39-YEAR-OLD WITH LEGIONELLA MYOCARDITIS

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Myocarditis is an inflammatory condition of the myocardium. Legionella is a known rare infectious cause of myocarditis. Additionally, it has been implicated with pericarditis and prosthetic valve endocarditis. We present a case of a 39-year-old male with legionella pneumonia with myocarditis, acute renal failure, and rhabdomyolysis. CASE PRESENTATION: A 39-year-old male with no known past medical history presented to the emergency department with worsening dyspnea after a viral syndrome for 3 weeks. He was intubated in the emergency department for respiratory failure. Chest x-ray showed multifocal atypical infiltrates. Electrocardiogram significant for diffuse ST depressions. Echocardiogram revealed severe left ventricular systolic dysfunction with ejection fraction of 30% with no valvular abnormalities. Lab analysis revealed hyponatremia, elevated troponins and acute renal failure with rhabdomyolysis requiring hemodialysis. Atypical serology was positive for Legionella which was treated with levofloxacin and azithromycin. SARS-CoV-2 PCR was negative and urine drug screen was negative. He was diagnosed with myocarditis given the legionella culture, elevated troponins, significant for electrocardiogram and echocardiogram findings. DISCUSSION: The first case of Legionella myocarditis was reported in 1981 by Gross [1]. Symptoms of myocarditis can range from a mild flu-like illness to cardiogenic shock or sudden death. Myocarditis is the cause of 12% of sudden deaths in young adults [2]. Diagnosis is typically made clinically with non-diagnostic exams, as endomyocardial biopsy is only used for special circumstances when other testing are non-diagnostic. A literature review of Legionella myocarditis as of 2017 portrayed ten patients with positive Legionella urine antigens, with eight having reduced left ventricular ejection fraction on echocardiogram. Only two of those cases were based on cardiac biopsy [3]. CONCLUSIONS: Extrapulmonary manifestations of Legionella such as myocarditis have been reported even in the absence of overt pneumonia, and most often in immunocompromised patients. Clinicians should be aware of Legionella in the setting of unexplained myocarditis with findings as above. Treatment should be initiated for this reversible cause of myocarditis without delay, resulting in favorable prognosis. REFERENCE #1: Armengol, S., Domingo, C., Messales, E., (1992). Myocarditis: a rare complication during Legionella infection. DOI: 10.1016/0167-5273(92)90276-9 REFERENCE #2: Damasio, A.F, Rodriguez, L., Miranda, L/, Coelho, P., Banazol, N., Colaco, J., Fragata, J. (2014). Fulminant myocarditis caused by Legionella pneumophila: Case report. Revista Portuguesa de Cardiologia. Vol 33, Issue 3. https://doi.org/10.1016/j.repce.2013.09.015 REFERENCE #3: Erdogan, Haluk & Eldem, Halil. (2017). A Patient with Suspected Myocarditis Associated with Legionnaires' Disease: A Case Report and Review of the Literature. Mediterr J Infect Microb Antimicrob. 6. 10.4274/mjima.2017.2. DISCLOSURES: No relevant relationships by James McGee, source=Web Response No relevant relationships by Visala Natarajan, source=Web Response no disclosure on file for Ben Shamian