Case and discussion by Adam Simons

R2 Boise VAMC

79yo man presented to the VA ER with fever and diarrhea x 3 days.

Diagnosed with gastroenteritis and discharged after supportive care.

Symptoms persisted x 1 week, now with worsening dyspnea.

Found by his S/O shivering and obtunded on edge of his bed.

It is summertime

DM since 1997: A1c = 7.9 CKD: Recent BUN = 35, Cr = 1.89 HTN, HLD Hypothyroid Chronic hip pain BPH: HCV: negative Abd u/s: 2.3cm AAA only Pneumovax 3 years PTA

Smoker @ 3-4 PPD x 30 years q. 1999

Retired glaser No recent travel, lives in a modern

apartment, no pets. No sick contacts Drinks well water Yard work with pesticides

Initial oxygen sat. 70% on room air T 100.3 P 78 BP 123/73 RR 35 Sat 95% NRB Somnolent, oriented to self. General: Diaphoretic, short

sentences. Weak cough. Resp: Diffuse ronchi, decreased BS on

left Remainder of exam normal

ABG 7.49/27/78 (15L NRB) WBC 10.4, Hct 30.7 Na 133, Co2 23, BUN 43, Cr. 2.5 Alb 2.6, Bili 1.4, AlkP 39, AST 415, ALT

265 Lactate 2.2 BNP 594 (0-99) CPK 1159, Myo 778, Trop 0.08 (0.09) UA: clean Sputum: Mixed.

Abdominal U/S• Cholelithiasis. • 1.9 cm hyperechoic lesion in the right lobe of the

liver posteriorly. This may represent a hemangioma. Solitary hyperechoic metastasis cannot be absolutely ruled out. No biliary dilatation.

• Ill-defined linear area of decreased density in the pancreas. Exact etiology is unclear. This may represent a mildly dilated pancreatic duct with debris.

• Minimal ascites.

Thoughts?

Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Chlamydophila pneumoniae Legionella species Mycoplasma pneumoniae viruses: influenza, RSV,

parainfluenza, adenovirus 14

Pt was intubated for impending respiratory failure

Treated with fluids, vancomycin, ceftriaxone, azithromycin and bronchodilator therapy.

Morning after admission, urine was found to be positive for Legionella pneumophila antigen

Legionnaires’ disease is a pulmonary infection caused by various species of Legionella, water borne bacteria. With the advent of more sensitive assays, legionella is increasingly recognized as a common cause of both community-acquired and health-care associated pneumonia.

Diarrhea Fever > 39°C HyponatremiaNeurologic findings including

confusionHepatic dysfunctionHematuria

Key characteristics

Mycoplasma pneumoniae

Legionnaire's disease

Chlamydophilia pneumoniae

Key characteristicsMycoplasma pneumoniae

Legionnaire's disease

Chlamydophilia pneumoniae

Symptoms  Splenomegaly − − −

 Mental confusion

− + −  Relative bradycardia − + −

 Prominent headache

− ± − Laboratory abnormalities

 Meningismus − − −  WBC count ↑/N ↑ N

 Myalgias ± ± ±  Acute thrombocytosis ± − −

 Ear Pain + − ±  Hyponatremia − + −

 Pleuritic pain − ± −  Hypophosphatemia − + −

 Abdominal pain

− + −  ↑ AST/ALT (SGOT/SGPT) − + −

 Diarrhea + + −  ↑ CPK − + −

Signs  ↑ CRP (>30) − + −

 Rash ± − −  ↑ Ferritin (>2 × n) − + −

 Nonexudative pharyngitis

+ − +  ↑ Cold agglutinins (≥1:64) + − −

 Hemoptysis − ± −  Microscopic hematuria − + −

 Wheezing − − + Chest x-ray

 Lobar consolidation

− ± −  Infiltrates PatchyPatchy or consolidation

“Circumscribed” lesions

 Cardiac involvement

±† −‡ −  Bilateral hilar adenopathy − − −

Cunha 2010

Convention of the American Legion, Philadelphia 1976

221 treated, 34 deaths Swine flu? Bacterial pathogen ID

January 18 1977

England 1985: Stafford District Hospital Water Tower: 28 deaths.

Netherlands 1999: Flower Exhibition Humidifier: 32 deaths.

Australia 2000: Aquarium Cooling Tower: 4 deaths

Spain 2001: Hospital cooling tower: 6 deaths

UK 2002: Arts center cooling tower: 7 d.

Urine Ag +

BAL DNA +

Negative

2005-2011: 783 tests sent. 7 positive. (1%)

23,076 cases reported to CDC 1990-2005

3,181 cases reported in 2008.

Neil et al 2008

Neil et al 2008

Cohort study: Ohio1991 data CAP requiring hospitalization 267/100K Extrapolation: 485,000 yearly

nationwide Cohort-wide culture/serology Extrapolated legionellosis rate: 8,000-

18,000 Compared with <4,000 cases reported Mycoplasma pneumoniae (18,700-108,000), Chlamydia pneumoniae (5890-49,700).

Marston et al 1997

Ensure appropriate treatment. Increased surveillance early action 20% of cases are travel associated

• Hotels• Cruise ships• Dispersed cases (long incubation)

Test Advantages Disadvantages

Culture Compare isolatesAll speciesSensitivity 0.8 , Specificity 0.99

Difficult, >5d growthAffected by rx.

Urine Ag Rapid: same daySensitivity 0.74 , Specificity 0.991

only Lp1 (80% of cases)No isolate comparison

Serology Not affected by treatmentSensitivity 0.7-0.8 , Specificity 0.9

Need paired sera5-10% of population has titer 1:≥256

PCR Sputum or NP swab. Fast Not widely availableNot FDA approved

Levofloxacin, moxifloxacin 7-10d Azithromycin, erythromycin 7-10d Adjunct Rifampin (severe illness)

Antibiotics were narrowed to azithromycin and ceftriaxone.

He was extubated on hospital day 5, given 14 day course of oral azithromycin monotherapy.

His diarrhea also resolved

After extubation, further conversation with the patient revealed that he was an avid gardener, and had constructed a system for misting his garden out of PVC pipe.

Sources:1. Mulazimoglu L, Yu VL. Can Legionnaires disease be diagnosed by clinical criteria? A

critical review. Chest. 2001;120(4):1049-1053.  2. Marston BJ, Plouffe JF, File TM, et al. Incidence of community-acquired pneumonia

requiring hospitalization. Results of a population-based active surveillance Study in Ohio. The Community-Based Pneumonia Incidence Study Group. Arch. Intern. Med. 1997;157(15):1709-1718.  

3. Neil K, Berkelman R. Increasing incidence of legionellosis in the United States, 1990-2005: changing epidemiologic trends. Clin. Infect. Dis. 2008;47(5):591-599.  

4. Stout JE, Yu VL. Legionellosis. N. Engl. J. Med. 1997;337(10):682-687.  5. Ng V, Tang P, Fisman DN. Our evolving understanding of legionellosis epidemiology:

learning to count. Clin. Infect. Dis. 2008;47(5):600-602.  6. Cunha BA, Mickail N, Syed U, Strollo S, Laguerre M. Rapid clinical diagnosis of

Legionnaires' disease during the "herald wave" of the swine influenza (H1N1) pandemic: The Legionnaires' disease triad. Heart & Lung: The Journal of Acute and Critical Care. 39(3):249-259.  

7. Shimada T, Noguchi Y, Jackson JL, et al. Systematic review and metaanalysis: urinary antigen tests for Legionellosis. Chest. 2009;136(6):1576-1585.