Q fever is a zoonotic disease caused by coxiella burnetii. The Jarisch-Herxheimer reaction (JHR) is associated with the antibiotic treatment of certain bacterial infections. We report a very rare case of a 36-year-old male with Q fever pneumonia that resulted in recurrent ARDS and presented the JHR during his treatment. The patient was admitted for treatment of community acquired pneumonia. He developed ARDS, was intubated and placed on mechanical ventilation. Doxycycline was empirically added to his antibiotic regiment. The patient presented an acute rise in temperature, tachycardia, tachypnea, hypoxia, hypotension and a temporary deterioration of his chest x-ray. The same 6-hour-long reaction which is known as JHR was presented another 3 times. Cultures were negative but antibodies against coxiella burnetii were positive. This case reminds us that any deterioration of a patient treated in the ICU should not be considered as a new septic episode and time should be allowed for the antibiotic regiments

Aloizos, Stavros

Gourgiotis, Stavros

Oikonomou, Konstantinos

Stakia, Paraskevi

English

PubMed

Stavros Aloizos

Stavros Gourgiotis

Konstantinos Oikonomou

Paraskevi Stakia

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Recurrent Jarisch-Herxheimer reaction in a patient with Q fever pneumonia: a case report

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BioMed CentralCases Journal
ssOpen AcceCase Report
Recurrent Jarisch-Herxheimer reaction in a patient with Q fever 
pneumonia: a case report
Stavros Aloizos1,4, Stavros Gourgiotis*2,4, Konstantinos Oikonomou2,4 and 
Paraskevi Stakia3,4
Address: 1Intensive Care Unit, 401 General Army Hospital of Athens, 14 Acheon Street, 15343, Ag. Paraskevi, Athens, Greece, 2Second Surgical 
Department, 401 General Army Hospital of Athens, 41 Zakinthinou Street, 15669, Papagou, Athens, Greece, 3Oncology Department, 401 General 
Army Hospital of Athens, 23 Filias Street, 15123 Marousi, Athens, Greece and 48 Pirgou Street, 16675, Glyfada, Athens, Greece
Email: Stavros Aloizos - saloizos@yahoo.com; Stavros Gourgiotis* - drsgourgiotis@tiscali.co.uk; 
Konstantinos Oikonomou - k.oikonomou@gmail.com; Paraskevi Stakia - vstakia@gmail.com
* Corresponding author    
Abstract
Q fever is a zoonotic disease caused by coxiella burnetii. The Jarisch-Herxheimer reaction (JHR) is
associated with the antibiotic treatment of certain bacterial infections. We report a very rare case
of a 36-year-old male with Q fever pneumonia that resulted in recurrent ARDS and presented the
JHR during his treatment. The patient was admitted for treatment of community acquired
pneumonia. He developed ARDS, was intubated and placed on mechanical ventilation. Doxycycline
was empirically added to his antibiotic regiment. The patient presented an acute rise in
temperature, tachycardia, tachypnea, hypoxia, hypotension and a temporary deterioration of his
chest x-ray. The same 6-hour-long reaction which is known as JHR was presented another 3 times.
Cultures were negative but antibodies against coxiella burnetii were positive. This case reminds us
that any deterioration of a patient treated in the ICU should not be considered as a new septic
episode and time should be allowed for the antibiotic regiments.
Case presentation
A 36-year-old man was presented with a 6-day history of
producing cough, shortness of breath, pleuritic chest pain
exaggerated on breathing, cold sweats, headache, joint
and muscle pain. He was a countryside resident and had
recently returned from a hunting trip. Chest x-ray revealed
bilateral pneumonia (Figure 1). The initial treatment
included 3rd generation cephalosporin and cinolone for
community acquired pneumonia.
Hours after his admission, the patient fell into acute respi-
ratory distress syndrome (ARDS) (Figure 2) and was trans-
ferred to the Intensive Care Unit (ICU) for further
treatment. He was intubated and placed on mechanical
ventilation which was extremely difficult (FiO2: 100%,
high ventilator pressures and continuous infusion of mus-
cle relaxants) for the first 48 hours. C-reactive protein
(CRP) elevation was marked while patient's renal func-
tion had to be supported via dialysis.
A few hours after the first doxycycline dose which was
added empirically to the previous antibiotics, the patient
presented an acute rise in temperature, tachycardia, tach-
ypnea, hypoxia, hypotension and a temporary deteriora-
tion of his chest x-ray (Figure 3). The same 6-hour-long
reaction which was later identified as Jarisch-Herxheimer
Published: 29 November 2008
Cases Journal 2008, 1:360 doi:10.1186/1757-1626-1-360
Received: 29 October 2008
Accepted: 29 November 2008
This article is available from: http://www.casesjournal.com/content/1/1/360
© 2008 Aloizos et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 5
(page number not for citation purposes)
Cases Journal 2008, 1:360 http://www.casesjournal.com/content/1/1/360
Page 2 of 5
(page number not for citation purposes)
Chest x-ray shows bilateral pneumoniaFigure 1
Chest x-ray shows bilateral pneumonia.
Cases Journal 2008, 1:360 http://www.casesjournal.com/content/1/1/360reaction (JHR) was presented another 3 times. During
these episodes, the patient had to be haemodynamically
supported and transient high mixtures of oxygen accord-
ing to the ARDSnet suggested treatment protocol which
includes Tidal Volume (TV): 6–12 ml/kg, high level of
PEEP & P plateau <30 mmHg and permissible hypercap-
nea [1]. Aggressive administration of insulin was also
employed so as to maintain blood glucose levels between
70 and 90 mg/dl. The results of blood, urine and broncho-
alveolar lavage (BAL) cultures were negative while the
tests for antibodies against coxiella burnetii showed acute
Q fever infection.
It should be noted that members of his family were subse-
quently tested and found also positive to Coxiella burnetii
without any signs of clinical illness. Inflammatory
cytokines were unfortunately not measured.
The patient was discharged 32 days after his initial admis-
sion.
Discussion
Q fever is a zoonotic disease caused by coxiella burnetii, a
species of bacteria with global distribution. It is now a
notifiable disease in the United States but reporting is not
required in many other countries. Because the disease is
underreported, scientists cannot reliably assess how many
cases of Q fever have actually occurred worldwide [2].
Cattle, sheep, and goats are the primary reservoirs of cox-
iella burnetii. The organisms are resistant to heat, drying
and many common disinfectants which enables the bac-
teria to survive for long periods in the environment. Infec-
tion of humans usually occurs by inhalation of these
organisms from air that contains airborne barnyard dust
contaminated by dried placental material, birth fluids,
Chest x-ray demonstrates ARDSFigure 2
Chest x-ray demonstrates ARDS.Page 3 of 5
(page number not for citation purposes)
Cases Journal 2008, 1:360 http://www.casesjournal.com/content/1/1/360and excreta of infected herd animals. Humans are often
very susceptible to the disease and very few organisms
may be required to cause infection.
50% of all people infected with coxiella burnetii show
signs of clinical illness. Most cases begin with sudden
onset of one or more of the following: high fevers (up to
40.5°C which usually lasts for 1 to 2 weeks), headache,
general malaise, myalgia, confusion, sore throat, chills,
sweats, non-productive cough, nausea, vomiting,
diarrhea, abdominal and chest pain. Weight loss can
occur and persist for some time [3]. 30–50% of patients
with a symptomatic infection will develop pneumonia
[4,5]. Most patients will recover to good health within sev-
eral months without any treatment. Only 1%–2% of peo-
ple with acute Q fever die of the disease [6].
The JHR occurs when large quantities of toxins are
released into the body as bacteria (typically spirochetal
bacteria, borellia or brucella) die due to antibiotic treat-
ment. The proposed mechanism behind this is that the
death of the bacteria and the subsequent release of endo-
toxins is faster that the rate the body can remove these tox-
ins via its natural pathways (liver, kidneys) thus resulting
in their accumulation. The intensity of the reaction
reflects the intensity of inflammation present [7].
In addition to the ARDSnet guidelines which have
reduced significantly the complications from mechanical
ventilation in ARDS patients [1], the aggressive controlled
administration of insulin so as to achieve a borderline
hypoglycemic status seems to help improve the gas
exchange of these patients as well [8,9]. The goal is to
increase the effectiveness of the Na-K ATP depended alve-
olar membrane ion pump and thus reduce the fluid accu-
mulation in the alveolus. This therapeutic approach has
been shown in experimental animal models to increase
the gas exchange ratio and improve the acid base balance.
Chest x-ray of recurrent ARDSFigure 3
Chest x-ray of recurrent ARDS.Page 4 of 5
(page number not for citation purposes)
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Its drawback is the necessity for careful and continuous
monitoring of blood glucose levels by the ICU staff.
In conclusions, the JHR is extremely rare and usually asso-
ciated with the antibiotic treatment of certain bacterial
infections but extremely rarely is presented during the
course of treatment for coxiella burnetii. Any deteriora-
tion of a patient treated in the ICU should not de facto be
considered as a new septic episode and adequate time
should be allowed for the antibiotic regiments, especially
if the culture sets fail to yield new microbes.
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
"PS and KO analyzed and interpreted the patient data. SA
was the responsible doctor of the patient. SG was a major
contributor in writing the manuscript. All authors read
and approved the final manuscript."
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Recurrent Jarisch-Herxheimer reaction in a patient with Q fever pneumonia: a case report

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