58-year-old white male admitted to hospital.

He is a heavy smoker for

many years, but generally healthy prior to illness.

Three day history of:

-Shaking chills

-High fever

-Confusion

-Productive cough with whitish sputum

Two days of:

-Abdominal pain

-Mild diarrhea

-Left lower chest pain, exacerbated by coughing and deep breathing

Examination:

-Moderately ill with confusion

-T104 (high), P84 (normal), RR26 (high), BP155/82 (high)

-HEENT normal

-Lung: bilateral fine rales, increased fremitus, dullness to percussion in

the lower left lung

-Abdomen: mild diffuse tenderness, no hepatomegaly

-Neuro: normal
DDx:

- Legionella disease

-Pneumonia

-Cancer with infection

-HIV with infection

Agents of illness:

-Legionella
*Legionella pneumophillia serogroup 1 (90%)

*Other member of Legionellaceae family (48 species, 70 serogroups)

-Pneumonia
*Bacterial: Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus
influenzae, etc.

*Fungal: Histoplasma capsulatum, Blastomyces, Cryptococcus neoformans, etc.

*Viral: influenza virus, respiratory syncytial virus (RSV), adenovirus

 Lab Tests

*CBC ($19)………sick patient, systemic response

*Chest X-ray ($80)…..check for pneumonia, cancer, lung disease, risk factor

*Arterial blood gases ($30)……check for level of distress, acidosis/alkalosis

*Urine Antigen for Legionella ($40)….L. pneumophillia

*If UA (-), Sputum stain/culture for Bacteria/Fungi ($100)…other pneumonia

*If stain/culture and UA (-), Legionella PCR ($200)….other Legionella

*If (+) for Legionella, Electrolyte/renal func ($20)…kidney failure risk factor

*HIV ($20)…………immunosuppression risk factor

Total: $509
 Lab Results

*Elevated WBC 15,000/cu mm

*Xray: extensive infiltrate left lower lung field, patchy infiltrates in the right

*Gases:

-PO2 58 mmHg (low)

-PCO2 27 mmHg (low)

-pH 7.48 (slightly high)

*UA: no answer, assuming (+)

*Urinalysis: 30-50 rbc (high <4)

*Sputum Gram stain: few polymorphonuclear leukocytes, no organism

*Cultures: pending

*Electrolytes:

-Na 127 mEq/L (low),

-SGOT 52 (low),

-LDH 260 u/L (1.5xnormal)

-Creatinine 0.9 mg/dl (normal)

*HIV: no answer

*Acid Fast Smear and blood culture: (-)

 Legionella Syndromes

Legionnaires' disease: patients usually have fever, chills, confusion, shortness of

breath and a cough, which may be dry or may produce sputum. Some patients also

have muscle aches, headache, tiredness, loss of appetite, nausea, vomiting,

stomach discomfort, and diarrhea. Laboratory tests may show decreased function

of the kidneys. Chest X-rays often show pneumonia.

-Acute respiratory distress syndrome

-Systemic inflammatory response syndrome

-Endocarditis

-Multi-organ failure

-Bacteremia and sepsis

-Death (15-20%)

-Pontiac Fever: mild flu-like symptoms that spontaneously resolve 2-5 days.
 Epidemiology

Legionella species are widespread in nature. Disease may be sporadic or epidemic

and may occur in the community or in hospitals. It can be spread person-to-person.

It mainly affects the elderly and those with compromised immune systems or

lungs.

Legionella organisms can be found in many types of water systems. However, the

bacteria reproduce to high numbers in warm, stagnant water (95-115F), such as

that found in certain plumbing systems and hot water tanks, cooling towers and

evaporative condensers of large air-conditioning systems, and whirlpool spas.

Cases of legionellosis have been identified throughout the United States (8000-

18000 per year) and in several foreign countries. The disease likely occurs

worldwide.
Pathogenesis
How do people contract Legionella?

        The most popular theory is that the organism is aerosolized in water

and people inhale the droplets containing Legionella. However, new

evidence suggests that another way of contracting Legionella is more

common.  "Aspiration" or choking such that secretions in the mouth get

past the choking reflexes and instead of going into the esophagus or

stomach, enter the lung.  The protective choking mechanism is defective

in patients who smoke or have lung disease.  Aspiration now appears to

be the most common mode of transmission.

Once inside a host, incubation may take up to two weeks. Initial

symptoms are flu-like but can become more severe. The disease is

generally not a threat to most healthy individuals.

 Prevention

-Improve the design and maintenance of cooling towers and plumbing

systems to limit the growth and aerosolization of Legionella organisms.

- Prevent additional cases of legionellosis by early recognition and

investigation of outbreaks. Identify the source of disease transmission

and recommend appropriate prevention and control measures, such as

decontamination of the water source.

-Medicate and provide prophylaxis to infected individuals.

 Therapy

Many antibiotics are highly effective against Legionella bacteria (gram

negative bacilli). The most potent are:

- Macrolides (azithromycin)

- Quinolones (ciprofloxacin, levofloxacin, moxifloxacin, gemifloxacin, )

Others include:

- tetracycline, doxycycline, minocycline, trimethoprim- sulfamethoxazole

Keep the patient hydrated and well ventilated