Cerebellitis from infection with Coxiella burnettii

Q-fever is a zoonosis caused by the intracellular Coxiella burnettii. There are a number of cases known with neurological complications, such as meningoencephalitis, optic neuritis, polyradiculoneuritis and mononeuropathia multiplex; manifestation as cerebellitis has so far mostly been reported in children.

We describe the case of a 43 year old female patient from the Spessart, one of the two areas where Q-fever was endemic in 2008, who was suffering from severe cerebillitis due to the infection. First Symptoms were ear pains and vertigo, the initial examination showed a spontaneous nystagmus.

Diagnosis of Q-fever was possible through the proof of antibodies from the serum about 20 days after onset of symptoms. Examination of the liquor cerebrospinalis 3 days after admittance to the hospital showed 71 cells/ml, 61 of those where lymphocytes.

Radiological findings, i.e. CMRI stayed without pathological findings during all stages of the infection, including a new examination after almost 2 months. The direct proof of Coxiella-DNA through PCR was not possible, neither were antibodies found in the CSF.

Electrophysiological testing of the brain-stem through acoustically evoked potentials and Orbicularis-oculi reflex was also without pathological results.

Apart from the cerebellitis the patient was as well suffering from hepatitis, which might also have been a side effect of the antibiotic therapy, and an allergic reaction to the drugs administered.

Unlike most other cases of parainfectious cerebellitis, a second hospitalisation of the patient about 2 months after the initial onset and rehabilitation does not indicate a good prognosis; although part of the symptoms in the later stages of the disease were psychosomatic; lab-findings at least did not suggest chronification and the cell – count from the CSF showed only 27 cells/ml.

The case described shows that infection with Coxiella burnettii should be considered a possible cause for cerebellitis, even when there are no other, more common symptoms of the disease; and that this might also be through a parainfectious, auto-immune mechanism, as neither the DNA of, nor antibodies against the agent could be found in the liquor cerebrospinalis. There also was no parallel or former medication of the patient with Lithium, which has been discussed as a possible facilitator for cerebellitis through Q-fever in two other cases.