Sheep, chills and "doughnut granuloma"--an atypical course of Coxiella infection

Q fever usually presents with high fever, headache and an atypical pneumonia. A case report of a 47-year-old patient with an atypical course of a coxiella infection is described. The dominant clinical symptoms were a liver and bone marrow involvement, whereas pulmonary manifestations were absent. The diagnosis of Q fever in this patient was based on the detection of cytoplasmatic inclusion bodies in macrophages and granulocytes. Furthermore fibrin-ring granulomas ("doughnut lesions") were found in liver tissue specimen and epitheloid-cell granulomas were detected in bone marrow specimen. Complement-fixation antibody titers and PCR resulted unspecific or negative on different occasions during the course of the disease. A confirmation of the diagnosis by complement-fixation antibody test was possible only after recovery from the disease. In Q fever with atypical clinical and serological presentation the screening of blood cells for inclusion bodies and liver or bone marrow tissue for granulomas may be important for establishing the diagnosis.