HOLY MOLY! A RARE CASE OF A CAVITARY LESION SECONDARY TO LEGIONELLA PNEUMOPHILA IN AN IMMUNOCOMPETENT PATIENT

Abstract

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Legionella pneumophila has been increasing in prevalence as a cause of community acquired pneumonia, especially in hospitalized patients. It is seen in both immunocompetent and immunocompromised patients. Immunocompromised patients have rare presentations, including lung abscesses and cavitary lesions. However, we present a case in which an immunocompetent patient with legionella pneumophila which was complicated with cavitary lesions and abscess formation. CASE PRESENTATION: A 75-year-old man with no past medical history presents to the emergency department with complaints of shortness of breath and generalized fatigue. The patient was febrile and saturating 91% on 2L nasal cannula. Laboratory testing was remarkable for leukocytosis with a white blood cell count of 14.7, hyponatremia with a sodium of 128, lactic acid of 2.9 and an elevated C-reactive protein of 39.4. Chest x-ray showed consolidation throughout the right lung as well as patchy consolidation in the left perihilar region. The patient was admitted and started on broad spectrum antibiotics. The following day, patient’s respiratory status deteriorated requiring intubation. Computed tomography revealed multifocal pneumonia with cavitation in the superior segment of the right lower lobe and left lower lobe. Legionella urine antigen was later found to be positive. The patient eventually developed acute respiratory distress syndrome requiring lung protective ventilation and prone positioning to help with hypoxia. DISCUSSION: In the case reported here, we had a patient with no findings suggesting immunosuppression, who initially presented with multifocal pneumonia and was later found to be legionella positive. Legionella pneumophila is a frequent cause of ICU admission, resulting in a high morbidity and an important public health problem worldwide. There are many case reports of immunocompromised patients that have rare complications including cavitary lesions and abscesses. This is likely secondary to depression of cell mediated immunity. These patients had poor outcomes, and many patients were diagnosed at the time of autopsy. Therefore, it is thought that early detection be implemented in immunocompromised patients. However, this case report shows that legionella pneumophila complications can be seen in immunocompetent patients as well. CONCLUSIONS: Despite complications of legionella pneumophila seen more common in immunocompromised patients, it should be considered in immunocompetent patients as well, especially those with worsening infiltrates and hypoxia despite broad spectrum antibiotics. Legionella pneumophila should be prophylactically treated in these patients, as it is difficult to isolate legionella in all commercially available tests. Reference #1: Girard, L. and Gregson, D. (2007). Community-Acquired Lung Abscess Caused by Legionella micdadei in a Myeloma Patient Receiving Thalidomide Treatment. Journal of Clinical Microbiology, 45(9), pp.3135-3137. Reference #2: Kumpers, P., Tiede, A., Kirschner, P., Girke, J., Ganser, A. and Peest, D. (2008). Legionnaires' disease in immunocompromised patients: a case report of Legionella longbeachae pneumonia and review of the literature. Journal of Medical Microbiology, 57(3), pp.384-387. Reference #3: Viasus, D., Di Yacovo, S., Garcia-Vidal, C., Verdaguer, R., Manresa, F., Dorca, J., Gudiol, F. and Carratalà, J. (2013). Community-Acquired Legionella pneumophila Pneumonia. Medicine, 92(1), pp.51-60. DISCLOSURES: No relevant relationships by William McGee, source=Web Response No relevant relationships by Peters Okonoboh, source=Web Response No relevant relationships by Kamran Sherwani, source=Web Response No relevant relationships by Quazi Kamran Uddin, source=Web Response