Disclosures: Caitlin Hartsgrove, MD:

Case Description: A patient with history of known atrial septal pouch (ASP) and multiple CVAs/transient ischemic attacks (TIAs) presented to acute care hospital with complaints of diminished right sided sensation, right sided weakness, and difficulty with ambulation. MRI showed acute brainstem infarct, for which the patient received tissue plasminogen activator (tPA) with resolution of symptoms. One month after completing inpatient rehabilitation, the patient again presented to acute care hospital with facial droop and altered mental status. Imaging revealed new bi-hemispheric embolic infarcts. Over the extended hospital course, further history revealed that patient had significant exposure to livestock/ranching in his home country, which he regularly visits. Transesophageal echocardiogram (TEE) revealed known left ASP without thrombus, no vegetations or valvular destruction. Serology was positive for coxiella burnetii IgG and positive coxiella burnetii IgM. The patient was ultimately discharged to acute rehabilitation.

Setting: Acute inpatient rehabilitation

Patient: 74 year-old male with history of multiple embolic cerebrovascular accidents (CVAs) Assessment/

Results: The patient began 18 month course of doxycycline and hydroxychloroquine upon diagnosis of Coxiella burnetii infection. Also, anticoagulation was changed from apixaban to warfarin given CVA while on apixaban at this time. He ultimately underwent surgical ASP closure as well.

Discussion: Given known history of ASP without thrombus found on TEE, Coxiella burnetii was deemed the most likely etiology of repeated CVAs/TIAs. Coxiella burnetii is very rare in the United States, with fewer than 200 cases reported to the Center for Disease Control in 2017. However, the patient had a pertinent social history that would prompt evaluation for zoonotic disease. Unfortunately, it was not until after his third CVA that he was diagnosed.

Conclusion: A thorough social history is important to evaluate for uncommon etiologies of CVA so that treatment can be implemented early in the disease course to prevent future debility.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/multiple-embolic-strokes-secondary-to-chronic-coxiella-burnetii-infection-a-case-report/