914: SEPSIS IN THE STREAM: SEVERE LEGIONELLA AND HISTOPLASMA PNEUMONIA ACQUIRED FROM SPRING WATER

Abstract

Introduction: Legionnaires’ disease (LD) and pulmonary histoplasmosis are important causes of community-acquired pneumonia (CAP). Both infections are acquired via inhalation from a myriad of reported contaminated environmental sources. Herein, we present a case of concurrent LD and pulmonary histoplasmosis ultimately linked to contaminated spring water used in a home continuous positive airway pressure (CPAP) device, highlighting the importance of source identification and proper patient education on device maintenance. Description: A 67-year-old male with obstructive sleep apnea (OSA) was admitted to our ICU for acute respiratory distress syndrome (ARDS) requiring endotracheal intubation after one week of dyspnea associated with fevers, vomiting, and diarrhea. Vital signs on arrival were significant for fever of 102.8°F, vasopressor-dependent hypotension, and refractory hypoxemia despite maximal ventilator support. Thoracic CT revealed bilateral multifocal consolidations and urine legionella antigen test was positive, confirming the diagnosis of LD. He was also diagnosed with possible pulmonary histoplasmosis after serum histoplasma antigen resulted positive. Treatment included salvage ARDS supportive measures and broad-spectrum antimicrobials, including levofloxacin and amphotericin B. His ICU course was complicated by a prolonged ventilator wean requiring tracheostomy. Upon further questioning, the patient’s family revealed he used a nearby spring as his primary water source, including in his home CPAP device. He ultimately transitioned to a step-down unit with plans for outpatient pulmonary follow-up on discharge. Discussion: Legionella pneumonia and pulmonary histoplasmosis both represent significant and potentially fatal causes of CAP. Environmental reservoirs remain the primary source of infection and may persist since investigations are often reserved for large outbreaks. Our case highlights a source of both legionella and histoplasmosis not previously reported. It demonstrates the value of taking a thorough history while recognizing non-traditional sources of both infections. It also highlights the importance of emphasizing proper device maintenance. Increased awareness of risk factors for these infections enables earlier diagnosis and treatment and ideally improves outcomes.