | 22 | 48 |
| 2023 October | 36 | 34 | 70 |
| 2023 September | 28 | 27 | 55 |
| 2023 August | 27 | 21 | 48 |
| 2023 July | 36 | 24 | 60 |
| 2023 June | 35 | 16 | 51 |
| 2023 May | 39 | 27 | 66 |
| 2023 April | 27 | 10 | 37 |
| 2023 March | 41 | 25 | 66 |
| 2023 February | 33 | 17 | 50 |
| 2023 January | 33 | 24 | 57 |
| 2022 December | 44 | 27 | 71 |
| 2022 November | 35 | 25 | 60 |
| 2022 October | 40 | 37 | 77 |
| 2022 September | 51 | 35 | 86 |
| 2022 August | 51 | 42 | 93 |
| 2022 July | 28 | 41 | 69 |
| 2022 June | 25 | 25 | 50 |
| 2022 May | 41 | 36 | 77 |
| 2022 April | 42 | 43 | 85 |
| 2022 March | 44 | 51 | 95 |
| 2022 February | 37 | 40 | 77 |
| 2022 January | 38 | 29 | 67 |
| 2021 December | 63 | 38 | 101 |
| 2021 November | 47 | 37 | 84 |
| 2021 October | 39 | 49 | 88 |
| 2021 September | 30 | 34 | 64 |
| 2021 August | 49 | 40 | 89 |
| 2021 July | 37 | 35 | 72 |
| 2021 June | 38 | 25 | 63 |
| 2021 May | 50 | 35 | 85 |
| 2021 April | 95 | 51 | 146 |
| 2021 March | 46 | 27 | 73 |
| 2021 February | 58 | 17 | 75 |
| 2021 January | 42 | 21 | 63 |
| 2020 December | 36 | 16 | 52 |
| 2020 November | 27 | 15 | 42 |
| 2020 October | 20 | 23 | 43 |
| 2020 September | 21 | 14 | 35 |
| 2020 August | 26 | 13 | 39 |
| 2020 July | 26 | 13 | 39 |
| 2020 June | 21 | 16 | 37 |
| 2020 May | 29 | 18 | 47 |
| 2020 April | 28 | 18 | 46 |
| 2020 March | 27 | 11 | 38 |
| 2020 February | 24 | 18 | 42 |
| 2020 January | 30 | 15 | 45 |
| 2019 December | 43 | 20 | 63 |
| 2019 November | 40 | 20 | 60 |
| 2019 October | 21 | 13 | 34 |
| 2019 September | 21 | 17 | 38 |
| 2019 August | 23 | 14 | 37 |
| 2019 July | 26 | 22 | 48 |
| 2019 June | 24 | 15 | 39 |
| 2019 May | 26 | 16 | 42 |
| 2019 April | 62 | 42 | 104 |
| 2019 March | 34 | 19 | 53 |
| 2019 February | 16 | 18 | 34 |
| 2019 January | 26 | 17 | 43 |
| 2018 December | 93 | 30 | 123 |
| 2018 November | 158 | 13 | 171 |
| 2018 October | 127 | 17 | 144 |
| 2018 September | 95 | 11 | 106 |
| 2018 August | 53 | 14 | 67 |
| 2018 July | 56 | 13 | 69 |
| 2018 June | 52 | 14 | 66 |
| 2018 May | 57 | 12 | 69 |
| 2018 April | 63 | 11 | 74 |
| 2018 March | 66 | 13 | 79 |
| 2018 February | 44 | 7 | 51 |
| 2018 January | 50 | 13 | 63 |
| 2017 December | 37 | 5 | 42 |
| 2017 November | 39 | 11 | 50 |
| 2017 October | 32 | 12 | 44 |
| 2017 September | 35 | 10 | 45 |
| 2017 August | 31 | 9 | 40 |
| 2017 July | 29 | 6 | 35 |
| 2017 June | 30 | 17 | 47 |
| 2017 May | 38 | 3 | 41 |
| 2017 April | 26 | 9 | 35 |
| 2017 March | 24 | 3 | 27 |
| 2017 February | 30 | 5 | 35 |
| 2017 January | 27 | 13 | 40 |
| 2016 December | 26 | 8 | 34 |
| 2016 November | 46 | 11 | 57 |
| 2016 October | 62 | 6 | 68 |
| 2016 September | 81 | 2 | 83 |
| 2016 August | 89 | 1 | 90 |
| 2016 July | 127 | 5 | 132 |
| 2016 June | 79 | 0 | 79 |
| 2016 May | 121 | 0 | 121 |
| 2016 April | 105 | 0 | 105 |
| 2016 March | 75 | 0 | 75 |
| 2016 February | 95 | 0 | 95 |
| 2016 January | 21 | 0 | 21 |
Show all
