{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,14]],"date-time":"2026-08-14T13:29:58Z","timestamp":1786714198423,"version":"build-2736575974"},"reference-count":15,"publisher":"BMJ","issue":"8","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Rep"],"accepted":{"date-parts":[[2026,8,3]]},"published-print":{"date-parts":[[2026,8]]},"abstract":"<jats:p>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.<\/jats:p>","DOI":"10.1136\/bcr-2026-274550","type":"journal-article","created":{"date-parts":[[2026,8,14]],"date-time":"2026-08-14T12:40:11Z","timestamp":1786711211000},"page":"e274550","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Biopsy-confirmed acute Q fever hepatitis complicating severe alcohol-associated hepatitis: a diagnostic and management challenge"],"prefix":"10.1136","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1104-1735","authenticated-orcid":false,"given":"Ali Galalah Mostafa","family":"Ismail","sequence":"first","affiliation":[{"name":"Gastroenterology and Hepatology, Royal Perth Hospital, Perth, Western Australia, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dilini","family":"Gunawardena","sequence":"additional","affiliation":[{"name":"Department of Anatomical Pathology, PathWest Laboratory Medicine Western Australia, Nedlands, Western Australia, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Justin","family":"Chin","sequence":"additional","affiliation":[{"name":"Gastroenterology and Hepatology, Royal Perth Hospital, Perth, Western Australia, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,8,14]]},"reference":[{"key":"2026081405400593000_19.8.e274550.1","doi-asserted-by":"publisher","DOI":"10.1002\/hep.30866"},{"key":"2026081405400593000_19.8.e274550.2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhep.2018.03.018"},{"key":"2026081405400593000_19.8.e274550.3","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa1412278"},{"key":"2026081405400593000_19.8.e274550.4","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhep.2017.06.013"},{"key":"2026081405400593000_19.8.e274550.5","doi-asserted-by":"publisher","DOI":"10.1128\/CMR.12.4.518"},{"key":"2026081405400593000_19.8.e274550.6","doi-asserted-by":"crossref","first-page":"2037","DOI":"10.1016\/j.vaccine.2009.02.007","article-title":"Australia\u2019s national Q fever vaccination program","volume":"27(14)","author":"Gidding","year":"2009","journal-title":"Vaccine"},{"key":"2026081405400593000_19.8.e274550.7","doi-asserted-by":"publisher","DOI":"10.1016\/S1473-3099(05)70052-9"},{"key":"2026081405400593000_19.8.e274550.8","doi-asserted-by":"publisher","DOI":"10.1016\/S0046-8177(80)80105-5"},{"key":"2026081405400593000_19.8.e274550.9","doi-asserted-by":"publisher","DOI":"10.1053\/j.gastro.2011.09.002"},{"key":"2026081405400593000_19.8.e274550.10","doi-asserted-by":"publisher","DOI":"10.14309\/ajg.0000000000002572"},{"key":"2026081405400593000_19.8.e274550.11","doi-asserted-by":"publisher","DOI":"10.1053\/j.gastro.2016.12.019"},{"key":"2026081405400593000_19.8.e274550.12","first-page":"1","article-title":"Diagnosis and management of Q fever--United States, 2013: recommendations from CDC and the Q Fever Working Group","volume":"62","author":"Anderson","year":"2013","journal-title":"MMWR Recomm Rep"},{"key":"2026081405400593000_19.8.e274550.13","doi-asserted-by":"publisher","DOI":"10.1016\/j.cld.2012.03.013"},{"key":"2026081405400593000_19.8.e274550.14","doi-asserted-by":"crossref","first-page":"34","DOI":"10.29328\/journal.acgh.1001036","article-title":"A case of coexistent acute severe alcoholic and Q fever hepatitis: The useful contribution of repeated liver biopsies","volume":"6","author":"Zampaglione","year":"2022","journal-title":"Ann Clin Gastroenterol Hepatol"},{"key":"2026081405400593000_19.8.e274550.15","doi-asserted-by":"publisher","DOI":"10.1016\/S0929-6646(08)60207-7"}],"container-title":["BMJ Case Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bcr-2026-274550","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,14]],"date-time":"2026-08-14T12:40:12Z","timestamp":1786711212000},"score":1,"resource":{"primary":{"URL":"https:\/\/casereports.bmj.com\/lookup\/doi\/10.1136\/bcr-2026-274550"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8]]},"references-count":15,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8,14]]},"published-print":{"date-parts":[[2026,8]]}},"alternative-id":["10.1136\/bcr-2026-274550"],"URL":"https:\/\/doi.org\/10.1136\/bcr-2026-274550","relation":{},"ISSN":["1757-790X"],"issn-type":[{"value":"1757-790X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8]]}}}