- Consider acute Coxiella burnetii infection in patients with alcohol-associated hepatitis who have persistent fever and rural livestock or family exposure.
- Liver biopsy can confirm dual pathology by showing alcohol-associated steatohepatitis and fibrin-ring granulomas indicative of Q fever.
- Treat proven Q fever with doxycycline before starting corticosteroids; start steroids only after infection controlled to improve outcomes.
BMJ Case Rep. 2026 Aug 14;19(8):e274550. doi: 10.1136/bcr-2026-274550.
ABSTRACT
We describe the case of a woman in her 40s with heavy alcohol use who presented with jaundice, persistent fever and severe liver dysfunction initially managed as alcohol-associated hepatitis. Despite broad-spectrum antibiotics and negative septic screening, she remained febrile. Further investigation, prompted by rural livestock exposure and recent family exposure to Q fever, revealed acute Coxiella burnetii infection, supported by phase II-predominant Q fever serology, including phase II IgG IFA titre 1:2048, and positive serum/blood PCR. Liver biopsy demonstrated moderate-to-severe alcohol-associated steatohepatitis with numerous fibrin-ring granulomas, confirming dual pathology. Fever resolved after doxycycline was commenced; however, severe hepatic dysfunction persisted. Prednisolone was initiated after doxycycline had started, fever had resolved and no uncontrolled bacterial focus was identified, resulting in marked biochemical improvement and a Lille score of 0.054. This case highlights the challenge of distinguishing infection from sterile inflammation in alcohol-associated hepatitis and emphasises the importance of considering atypical zoonotic infection before immunosuppressive therapy.
PMID:42601077 | DOI:10.1136/bcr-2026-274550
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