Biopsy-confirmed acute Q fever hepatitis complicating severe alcohol-associated hepatitis: a diagnostic and management challenge

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.