Sporadic cases of Legionnaires' disease in the Netherlands

Legionella pneumophila lung abscess associated with immune suppression

Legionella species are a common cause of community-acquired pneumonia, infrequently complicated by cavitary disease. We describe Legionella pneumophila pneumonia and abscess formation in an immunosuppressed patient receiving corticosteroid therapy for metastatic breast carcinoma. The predisposing role of corticosteroids is discussed and the management of this complication is reviewed.

Rapid diagnosis of Legionnaires' disease using an immunochromatographic assay for Legionella pneumophila serogroup 1 antigen in urine during an outbreak in the Netherlands

A new immunochromatographic assay for rapid qualitative detection of Legionella pneumophila serogroup 1 antigen in urine specimens was used during an outbreak of legionellosis in The Netherlands. The assay seems of the utmost value in providing a rapid diagnosis of Legionnaires' disease in patients with severe community-acquired pneumonia in an outbreak setting.

Comparative study of the clinical presentation of Legionella pneumonia and other community-acquired pneumonias

The aim of this study was to compare the clinical, biological, and radiologic features of presentation in the emergency ward of community-acquired pneumonia (CAP) by Legionella pneumophila (LP) and other community-acquired bacterial pneumonias to help in early diagnosis of CAP by LP. Three hundred ninety-two patients with CAP were studied prospectively in the emergency department of a 600-bed university hospital. Univariate and multivariate analyses were performed to compare epidemiologic and demographic data and clinical, analytical, and radiologic features of presentation in 48 patients with CAP by LP and 125 patients with CAP by other bacterial etiology (68 by Streptococcus pneumoniae, 41 by Chlamydia pneumoniae, 5 by Mycoplasma pneumoniae, 4 by Coxiella burnetii, 3 by Pseudomonas aeruginosa, 2 by Haemophilus influenzae, and 2 by Nocardia species. Univariate analysis showed that CAP by LP was more frequent in middle-aged, male healthy (but alcohol drinking) patients than CAP by other etiology. Moreover, the lack of response to previous beta-lactamic drugs, headache, diarrhea, severe hyponatremia, and elevation in serum creatine kinase (CK) levels on presentation were more frequent in CAP by LP, while cough, expectoration, and thoracic pain were more frequent in CAP by other bacterial etiology. However, multivariate analysis only confirmed these differences with respect to lack of underlying disease, diarrhea, and elevation in the CK level. We conclude that detailed analysis of features of presentation of CAP allows suspicion of Legionnaire's disease in the emergency department. The initiation of antibiotic treatment, including a macrolide, and the performance of rapid diagnostic techniques are mandatory in these cases.

Rifampin resistance of Legionella pneumophila is not increased during therapy for experimental Legionnaires disease: study of rifampin resistance using a guinea pig model of Legionnaires disease

Isolates of Legionella pneumophila serogroup 1, obtained from guinea pigs with experimentally induced Legionnaires disease, were tested for rifampin resistance. Thirteen isolates were from animals treated with rifampin alone, four isolates were from animals treated with saline, and three isolates each were from animals treated with erythromycin or erythromycin plus rifampin; all of these isolates were derived from the same parent strain, F889. Most of the isolates were obtained from rifampin-treated animals that survived infection but had persistence of bacteria in their lungs at necropsy. No differences in rifampin agar dilution MICs were detected for the 23 isolates and parent strain that were tested. None of the 13 isolates from animals treated with rifampin alone had a high number of resistant organisms detected by using a rifampin gradient plate assay. Thirteen isolates plus the parent strain were tested by using a quantitative method of determining resistance frequency. Considerable heterogeneity among isolates was observed, but there was no evidence of increased resistance for any treatment group. The range of rifampin resistance frequencies was 10(-7) to 10(-8). No evidence for rifampin-induced resistance of L. pneumophila was found in this study.

Incidence of Legionella pneumophila infection in tourists: Italy

Legionella pneumophila has frequently been recognised as a cause of infection in tourists. From 1973 to 1987, 117 cases of legionellosis were reported in tourists who spent one or more weeks in Italian summer resorts. 6 (5.1%) patients died. 42 (35.9%) were sporadic cases, and 75 (64.1%) were related to clusters or outbreaks. Among the 117 cases, 63 were reported to the Istituto Superiore di Sanità by the health authorities of other countries. Some travellers became ill while in Italy, others soon after they returned home. All tourists but two had stayed in hotels. L. pneumophila was isolated from the water system of 10 hotels, and in another hotel the same Legionella species was detected by direct immunofluorescence. Persistent and/or recurrent sources of infection seem to be present in some summer resorts on the Adriatic Coast and in the Lake Garda area in northern Italy. Some groups of cases were associated with particular hotels over a period of several months and sometimes years. Investigations have implicated potable water as the likely vehicle and the source of infection for tourists. The need of a greater awareness amongst clinicians that travel is a risk factor for legionellosis, and for better international surveillance and cooperation, is stressed.

A self-limited febrile illness produced in guinea pigs associated with oral administration of Legionella pneumophila

The presumed route of human infection by Legionella pneumophila is inhalation. We investigated possible oral transmission of legionellosis in guinea pigs. Fifty-six guinea pigs (group 1) were given virulent L. pneumophila, serogroup 1, in drinking water. Fifty-nine guinea pigs (group 2) were inoculated with L. pneumophila via gastric intubation. Nineteen guinea pigs (group 3) were given heat-killed L. pneumophila in drinking water. Twenty-four guinea pigs (group 4, positive control) were inoculated intraperitoneally with L. pneumophila. Twenty-seven guinea pigs (group 5, negative control) were either intubated gastrically with phosphate-buffered saline or given drinking water without L. pneumophila. Sixty-six of 115 (57%) of the guinea pigs orally inoculated with viable L. pneumophila (groups 1 and 2) had a temperature greater than or equal to 103 degrees F and 8 of 115 (7%) had diarrhea, compared with 0 of 19 (0%) and 0 of 19 (0%), respectively, in group 3 and 1 of 27 (4%) and 0 of 27 (0%), respectively, in group 5. There were no fatalities in groups 1, 2, 3, and 5 compared with 15 of 24 (63%) in group 4. Groups 1, 2, and 4 consistently showed pneumonitis and splenitis. The pneumonitis of groups 1 and 2 was mild, predominantly interstitial, and mainly composed of macrophages; neither gross nor microscopic evidence of aspiration was seen. In group 1, 4 of 29 (14%) guinea pigs tested seroconverted to L. pneumophila compared with 0 of 7 (0%) in group 3 and 0 of 10 (0%) in group 5. In groups 1 and 2 combined, L. pneumophila was isolated from the lung of 5 of 57 (11%) guinea pigs and spleen of 5 of 47 (11%) guinea pigs compared with 0 of 14 guinea pigs in group 5. We conclude that viable L. pneumophila administered orally produces a self-limited febrile illness in guinea pigs.

Legionella infection with acute renal failure and thrombocytopenia mimicking allograft rejection. A pitfall in post-transplantation diagnosis

A patient is described who developed cavitary Legionella pneumonia 2 weeks after kidney transplantation. The initial pulmonary symptoms were followed by severe thrombocytopenia and acute renal failure. Although acute irreversible graft rejection was suspected, this was not supported by the pathology findings in the resected kidney, which were compatible with tubular damage. We presume that the extrapulmonary symptoms were caused by Legionellosis.

Legionella lung abscess after renal transplantation

Although Legionella infections have been widely reported, the clinical importance of Legionella lung abscess has not been sufficiently emphasised. A renal transplant recipient with a pulmonary abscess due to Legionella pneumophila is presented and 21 other cases from the literature are reviewed. Seven abscesses arose in renal transplant patients. Even though an abscess may develop during treatment, superimposed infection with other micro-organisms appears to be uncommon, and an abscess may be expected to resolve with prolonged appropriate antimicrobial therapy alone. Recognition of lung abscess as a complication of legionella infection will therefore prevent unnecessary operations.

An outbreak of Legionnaires' disease in Sweden: report of sixty-eight cases

From August 27 to September 21, 1979, 58 patients fell ill with Legionnaires' disease (LD) in the town Västerås, Sweden. All patients had been staying in the town some time during 2 weeks preceding their illness, as had 10 LD patients who fell ill from mid-June to mid-August the same year. Clinically, high fever, headache, dizziness and gastrointestinal symptoms were dominating. Respiratory symptoms were moderate, radiologically verified pneumonia was seen in 59 of 64 patients examined. One patient died. The diagnosis was verified by serology, using the IFL method, in all cases. Legionella pneumophila serogroup 1 was isolated from a closed lung biopsy from 3 patients. Isolates of identical strains were made from the cooling tower on the roof of an indoor shopping centre in Västerås, visited by 57 of the patients during the incubation period.

Neurological involvement in legionellosis

A study of the clinical, electrophysiological and biochemical features of 16 patients with legionellosis has been performed. Evidence of central and peripheral nervous system involvement has been found in the majority of patients. This is characterised by confusion out of keeping with the degree of toxic or metabolic upset, signs of anterior midline cerebellar dysfunction, grossly elevated creatinine kinase of skeletal muscle origin, and a subclinical peripheral neuropathy.

Legionnaires' disease among pneumonias in Iowa (FY 1972-1978) II. Epidemiologic and clinical features of 30 sporadic cases of L. pneumophila infection

We reviewed retrospectively the clinical records of 30 cases of sporadic Legionella pneumophila infection that occurred in Iowa between FY 1972 and 1978. Cases occurred throughout the year, most between May and December. Twenty-one male patients and 9 female patients ranging in age from 5-80 years were infected. Half the patients smoked or had an underlying illness; five were receiving corticosteroids or immunosuppressive therapy. Occupations and exposures related to hospitals, construction and travel were common; four patients had been exposed to birds. In addition to L. pneumophila infection, six patients had evidence of infection with a viral, mycoplasmal, bacterial, mycobacterial or fungal pathogen; three had had preceding dental infections. Twenty-seven cases were pneumonias visible on radiographs. Fever, cough, chills, myalgia and rales occurred inover half the cases. Headache, gastrointestinal symptoms and encephalopathy also were seen. Upper respiratory symptoms were uncommon. Urinalysis and blood studies often suggested renal and hepatic involvement, but other routine laboratory diagnostic tests were not helpful. All but two patients were hospitalized; seven required intensive care. The median duration of hospitalization was 12 days. Two patients who did not receive erythromycin or tetracycline therapy died.

Pneumonia due to Legionella pneumophila: the first imported case in Finland

The first imported case of legionnaires' disease in Finland is reported. A 64-year-old woman fell ill 1 day after returning from a holiday in mallorca. Chest film revealed a bronchopneumonic infiltrate; however, the patient had no respiratory symptoms at all during her illness. The course of disease was benign, possibly due to early onset of treatment with erythromycin.

Legionnaires' disease

Described here is a unique case of Legionnaires' disease in a previously healthy 46 year old man in whom disseminated disease was demonstrated in the kidneys, bone marrow, spleen and multiple peripheral lymph nodes at autopsy. The pathologic distribution of the lesions suggests that dissemination occurred by both hematogenous and lymphatic pathways. Pancytopenia associated with bone marrow destruction and fibrosis suggests that substances toxic to hematopoietic cells were present. It is likely that many of the unusual systemic manifestations of this disease are related to dissemination of the bacterium. The findings presented extend the spectrum of the clinical and pathologic manifestations of Legionnaires' disease from a mild and self-limited illness to a severe and fatal disseminated form of the disease.

Legionnaires' disease: case report with special emphasis on electron microscopy and potential risk of infection at autopsy

A case of Legionnaires' disease (LD) is presented in which the diagnosis was made initially by EM and later confirmed by specific immunofluorescence of formalin-fixed, paraffin-embedded lung tissue. The possibility of an infection with Legionella pneumophila during autopsy is suggested by the fact that the pathologist who performed the post-mortem examination developed signs and symptoms of an upper respiratory tract infection 2 weeks afterwards. Approximately 4 weeks after the onset of his illness a significant antibody titre against L. pneumophila was found in his serum, whereas 6 months later the antibody titre was insignificant.