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LETTERS five of the patients with watery had the pathogenic marker for entero- 7. Nataro JP, Kaper JP. Diarrheagenic Escher- chronic (one patient died), aggregative E. coli. These findings ichia coli. Clin Microbiol Rev improved within 10 days of treatment. suggest that not only is K. pneumo- 1998;11:142–66. 8. World Health Organization. Guidelines for In Dakar, during the study describ- niae associated with chronic diarrhea the clinical management of HIV ing ordinary and opportunistic entero- in HIV-infected persons but also that in adults. pub no. WHO/GPA/IDS/HCS/ pathogens associated with diarrhea in infection with particular HEp-2- 91.6. Geneva: The Organization, Global adults (5), stool samples were col- adherent K. pneumoniae subtypes Program on AIDS; 1991. lected from five HIV-infected adults may be associated with specific clini- with watery chronic diarrhea. In all cal illness. Address for correspondence: Yves Germani, cases, heavy K. pneumoniae growth Unité des Maladies Infectieuses Opportunistes, was observed on the primary culture Financial support was provided by BP 923, Bangui, Central African Republic; fax: media, and no other known pathogens Agence Nationale de Recherche sur le 236 61 01 09; e-mail: [email protected] were recovered. These K. pneumo- SIDA (contract 1227) and Groupe d'Etude niae strains were subjected to the des Diarrhéiques (ACIP, Réseau same phenotypic and genotypic tests International des Instituts Pasteur et Insti- as the strains isolated in Bangui. HEp- tuts Associés). Granulomatous 2–adherent K. pneumoniae was identi- Lymphadenitis as fied in four of these five samples. The a Manifestation condition of all the patients rapidly Phuong L. Nguyen Thi,* improved after treatment with ofloxa- Simon Yassibanda,† Awa Aidara,‡ of Q cin. In Bangui and Dakar, repeated Chantal Le Bouguénec,§ stool cultures were negative for K. and Yves Germani* To the Editor: is a world- pneumoniae by the end of treatment, wide zoonosis caused by the obligate providing further evidence that these *Institut Pasteur de Bangui, Bangui, Central intracellular pathogen Coxiella bur- K. pneumoniae were of etiologic African Republic; †Hôpital de l'Amitié, Ban- gui, Bangui, Central African Republic; netii (1). Human infection is usually importance, especially the HEp-2– ‡Institut Pasteur de Dakar, Dakar, Sénégal; the result of exposure to infected cat- adherent K. pneumoniae strains. and §Institut Pasteur, Paris, France tle, sheep or goats. Q fever may Only seven patients (four with be asymptomatic or manifest as a self- mild, two with watery, and one with References limiting febrile illness, , bloody chronic diarrhea) had not 1. Ananthan S, Raju S, Alavandi S. Entero- hepatitis, or meningoencephalitis. taken antibiotics during the 2 weeks toxigenicity of Most cases of acute Q fever will before stool collection. The stool associated with childhood gastroenteritis in Madras, India. Jpn J Infect Dis resolve without sequelae, but specimens from these seven patients 1999;52:16–7. , granulomatous hepatitis, yielded pure primary cultures of HEp- 2. Arora DR, Chugh TD, Vadhera DY. Entero- osteomyelitis, and endovascular infec- 2–adherent K. pneumoniae and no toxigenicity of Klebsiella pneumoniae. Ind tions are well-documented manifesta- other bacterial enteric pathogens. J Pathol Microbiol 1983;26:65–70. tions of chronic C. burnetii infection None of these seven participants was 3. Guerin F, Le Bouguenec C, Gilquin J, Had- dad F, Goldstein FW. Bloody diarrhea (1). Recently, various atypical mani- diagnosed with pseudomembranous caused by Klebsiella pneumoniae: a new festations of acute (2), and chronic (3) colitis. The HEp-2–adherent K. pneu- mechanism of bacterial virulence? Clin Q fever have been reported as well as moniae strains isolated from the two Infect Dis 1998;27:648–9. changing clinical presentation of Q participants with watery chronic diar- 4. Guerrant RL, Moore RA, Kerschfeld PM, fever endocarditis (4) and changing rhea induced the accumulation of Sande MA. Role of toxigenic and invasive in acute diarrhea of childhood. N epidemiology of Q fever (5). fluid in ligated rabbit ileal loops, and Engl J Med 1975;293:567–71. Researchers have suggested that the HEp-2–adherent strains isolated 5. Gassama A, Sow PS, Fall F, Camara P, heightened awareness of Q fever from three of the participants with Philippe H, Guèye-N’Diay A. Ordinary and among doctors, coupled with mild chronic diarrhea carried the astA opportunistic enteropathogens associated improved diagnostic methods, could gene, which is associated with patho- with diarrhea in Senegalese adults in rela- tion to human immunodeficiency virus increase the medical knowledge about genic EAEC. Among the five patients serostatus. Int J Infect Dis 2001;5:192–8. this difficult-to-diagnose and difficult- with pseudomembranous colitis, all of 6. Germani Y, Minssart P, Vohito M, Yassi- to-treat infection (4). We report two whom had received antibiotics before banda S, Glaziou P, Hocquet D, et al. Etiol- cases of granulomatous lymphadeni- the onset of illness, we found that the ogies of acute, persistent, and dysenteric tis associated with C. burnetii infec- four isolates from the patients with diarrheas in adults in Bangui, Central Afri- can Republic, in relation to human immun- tion. bloody chronic diarrhea were cyto- odeficiency virus serostatus. Am J Trop A 70-year-old man was admitted pathogenic; the one isolate from the Med Hyg 1998;59:1008–14. to the hospital because of weight loss, patient with watery chronic diarrhea night sweats, and a continuous high-

Emerging Infectious Diseases • Vol. 9, No. 1, January 2003 137 LETTERS grade fever of 2 months’ duration. His and fungal infections (parasitologic 3. Hatchette TF, Marrie TJ. Atypical manifes- past medical history was unremark- studies on tissue). Antinu- tations of chronic Q fever. Clin Infect Dis able, except for pulmonary tuberculo- clear were absent, and 2001;33:1347–51. 4. Houpikian P, Habib G, Mesana T, Raoult D. sis treated 55 years earlier and chronic angiotensin-converting-enzyme val- Changing clinical presentation of Q fever glaucoma. He lived in a rural area and ues were normal. Both patients endocarditis. Clin Infect Dis 2002;34:E28– had rare contact with cattle. On admis- received , 200 mg once a 31. sion, his body temperature was day, and rifampin, 600 mg twice a day, 5. Hellenbrand W, Breuer T, Petersen L. 39.5°C; his right laterocervical lymph for 1 year, and the symptoms resolved Changing epidemiology of Q fever in Ger- many, 1947-1999. Emerg Infect Dis nodes were enlarged (3 cm x 4 cm) (follow-up at 18 months for patient 1 2001;7:789–96. and inflamed. Blood values were unre- and 9 months for patient 2, respec- 6. Fournier PE, Marrie TJ, Raoult D. Diagno- markable except for an elevated C- tively). For patient 1, serologic testing sis of Q fever. J Clin Microbiol reactive protein level of 150 mg/L after 1 year of treatment showed an 1998;36:1823–34. (normal<6). A computed tomography IgG antibody titer to phase 1 antigen 7. Swartz MN. Lymphadenitis and lymphan- gitis. In: Mandell GL, Douglas JE, Bennett scan of the chest showed hilar calcifi- of 320. R, editors. Principles and practice of infec- cations and enlarged mediastinal Granulomatous lymphadenitis has tious diseases. Philadelphia: Churchill Liv- lymph nodes. A biopsy of cervical been described during mycobacterial ingstone; 2000. p. 1066–75. lymph nodes indicated granulomatous infections, , cat scratch dis- 8. Ariga T, Nagaoka H, Miyanoshita A, lymphadenitis with foci of necrosis. C. ease, , lymphogranuloma Kusunoki Y, Watanabe T, Shinohara T, et al. lymphadenitis: a pos- burnetii DNA was detected on the venereum, histoplasmosis, coccidio- sible fever focus in acute Q fever. Pediatr lymph nodes with a C. burnetii–spe- idomycosis, and chronic - Int 2000;42:711–4. cific pair of primers that amplified an tous diseases (7). One well- htpAB-associated repetitive element documented case of acute Q fever (6). Results of serologic testing by with necrotic cervical lymphadenitis Address for correspondence: Pierre Tattevin, Clinique des Maladies Infectieuses, CHU indirect (IF) has been recently reported (8); to our Pontchaillou, 35033 Rennes Cedex, France; fax: were positive for C. burnetii with knowledge, granulomatous lymphad- 00 33 2 99282452; e-mail: pierre.tattevin@ immunoglobulin (Ig) G titer enitis has never been reported during chu-rennes.fr to phase 1 and phase 2 antigen of 800 Q fever. In both cases reported here, and 1,600, respectively, and IgM anti- C. burnetii was the likely etiologic body titer to phase 2 antigen of 50. agent, given the results of polymerase A 44-year-old man was admitted chain reaction and serologic studies Has Coxiella to the hospital because of a continuous (patient 1) or the patient’s occupation burnetii (Q fever) low-grade fever of 3 months’ duration. and results of the serologic testing He had worked as a farmer for 15 (patient 2). Moreover, for both, no Been Introduced years and assisted in the birth of sheep other potential cause could be identi- into New Zealand? and cattle. On admission, his body fied, and the response to doxycycline- temperature was 38°C, and right rifampin regimen was favorable. We To the Editor: New Zealand has inguinal lymph nodes were inflamed, suggest that granulomatous lymphad- been an exception to the panglobal measuring 4 x 4 cm. A lymph node enitis be added to the list of atypical distribution of Coxiella burnetii (1), biopsy showed granulomatous lym- presentations of Q fever. the causative organism of Q fever, as phadenitis with stellate abscesses sur- Pierre Tattevin,* Cédric Arvieux,* shown in a 1990–1991 study (2) of rounded by palisading epithelioid 12,556 sheepdogs and 2,181 aborting cells. Serologic testing by indirect IF Mathieu Dupont,* Pascal Guggenbuhl,† cattle, all seronegative for C. burnetii. was positive for C. burnetii with an Alexandre Lemeur,† In 1997, the Rabbit hemorrhagic dis- IgG antibody titer to phase 1 antigen and Christian Michelet* ease virus (RHDV) was illegally of 320. imported from Australia into Central For both patients, results of Ziehl * Hôpital Pontchaillou, Rennes, France; and Otago, New Zealand, for the purpose †Hôpital Sud, Rennes, France staining and Lowenstein (Bio-Rad, of rabbit control. The unknown source Marne-La-Coquette, France) cultures and purity of RHDV, and the potential References of gastric aspirates (x 3) and lymph use of infected rabbits or their organs node specimens were negative for 1. Raoult D, Marrie T. Q fever. Clin Infect Dis 1995;20:489–95. to transport it, meant that C. burnetii mycobaceria, as were the results of 2. Fournier PE, Etienne J, Harle JR, Habib G, could have been coincidentally intro- tuberculin skin tests. Other diseases Raoult D. , a rare but severe duced along with the RHDV-infected were ruled out, including , manifestation of Q fever: report of 8 cases rabbit material. To establish whether and review of the literature. Clin Infect Dis yersiniosis, , and chlamy- this occurred, we examined serum dial infections (by serologic testing) 2001;32:1440–7.

138 Emerging Infectious Diseases • Vol. 9, No. 1, January 2003