D0564 - Acute Q Fever Diagnosis in a Patient Presenting With Alcohol Associated Hepatitis and Positive Autoantibodies

Tuesday, October 25, 2022

10:00 AM – 12:00 PM ET

Location: Crown Ballroom

Presenting Author(s)

CF

Charlie W. Fox, MD

University of Utah
Salt Lake City, UT

Charlie W. Fox, MD, Juan F. Gallegos-Orozco, MD, Jordon K. March, MD
University of Utah, Salt Lake City, UT

Introduction: Q fever is caused by infection with zoonotic organism Coxiella burnetti (CB). It is often characterized by fever, headaches, myalgias and malaise. It commonly affects the liver leading to elevated aminotransferases. There are case reports of autoantibody positivity in cases of Q fever, namely smooth muscle antibodies and Anti-neutrophilic antibodies. There are no reports discussing the presentation or management of both alcohol associated hepatitis (AAH) and acute Q fever in a patient with positive liver autoantibodies. In this case we report a patient presenting with AAH and positive autoantibodies who was diagnosed with acute Q fever.

Case Description/Methods: 59-year-old male presents with jaundice, nausea, vomiting and abdominal pain. He drank ten beers daily for more than ten years and quit two weeks prior to presentation. Admission labs shown in Table 1. Unremarkable abdominal ultrasound. He was diagnosed with severe AAH, MELD 25, DF 59.5, started on prednisolone. Liver biopsy demonstrated active and chronic steatohepatitis with significant hepatocyte ballooning and Mallory-Denk bodies with stage 3 fibrosis. There were also fibrin ring granulomas typical of CB infection. CB titers were typical of acute infection. He started doxycycline 100mg BID for 14 days. At follow up labs were improved and symptoms had resolved.

Discussion: Presentation was consistent with AAH for which he was started on corticosteroids. However, elevated auto-antibodies raised concern for AIH so biopsy was performed. The findings confirmed that alcohol was the main etiology with active steatohepatitis. However, the presence of fibrin ring granulomas was a surprise and was another possible etiology for his acute liver injury. Testing for CB confirmed acute Q fever. Prednisolone was stopped and he started antibiotics. Q fever diagnosis was intriguing because he did not present with classic symptoms. His elevated autoantibodies are interesting as there have been previous cases reporting an association between Q fever and AIH. We did not find evidence of this on biopsy and he improved with antibiotics alone. This case reminds us to maintain a broad differential diagnosis in patients with acute liver injury because there may be more than one process contributing. It reinforces the value of liver biopsy in clarifying the diagnosis, especially when there are positive autoimmune markers. Furthermore, it highlights knowledge gaps regarding the role of autoimmune markers in both infectious and primary autoimmune liver disease.

Figure: Fibrin Ring Granuloma on Liver Biopsy

	Total Bilirubin	Alkaline Phosphatase	AST	ALT	F-actin Ab IgG (ref< 19)	Mitochondrial Ab IgG (ref< 20)	Serum IgG	INR	CB IgG phase II titer	CB IgM phase II titer
Admission	19	159	142	100	63	73.6	1408	1.8	1:131,072	1:4,096
Follow up	2	319	52	60	-	-	-	1.2	-	-

Table: Table 1

Disclosures:

Charlie Fox indicated no relevant financial relationships.

Juan Gallegos-Orozco: Allergan – Independent Contractor. Durect – Independent Contractor. Genfit – Independent Contractor. Gilead – Independent Contractor. Hanmi – Independent Contractor. Intercept – Independent Contractor. Mallinckrodt – Independent Contractor.

Jordon March indicated no relevant financial relationships.

Charlie W. Fox, MD, Juan F. Gallegos-Orozco, MD, Jordon K. March, MD. D0564 - Acute Q Fever Diagnosis in a Patient Presenting With Alcohol Associated Hepatitis and Positive Autoantibodies, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.