Form 0920-1305 Q Fever Case Report

Form Approved
OMB Control No.:0920-1305
Expiration date: xx/xx/xxxx

QID:________
Chronic Q Fever – Enhanced Surveillance
ENROLLMENT/FIRST FORM

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6.

When was this patient first diagnosed with chronic Q fever? ____________ (mm/yyyy)
Patient’s date of birth ______________ (mm/dd/yyyy)
Sex of patient: Male Female Transgender Non-binary Something Else Not specified
State of residence ________
Race: White Black American Indian/Alaska Native Asian Pacific Islander Not specified
Hispanic ethnicity: Yes No Unknown

Acute Q Fever History:
7. Was this patient previously diagnosed with acute Q fever? Yes No Unknown
(If ‘no’ or ‘unknown’, skip to question 8)
a. Date of acute Q fever diagnosis: _____________ (mm/dd/yyyy) or Date Unknown
b. How was initial diagnosis made?
PCR Paired Serology Single serology Other __________________ Unknown
c. Was the patient treated for acute Q fever? Yes No Unknown
i. If yes, what medication(s) were/was used and for what
duration__________________________________________
d. Was treatment completed? Yes No Unknown
8. For female patients: was this patient pregnant at the time of acute Q fever diagnosis?
Yes No Unknown NA
(If ‘no’ or ‘unknown’, skip to question 9)
a. In which trimester did the symptoms begin (if unknown use diagnosis):  1st (weeks 1-12)
 2nd (weeks 13-28)  3rd (weeks 29-42) Unknown
b. Was the patient treated during pregnancy? Yes No Unknown (If ‘no’ or ‘unknown’, skip
to question 8f)
c. At what week gestation did treatment begin? _____ weeks
d. When was treatment discontinued? _______ weeks or Still receiving treatment
e. Was treatment completed? Yes No Unknown
f. What antibiotics were used? Trimethoprim/sulfamethoxazole Other __________
Unknown
g. What was the duration of treatment? ______ weeks
h. Did this patient develop placentitis? Yes No Unknown
i. Did the patient develop any of the following complications of pregnancy (select all that apply):
intrauterine growth restriction (IUGR) stillbirth miscarriage
premature delivery Other→Please specify other complications:
__________________________________
Public reporting burden of this collection of information is estimated to 20 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it
displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS H21-8,
Atlanta, Georgia 30333; ATTN: PRA 0920-1305

QID:________
j.

Where any of the following newborn complications present?
malformations (specify type:__________) hyperbilirubinemia
 kernicterus 
Other→Please specify other complications: _______
k. What was the gestational age at birth? _____________ weeks Unknown
l. What was the weight at birth? ________ lbs. _________ozs. Unknown

Risk Factors:
9. Did this patient have a history of any of the following cardiovascular conditions? (check all that apply):
 Rheumatic heart disease
 Aortic valve stenosis
 Aortic valve prolapse
 Aortic valve regurgitation
 Mitral valve stenosis
 Mitral valve prolapse
 Mitral valve regurgitation
 Pulmonic valve stenosis
 Pulmonic valve prolapse
 Pulmonic valve regurgitation
 Tricuspid valve stenosis
 Tricuspid valve prolapse
 Tricuspid valve regurgitation
 Prosthetic valve
→Which valve was replaced? (check all that apply)
 Aortic
 Mitral
 Pulmonic
 Tricuspid
→Date of most recent replacement: _______________ (mm/dd/yyyy)
→What type of valve replacement did the patient receive?
 Manufactured mechanical valve
 Human Donor valve  Bioprostheticbovine  Bioprosthetic- porcine
→History of >1 valve replacement Yes No Unknown
 Aneurysm
 Vascular graft/stent
 Atrial septal defect
 Patent ductus arteriosus
 Ventricular septal defect
 Tetralogy of Fallot
 Other congenital heart defect →Please specify:_______________________________
 Other heart valve problem →Please specify:______________________________

Clinical Findings:
10. What clinical signs and symptoms has the patient exhibited during the course of their illness? Select all
that apply.
relapsing fever chills weight loss night sweats fatigue  Shortness of breath
hepatosplenomegaly Other __________

QID:________
11. Did this patient have culture negative endocarditis? Yes No Unknown
(If ‘no’ or ‘unknown’, skip to question 12)
a. Please specify affected valve(s) (Check all that apply):
 Aortic valve
 Mitral valve
 Pulmonary valve
 Tricuspid valve
 Unknown or None
b. What imaging technologies were used to diagnose endocarditis (check all that apply)?
 Transthoracic echocardiogram
Transesophageal echocardiogram
PET Scan  CT Scan  MRI
Other __________
c. Was infected valve removed?  Yes No Unknown
(If ‘no’ or ‘unknown’, skip to question 12)
d. If yes, specify date of removal: ___________________ (mm/dd/yyyy)
e. If removed, was the valve tested for presence of Coxiella burnetii?  Yes
No
Unknown
(If ‘no’ or ‘unknown’, skip to question 12)
f. Testing method:  PCR
 IHC
 Culture
 Next-generation sequencing
Unknown
g. Results:  Positive
 Negative
 Results not available
12. Did this patient have a vascular infection (i.e. infection of vascular graft, stent, or aneurysm) caused by
Coxiella burnetii?
 Yes No Unknown
(If ‘no’ or ‘unknown’, skip to question 13)
a. If yes, please specify which type of vascular infection
vascular graft
stent
 aneurysm
 other ____
b. Please specify location of infection: abdominal aorta thoracic aorta
 other ____
c. Specify date of graft/stent placement: ___________________ (mm/dd/yyyy)
 NA
d. Was infected graft/stent removed or aneurysm repaired?  Yes
No
Unknown
(If ‘no’ or ‘unknown’, skip to question 12f)
e. If yes, specify date of removal or repair: ___________________ (mm/dd/yyyy)
f. Was the vascular infection tested for presence of Coxiella burnetii?  Yes
No
Unknown
(If ‘no’ or ‘unknown’, skip to question 13)
g. Testing method:  PCR
 IHC
 Culture
 Next-generation sequencing
Unknown
a. PCR Results:  Positive  Negative
 Results not available
b. IHC Results:  Positive  Negative
 Results not available
c. Culture Results:  Positive
 Negative
 Results not available
d. NGS Results:  Positive
 Negative
 Results not available
13. Did this patient have an osteoarticular infection (e.g. osteomyelitis or spondylodiscitis) caused by
Coxiella burnetii? Yes No Unknown
(If ‘no’ or ‘unknown’, skip to question 14)
a. Please specify location of osteoarticular infection :_________________________________
b. Was this a native joint? Yes No Unknown
c. Was surgical debridement of the diseased tissue and bone performed?  Yes No
Unknown
(If ‘no’ or ‘unknown’, skip to question 14)

QID:________
d. If yes, specify date of most recent debridement: ___________________ (mm/yyyy)
e. During the debridement, was any tissue tested for presence of Coxiella burnetii?  Yes No
Unknown
(If ‘no’ or ‘unknown’, skip to question 14)
f. Testing method:  PCR
 IHC
 Culture
 Next-generation sequencing
Unknown
a. PCR Results:  Positive  Negative
 Results not available
b. IHC Results:  Positive  Negative
 Results not available
c. Culture Results:  Positive
 Negative
 Results not available
d. NGS Results:  Positive
 Negative
 Results not available
14. Did this patient have evidence of granulomatous hepatitis?  Yes No Unknown
(If ‘no’ or ‘unknown’, skip to question 15)
a. Which of the following liver enzymes was elevated? (check all that apply)
Alk Phos
ALT
AST LDH
Bilirubin
b. Was a liver biopsy performed?  Yes No Unknown
(If ‘no’ or ‘unknown’, skip to question 15)
c. Was the biopsy tested for presence of Coxiella burnetii?  Yes No Unknown
(If ‘no’ or ‘unknown’, skip to question 15)
d. Testing method:  PCR IHC  Culture
 Next-generation sequencing Unknown
a. PCR Results:  Positive  Negative
 Results not available
b. IHC Results:  Positive  Negative
 Results not available
c. Culture Results:  Positive
 Negative
 Results not available
d. NGS Results:  Positive
 Negative
 Results not available
15. Did this patient develop lymphadenopathy?  Yes No Unknown
(If ‘no’ or ‘unknown’, skip to question 16)
a. Please specify location of lymphadenopathy(s): (check all that apply)
Cervical
Supraclavicular
 Axillary
 Perihilar
Mediastinal
Mesenteric Inguinal
Popliteal
Other:___________________________________________________
b. Was a lymph node biopsy performed?  Yes No Unknown
(If ‘no’ or ‘unknown’, skip to question 16)
c. Was the biopsy tested for presence of Coxiella burnetii?  Yes No Unknown
(If ‘no’ or ‘unknown’, skip to question 16)
d. Testing method:  PCR
 IHC
 Culture
 Next-generation sequencing
Unknown
a. PCR Results:  Positive  Negative
 Results not available
b. IHC Results:  Positive  Negative
 Results not available
c. Culture Results:  Positive
 Negative
 Results not available
d. NGS Results:  Positive
 Negative
 Results not available
16. Did this patient develop either of the following complications? (check all that apply)
 Psoas abscess
 Cardiac abscess
Empyema or other pulmonary abscess
 Other abscess → please specify location(s):_________________________________________
 Ruptured aneurism
 None of the above
(If none of the above selected, skip to question 17.)
a. Was medical intervention performed?  Yes No Unknown
(If ‘no’ or ‘unknown’, skip to question 17)

QID:________
b. What interventions were performed?  incision and drainage  marsupialization
indwelling drain
Other, specify __________________________________
c. Was any material from the abscess or rupture tested for Coxiella burnetii? Yes No
Unknown
(If ‘no’ or ‘unknown’ skip to question 17.)
d. What was the method used to test material from the abscess?
 PCR  IHC  Culture
Unknown
e. What was the result of testing?  Positive
 Negative
 Results not available

17. Did this patient develop an embolic stroke or infarct? Yes No Unknown
(If ‘no’ or ‘unknown’, skip to question 18.)
a. Please specify location: ___________________________________________________________
b. Date of stroke or infarct occurrence:_____________ (mm/dd/yyyy)
18. Was this patient admitted to the hospital for this illness? Yes No Unknown
(If ‘no’ or ‘unknown’, skip to question 19.)
a. First date of admission: __/__/____ and date of discharge: __/__/____
b. Please provide the number of times the patient was hospitalized at least overnight for
complications of chronic Q fever since the initial chronic Q diagnosis. _____________
19. Which antibiotics did the patient receive? Doxycycline Hydroxychloroquine None Other
________ (please write name of medication)
a. How long has/was the patient on antibiotic therapy? ______(months)
b. Has the patient completed antibiotic therapy? Yes No Unknown
c. Was the patient taken off any antibiotic during treatment due to side effects? Yes No
Unknown ((If ‘no’ or ‘unknown’, skip to question 19e.)
d. If yes which medication (s) were stopped? Doxycycline Hydroxychloroquine Other
________
e. And what were the side effects? nausea vomiting fatigue photosensitivity
 Other:______  Unknown
f. Did the patient develop any of the following side effects or complications from antibiotic
therapy (select all that apply)?
 Nausea/other GI upset
 Retinal damage
QT prolongation
Photosensitivity
irreversible skin pigmentation
Other _______________
 None

20. On average, how frequently were Q fever serologies collected from the patient? Every _____ months
(on average)
a. What was the highest Phase 1 IgG titer value recorded
date _______
b. What was the highest Phase 2 IgG titer value recorded
date _______
c. What was the lowest Phase 1 IgG titer value recorded
date _______
d. What was the lowest Phase 2 IgG titer value recorded
date _______
21. Did the patient die from complications of this illness? Yes No Unknown
(If ‘no’ or ‘unknown’, skip to end of survey.)
a. Date of death: __/__/____
b. Cause of death per death certificate: _____________________________________________