Exposures

The history taken by infectious disease doctors includes some interesting questions. In asking about exposures, it's important to elicit unusual activities that might put someone at risk for rare infections. Recently, I admitted a transfer from an outside hospital of a young woman with progressive subacute shortness of breath. She had initially gone to her regular doctor with dyspnea on exertion, fevers, and generalized weakness. She was diagnosed with community acquired pneumonia and prescribed azithromycin. She did not improve after a week so the physician switched her to levofloxacin. A week after that, she was so winded, she could not go to the bathroom without stopping to rest. She was admitted to the hospital and started on ceftriaxone and fluconazole (for coccidioidomycosis, which is endemic in the area she's from). Lab tests at that time were surprising for elevated liver function tests (AST/ALT in the 200s) and CK elevation to 2000-3000. She was then transferred to Stanford for further workup.

Our initial considerations were infectious and rheumatologic. Because initial treatment for community acquired pneumonia failed, we started entertaining more exotic causes for pulmonary disease. A thorough history revealed that the patient rode horses, delivered cattle, took care of hogs, and hunted wild game. A CT scan showed diffuse ill-defined ground glass opacities. A Coxiella burnetti titer came back positive. We started doxycycline.

Q fever is one of those diseases that is often proposed and theorized and never turns out to be true. But this could be the first case of Q fever I've seen. At this moment, no firm diagnosis has been made, but lung biopsies and microbiological samples are pending.

Separately, I had a different patient whose prior occupation was a big game hunter - moose, coyotes, deer, and bears. It's fun to talk to people who have such diverse and unusual experiences.