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War Surgery and Medicine

Atypical Pneumonia and Q Fever in Second World War

Atypical Pneumonia and Q Fever in Second World War

Q fever was one of the two new diseases of armies that came to be recognised during the Second World War. In Italy in the winter of 1943–44 there were several epidemics of what was called primary atypical pneumonia, which are now thought to have been Q fever. This was when New Zealanders first experienced it. page 583 In February 1944 there were between 70 and 80 cases admitted to 2 NZ General Hospital at Caserta, 48 of them arising from 7 NZ Anti-Tank Regiment, and sporadic cases from other divisional units then bivouacked 10 miles south of Cassino. Some 30 cases were evacuated to hospital from the Anti-Tank Regiment within two or three days. Most of the cases began in one battery and nearly all came from two batteries. The disease was supposed to be spread by droplet infection, but in an investigation the Consultant Physician 2 NZEF and the RMO of the unit found little to support this contention. The Consultant Physician was inclined to the view that the disease was a virus infection.

The area occupied by the unit was a morass of mud as the result of constant rain, and the men were living in square tents holding four to six men, or else in small bivouac tents. Battery Headquarters was in some Italian farm buildings, but the men had not been living in Italian houses in any numbers and their general health was first class. Cooking was by individual battery arrangements. Sanitary facilities in the area were primitive and unpleasant.

Clinically the sudden onset with severe frontal headache and prostration were the salient features of the outbreak. Another striking feature was that the early stages were characterised by a complete absence of catarrhal symptoms. There was no coryza or sinusitis, and cough was unusual in the first day or two. The cough which developed about the third day never became troublesome or painful; there was little if any sputum, and what there was was clear and mucoid. The patients for the most part were very toxic, but physical signs were scanty throughout the illness. Treatment was only symptomatic, and there was no response to sulphonamide therapy. X-ray examinations, however, revealed typical shadows which were found to persist for some weeks after apparent clinical recovery. The consolidation might be generalised, or merely at the apex or in the region of the interlobar fissure. Often the fan-shaped appearance of the consolidation was characteristic. Increased bronchial markings were also a feature. There was cellular infiltration around the alveoli and a certain amount of intra-alveolar exudation and exfoliation of epithelium.

Turner reported a similar epidemic of 280 cases from the Naples area. During the same year the Germans, who were still in occupation of Greece, had their troubles with primary atypical pneumonia, which was referred to by them as the ‘Balkan Grippe’. Dr Caminopetros of the Pasteur Institute of Greece was able to establish the infective agent in guinea pigs by injection of blood from patients in the acute stage of the illness. Subsequently blood page 584 from these guinea pigs was flown to the United States and investigated at the laboratories of the Commission on Acute Respiratory Diseases at Fort Bragg, North Carolina, and the Rickettsia burneti was isolated.

Epidemics of primary atypical pneumonia recurred in Italy in the winter of 1945 among British and United States troops. Adams, Staveley, Rolleston, Henley and Caughey recorded a study of fifty cases which occurred among New Zealand and British troops in the Caserta and Naples area. Four epidemics of a similar nature, among United States troops in northern Italy, were investigated and the R. burneti was isolated as the infective agent, and by serological tests it was established that at least three-quarters of the cases of atypical pneumonia occurring in the same area were, in fact, cases of Q fever. Details of these epidemics have been published in the American Journal of Hygiene (1946).

In May 1945 an epidemic of primary atypical pneumonia occurred in mid-Atlantic among a group of airmen who had recently been stationed at Grottaglie air base in southern Italy in the Taranto area. These were fully investigated when the airmen arrived at Camp Patrick Henry, Virginia. Epidemiological and etiological studies were made by the Commission on Acute Respiratory Diseases and it was demonstrated that the infective agent was the ‘Balkan Grippe’ type of the R. burneti.