Journal of IiME Volume 1 Issue 2 Chronic Fatigue Syndrome after Q fever (continued) and after the treatment. The questionnaire survey included subjective symptoms: fatigue, lack of concentration, no refreshing sleep, sore throat, tender cervical or axillary lymph nodes, joint pain without swelling, muscle pain, headache, and malaise lasting longer than 24 hours after exertion. These symptoms were evaluated according to four grades (0: absent, 1: mild, 2: moderate, 3: severe). If the summed result of the survey was halved after the treatment, the effect of antibiotic therapy was considered favorable (Table 1). CASE REPORTS Case 1 A 34-year-old male shopkeeper with atypical pneumonia caused by Coxiella burnetii was treated at the Department for Pulmonary Diseases in February 2000. He did not have any serious illness before he caught Q fever. He arrived from a rural area where Q fever is endemic. Laboratory results showed an erythrocyte sedimentation rate (ESR) of 72 mm/hour, while the other hematological and biochemical parameters showed no abnormalities. The patient received a combination of erythromycin 4×500 mg/day p.o. and gentamycin 1×240 mg/day i.v for two weeks. The clinical response was good. A control chest x-ray was normal. The etiology was confirmed by the complement-binding reaction (CBR), which showed a titer for Coxiella burnetii of 1:64. A repeat CBR for Coxiella burnetii after six weeks was 1:1024. During follow-up within the year 2000, the patient complained of disrupted sleep, morning fatigue, intense headache, prolonged fatigue lasting more than 24 hours after physical work, muscle pain, and persistent low-grade fever. Transthoracic heart ultrasound was normal. Serology for the phase I and phase II replication cycle of Coxiella burnetii did not confirm chronic infection (Table 2). After a one-year duration of symptoms, nine months of treatment with ciprofloxacin (2×500 mg/day p.o.) and doxycycline (2×100 mg/day p.o.) was instituted. The muscle pain and low-grade fever disappeared after this therapy, but the mild headache persisted. Therefore, in January 2002 a lumbar tap was performed. Cytology and biochemistry of CSF showed no abnormalities. The CSF sample was tested for Coxiella burnetii using an indirect immunofl uorescence assay and the result was negative. The patient still has low intensity headache and he suffers from fatigue after physical activity, but it disappears after half an hour of rest. He has returned to work, but has changed his job from shopkeeper to watchman. He now suffers from hyperlipidemia and does not show criteria for chronic fatigue syndrome (Table 1). Case 2 A 32-year-old housewife with pneumonia caused by Coxiella burnetii was treated at the Department for Infectious Diseases in February 2003. Laboratory results showed an ESR of 92 mm/hour. Other hematological and biochemical results, were within physiological limits. She was treated with doxycycline for two weeks with a good clinical response, and her chest x-ray after two weeks confirmed complete regression of pulmonary infiltrations. An indirect immunofluorescence test (IFT) in the acute stage of the disease showed positive IgM (titer: 1:160) and IgG (titer: 1:640) for Coxiella burnetii. Repeated serology one month later showed IgM 1:320 and IgG 1:1280. After she had felt well for two months, she started experiencing pain in her neck. Six months later, in August 2003, in addition to the neck pain she began to suffer from insomnia, headache, sweating, and fatigue, which did not resolve after sleep. The symptoms persisted for 12 months. She was admitted to the Department for Infectious Diseases again in October 2004. Repeated hematological and biochemical results were within physiological values. Electromyography of the upper and lower extremities showed no abnormalities and transthoracic and transesophageal heart ultrasound showed no signs of endocarditis. Rheumatoid factor, antinuclear antibodies, and antimitochondrial antibodies as well as serology for Epstein-Barr virus, cytomegalovirus, and toxoplasmosis were negative. Anti-HIV and hepatitis B and C markers were also negative, and thyroid hormones were within normal ranges. Paired serum samples in ELISA for Coxiella burnetii showed positive phase I IgA and IgG antibodies (Table 2). The therapy included ciprofloxacin (2×500 mg/day p.o.) for two months followed by doxycycline (2×100 mg/day p.o.) for four months. The result of the six months of treatment was regression of symptoms, with only a minor headache persisting. She is now capable of doing all her housework and does not fulfill the criteria for CFS (Table 1). Case 3 A 30-year-old male professional soldier with interstitial pneumonia was treated at the Department for Pulmonary Diseases of the Clinical Hospital of Split in February 2004. In the acute phase of illness his ESR was 46 mm/hour, while other hematological test results were normal. Blood chemistry values were normal with the exception of AST 62 U/l (normal range: 0–29) and ALT 54 U/l (normal range: 0–30). After two weeks of treatment with doxycycline, pulmonary infiltrates resolved and hematological and other laboratory results were all within the normal ranges. IFA for Coxiella burnetii revealed positive IgM 1:64 and IgG 1:320 in a first and IgM 1:320 IgG 1:640 one month later in a second serum sample. Four months later the patient started complaining of fatigue, disrupted sleep, headaches, and muscle and joint pain. Therapy with corticosteroids was introduced and continued for one month without success. In January 2005 the patient was admitted to the Department for Infectious Diseases, and his routine hematological and biochemical tests were within physiological limits. ELISA for Epstein-Barr virus, cytomegalovirus, HIV, and Toxoplasma gondii were (continued on page 32) Invest in ME Charity Nr 1114035 Page 31/72 www.investinme.org

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