Legionnaire's Disease Research Articles

Aerosol generation in public restrooms.

Aerosolized droplets play a central role in the transmission of various infectious diseases, including Legionnaire's disease, gastroenteritis-causing norovirus, and most recently COVID-19. Respiratory droplets are known to be the most prominent source of transmission for COVID-19; however, alternative routes may exist given the discovery of small numbers of viable viruses in urine and stool samples. Flushing biomatter can lead to the aerosolization of micro-organisms; thus, there is a likelihood that bioaerosols generated in public restrooms may pose a concern for the transmission of COVID-19, especially since these areas are relatively confined, experience heavy foot traffic, and may suffer from inadequate ventilation. To quantify the extent of aerosolization, we measure the size and number of droplets generated by flushing toilets and urinals in a public restroom. The results indicate that the particular designs tested in the study generate a large number of droplets in the size range –, which can reach heights of at least 1.52 m. Covering the toilet reduced aerosol levels but did not eliminate them completely, suggesting that aerosolized droplets escaped through small gaps between the cover and the seat. In addition to consistent increases in aerosol levels immediately after flushing, there was a notable rise in ambient aerosol levels due to the accumulation of droplets from multiple flushes conducted during the tests. This highlights the need for incorporating adequate ventilation in the design and operation of public spaces, which can help prevent aerosol accumulation in high occupancy areas and mitigate the risk of airborne disease transmission.

An outbreak investigation of Legionella non-pneumophila Legionnaires’ disease in Sweden, April to August 2018: Gardening and use of commercial bagged soil associated with infections

In early June 2018, an increase in non-travel-related cases of Legionella non-pneumophila Legionnaires’ disease (LD) was observed in Sweden and a national outbreak investigation was started. Outbreak cases were defined as notified confirmed or probable cases of L. non-pneumophila LD, with symptom onset after 1 April 2018. From April to August 2018, 41 cases were reported, 30 of whom were identified as L. longbeachae. We conducted a case–control study with 27 cases and 182 matched controls. Results from the case–control study indicated that gardening and handling commercial bagged soil, especially dusty dry soil, were associated with disease. L. longbeachae was isolated in soils from cases’ homes or gardens, but joint analysis of soil and human specimens did not identify any genetic clonality. Substantial polyclonality was noted between and within soil samples, which made finding a genetic match between soil and human specimens unlikely. Therefore, whole genome sequencing may be of limited use to confirm a specific soil as a vehicle of transmission for L. longbeachae. Handling soil for residential gardening was associated with disease and the isolation of L. longbeachae in different soils provided further evidence for Legionella non-pneumophila infection from soil.

Immune-Mediated Encephalopathy in the Setting of Legionnaires Disease: A Case Report and Review of the Literature

Background: Legionnaires disease is the systemic manifestation of an infection by the gram-negative bacterium Legionella pneumophila. It most commonly presents with pneumonia, but can also cause extrapulmonary manifestations like cardiac, renal, gastrointestinal as well as neurologic symptoms like encephalopathy. It tends to occur in people who are elderly, immunocompromised and those with impaired respiratory (smokers) or cardiac (advanced heart failure) functions. The Legionella Urinary antigen is commonly used to diagnose Legionella infection. Almost half of the patients diagnosed with Legionnaires disease exhibit neurologic signs and symptoms. These neurologic abnormalities are usually not evident on neuroimaging, laboratory findings, and neuropathology.

Legionella pneumophila as a cause of cavitary lung disease in systemic lupus erythematous

Legionnaire's disease (LD) is most commonly caused by Legionella pneumophila (L. pneumophila). In immunocompromised patients LD can cause necrosis of the lung parenchyma with abscess formation and cavitation. Systemic lupus erythematosus (SLE) is an autoimmune disorder with features of both primary and secondary immunodeficiency. SLE patients often develop pulmonary abnormalities, but rarely develop lung cavitations. We report a case of cavitary pneumonia caused by L. pneumophila in a 64-year-old female patient with SLE. We also highlight reasons why SLE patients are more prone to L. pneumophila infections. The importance of using correct diagnostic methods for recognizing and treating such infections is also discussed, as mistreatment of cavitary lesions in SLE patients with steroid therapy can have fatal outcomes as the infectious process can significantly worsen.

Health after Legionnaires' disease: A description of hospitalizations up to 5 years after Legionella pneumonia.

Background and objectivesResearch on Legionnaires’ Disease (LD) suggests there may be long-term health complications, but data are limited. This study investigated whether Intensive Care Unit (ICU) admission during LD hospitalization may be associated with adverse health outcomes and characterized subsequent discharge diagnoses in patients with LD up to 5 years post-LD.MethodsWe conducted a retrospective case series study with follow up for 5 years among patients hospitalized at a Department of Veterans Affairs (VA) Medical Center between 2005 and 2010 with LD. Data were collected from medical records on health history, LD severity (including ICU admission), and discharge diagnoses for 5 years post-LD or until death. We used ordinal logistic regression to explore associations between ICU admission and hospitalizations post-LD. Frequency counts were used to determine the most prevalent discharge diagnoses in the 5 years post-LD.ResultsFor the 292 patients with laboratory-confirmed LD, those admitted to the ICU during LD hospitalization were more likely to have a greater number of hospitalizations within 5 years compared to non-ICU patients (ORHosp 1.92 CI95% 1.25, 2.95). Fifty-five percent (161/292) had ≥ 1 hospitalization within 5 years post-LD. After accounting for pre-existing diagnosis codes in patients with at least one hospitalization in the 2 years prior to LD (n = 77/161 patients, 47.8%), three of the four most frequent new diagnoses in the 5 years post-LD were non-chronic conditions: acute renal failure (n = 22, 28.6%), acute respiratory failure (n = 17, 22.1%) and unspecified pneumonia (n = 15, 19.5%).ConclusionsOur findings indicate that LD requiring ICU admission is associated with more subsequent hospitalizations, a factor that could contribute to poorer future health for people with severe LD. In addition to chronic conditions prevalent in this study population, we found new diagnoses in the 5-year post-LD period including acute renal failure. With LD incidence increasing, more research is needed to understand conditions and factors that influence long term health after LD.

A Methodology for Classifying Root Causes of Outbreaks of Legionnaires' Disease: Deficiencies in Environmental Control and Water Management.

We piloted a methodology for collecting and interpreting root cause—or environmental deficiency (ED)—information from Legionnaires’ disease (LD) outbreak investigation reports. The methodology included a classification framework to assess common failures observed in the implementation of water management programs (WMPs). We reviewed reports from fourteen CDC-led investigations between 1 January 2015 and 21 June 2019 to identify EDs associated with outbreaks of LD. We developed an abstraction guide to standardize data collection from outbreak reports and define relevant parameters. We categorized each ED according to three criteria: ED type, WMP-deficiency type, and source of deficiency. We calculated the prevalence of EDs among facilities and explored differences between facilities with and without WMPs. A majority of EDs identified (81%) were classified as process failures. Facilities with WMPs (n = 8) had lower prevalence of EDs attributed to plumbed devices (9.1%) and infrastructure design (0%) than facilities without WMPs (n = 6; 33.3% and 24.2%, respectively). About three quarters (72%) of LD cases and 81% of the fatalities in our sample originated at facilities without a WMP. This report highlights the importance of WMPs in preventing and mitigating outbreaks of LD. Building water system process management is a primary obstacle toward limiting the root causes of LD outbreaks. Greater emphasis on the documentation, verification, validation, and continuous program review steps will be important in maximizing the effectiveness of WMPs.

Pneumonia and Other Pulmonary Infections

Pulmonary infections span a wide spectrum, ranging from self-limited to life threatening. Pneumonia refers to infection of lung parenchyma, specifically the alveolar or gas-exchanging portions of the lung. Taken together, pneumonia and influenza rank as the sixth leading cause of death in the United States and the leading infectious cause of death in the United States and the world. Tuberculosis (TB) is a bacterial disease caused by Mycobacterium tuberculosis. TB, historically a leading cause of death worldwide, remains an enormous global public health epidemic in much of the developing world. Rates of coinfection with HIV are high, and HIV increases the morbidity and mortality associated with TB. This review details the pathophysiology, epidemiology, clinical presentation, and treatment of pulmonary infection, including pneumonia, empyema, pulmonary abscess, and tuberculosis (TB). Figures show chest radiographs of reactivation pulmonary tuberculosis, HIV-infected patients with proven culture-confirmed tuberculosis, prominent hilar adenopathy with clear lung fields, and bilateral interstitial changes; and treatment of drug-susceptible pulmonary tuberculosis. Tables list major causes of pulmonary infection, host defence mechanisms against pulmonary infection, initial empirical antibiotic therapy in patients with suspected community-acquired pneumonia, initial antibiotic therapy for community-acquired pneumonia in outpatients, initial antibiotic therapy for community-acquired pneumonia in patients who require hospitalization, antibiotic choices for aspiration pneumonia, pneumonia severity index scoring, and mortality by pneumonia severity index point score. This review contains 2 figures, 9 tables, and 87 references Key words: Pulmonary infections; Pneumonia; Tuberculosis; Lung infection; Mycobacteria; Community-acquired pneumonia; Health care-associated pneumonia; Aspiration pneumonia; Empyema; Legionnaires disease

Pneumonia and Other Pulmonary Infections

Pulmonary infections span a wide spectrum, ranging from self-limited to life threatening. Pneumonia refers to infection of lung parenchyma, specifically the alveolar or gas-exchanging portions of the lung. Taken together, pneumonia and influenza rank as the sixth leading cause of death in the United States and the leading infectious cause of death in the United States and the world. Tuberculosis (TB) is a bacterial disease caused by Mycobacterium tuberculosis. TB, historically a leading cause of death worldwide, remains an enormous global public health epidemic in much of the developing world. Rates of coinfection with HIV are high, and HIV increases the morbidity and mortality associated with TB. This review details the pathophysiology, epidemiology, clinical presentation, and treatment of pulmonary infection, including pneumonia, empyema, pulmonary abscess, and tuberculosis (TB). Figures show chest radiographs of reactivation pulmonary tuberculosis, HIV-infected patients with proven culture-confirmed tuberculosis, prominent hilar adenopathy with clear lung fields, and bilateral interstitial changes; and treatment of drug-susceptible pulmonary tuberculosis. Tables list major causes of pulmonary infection, host defence mechanisms against pulmonary infection, initial empirical antibiotic therapy in patients with suspected community-acquired pneumonia, initial antibiotic therapy for community-acquired pneumonia in outpatients, initial antibiotic therapy for community-acquired pneumonia in patients who require hospitalization, antibiotic choices for aspiration pneumonia, pneumonia severity index scoring, and mortality by pneumonia severity index point score. This review contains 2 figures, 9 tables, and 87 references Key words: Pulmonary infections; Pneumonia; Tuberculosis; Lung infection; Mycobacteria; Community-acquired pneumonia; Health care-associated pneumonia; Aspiration pneumonia; Empyema; Legionnaires disease

The Impact of Storms on Legionella pneumophila in Cooling Tower Water, Implications for Human Health.

At the U.S. Department of Energy’s Savannah River Site (SRS) in Aiken, SC, cooling tower water is routinely monitored for Legionella pneumophila concentrations using a direct fluorescent antibody (DFA) technique. Historically, 25–30 operating SRS cooling towers have varying concentrations of Legionella in all seasons of the year, with patterns that are unpredictable. Legionellosis, or Legionnaires’ disease (LD), is a pneumonia caused by Legionella bacteria that thrive both in man-made water distribution systems and natural surface waters including lakes, streams, and wet soil. Legionnaires’ disease is typically contracted by inhaling L. pneumophila, most often in aerosolized mists that contain the bacteria. At the SRS, L. pneumophila is typically found in cooling towers ranging from non-detectable up to 108 cells/L in cooling tower water systems. Extreme weather conditions contributed to elevations in L. pneumophila to 107–108 cells/L in SRS cooling tower water systems in July–August 2017. L. pneumophila concentrations in Cooling Tower 785-A/2A located in SRS A-Area, stayed in the 108 cells/L range despite biocide addition. During this time, other SRS cooling towers did not demonstrate this L. pneumophila increase. No significant difference was observed in the mean L. pneumophila mean concentrations for the towers (p < 0.05). There was a significant variance observed in the 285-2A/A Tower L. pneumophila results (p < 0.05). Looking to see if we could find “effects” led to model development by analyzing 13 months of water chemistry and microbial data for the main factors influencing the L. pneumophila concentrations in five cooling towers for this year. It indicated chlorine and dissolved oxygen had a significant impact (p < 0.0002) on cooling tower 785A/2A. Thus, while the variation in the log count data for the A-area tower is statistically greater than that of the other four towers, the average of the log count data for the A-Area tower was in line with that of the other towers. It was also observed that the location of 785A/2A and basin resulted in more debris entering the system during storm events. Our results suggest that future analyses should evaluate the impact of environmental conditions and cooling tower design on L. pneumophila water concentrations and human health.

Travel-associated cases of Legionnaires’ disease in the United States, 2015–2016

BackgroundRecent travel is associated with ~20% of reported Legionnaires’ disease (LD) cases worldwide. MethodsWe analyzed LD cases reported to the Centers for Disease Control and Prevention (CDC) during 2015–2016. Travel-associated cases met case criteria for confirmed LD in someone who spent ≥1 night away from home during the 10 days before symptom onset. Most analyses were limited to travel-associated, public accommodation stay (TAPAS) cases. We used reported travel dates to estimate the number of TAPAS cases acquired during travel. ResultsOf 12,200 LD cases reported among U.S. residents, 12.3% were travel-associated; 8.7% were TAPAS. Median patient age for TAPAS cases was 61 years; 64.4% were male; 67.3% were white; 77.9% were non-Hispanic; 96.1% were hospitalized; 4.5% died. Among 887 TAPAS cases involving U.S. destinations, an estimated 29.8% were acquired during travel; 4.28 TAPAS cases were reported, and an estimated 1.10 TAPAS cases were acquired during travel, per 10,000,000 hotel room nights booked. Sixty-eight U.S. TAPAS clusters were detected. ConclusionsWhile acquisition during travel accounted for a relatively small proportion of all LD cases, clusters of TAPAS cases were frequently detected. Prompt notification of these cases to CDC facilitates cluster detection and expedites intervention.

Dual infection: Dengue fever with Legionella pneumonia complicated with acute kidney injury and rhabdomyolysis

Background: Concurrent infection of dengue fever with legionella pneumonia is relatively rare occurrence as there is no case report documented in literatures. Treating dengue fever with bacterial infection has been an emerging challenge for physician. Legionella pneumophila is a common, usually underreported and undiagnosed cause of community acquired pneumonia which can lead to significant morbidity and mortality. We present a case of previously healthy man diagnosed as dengue fever with legionella pneumonia complicated with severe acute respiratory distress syndrome, acute renal failure and rhabdomyolysis. Case Description: A 42 y old gentleman with underlying bronchial asthma presented to emergency department with three days history of fever, nonproductive cough for two d with shortness of breath and chest discomfort. He was febrile, tachypneic and tachycardic. His blood pressure was 150/80 mmHg and saturating at 95% on room air. Crepitations were present on the right lower zone. Reviews of other system unremarkable. His full blood count showed leucopenia with thrombocytopenia. His Urea and creatinine were high. Creatine kinase was tremendously high reaches 34000 U/L indicates rhabdomyolysis. Arterial blood gas showed type 1 respiratory failure. Chest xray revealed consolidation over right basal with right sided pleural effusion. His rapid dengue serology noted NS1 antigen positive and dengue PCR revealed dengue genotype 1. He was placed on mechanical ventilation as respiratory distress worsened with hypoxemia. Empirically intravenous ceftriaxone was given to cover for pneumonia. However, he was rapidly deteriorated into septic shock. Subsequently noted that Legionella pneumophila Urinary Antigen was positive. Thus, azithromycin was prescribed. He has improved dramatically over the next 48 h and became hemodynamically stable. Discussion: Legionnaires disease was diagnosed as the cause of the clinical spectrum described. Acute kidney injury and rhabdomyolysis gradually improved after azithromycin commencement. In this case as the patient had dengue fever with legionella pneumonia, the cause for pleural effusion became a challenging part for physician. Treatment with appropriate fluid resuscitation, antibiotics and various modes of mechanical ventilation in the intensive care unit were successful. Conclusion: The presentation of progressively worsening respiratory distress or sepsis with dengue fever should raise the treating physician's suspicion of concurrent infection to reduce dengue fever associated mortality.

Distribution of Virulence Genes and Sequence-Based Types Among Legionella pneumophila Isolated From the Water Systems of a Tertiary Care Hospital in India

Background: Legionnaires' disease (LD) is a potentially fatal pneumonia predominantly caused by infection due to Legionella pneumophila although more than 50 other Legionella species are described. Water systems contaminated with Legionella spp. are the implicated sources of Legionnaires' disease. In this study, we aimed to assess Legionella contamination in the water sources of a tertiary care hospital and to determine the virulence properties and molecular characteristics of L. pneumophila environmental isolates.Methods: During May 2015 through August 2018, a total of 201 hospital water samples were tested for L. pneumophila by standardized culture procedures; environmental isolates were examined for the presence of two virulence genes: Legionella vir homolog (lvh) and repeats in structural toxin (rtxA) by PCR. The genotyping of isolates was performed by sequence-based typing (SBT) according to the protocol of the European Study Group for Legionella Infections (ESGLI).Results: L. pneumophila was isolated from 38/201 (18.9%) water samples; among the 46 isolates, the lvh locus was present in 45 (97.8%), the rtxA locus was found in 45 (97.8%), and both loci were found in 44 (95.7%) isolates. A total of 23 sequence types (STs) were identified among the 44 isolates (index of discrimination [IOD] of 0.929), and 11/23 (47.8%) STs were new to the ESGLI database.Conclusions: The study results showed genetic diversity in L. pneumophila isolates from the hospital environment along with a high percentage of pathogenicity loci. Besides, certain STs may have an increased ability to cause legionellosis, thus requires specific infection control and prevention strategies whenever identified.

‘Contagion’ Across Disciplines: Five Must-read Books on COVID-19

A book which has received well-deserved acclaim globally, The Pandemic Century tells the story of contagion that has plagued human history through various disease outbreaks leading up to the COVID-19 crisis. By tracing the origin, evolution and responses to infamous pandemics like the Spanish Flu, AIDS, SARS, and Ebola to lesser known scourges like ‘Parrot-fever’ and the Philadelphia Legionnaire's Disease, the book attempts to map a century of human engagement with pandemics, and its consequences for the trying present. A deft narrative technique is used to bring together intensive research and analysis of medical history, culture, politics, the environment, and Vantage: Journal of Thematic Analysis, 2020; 1(2): 166-172 167 contributions of individuals to this history. Since its original publication in 2019, the book has been thrown into limelight in the present situation and has been republished with an updated chapter on the Coronavirus.

Legionella Test Reporting at a Regional Veteran Affairs Medical Center

Abstract Introduction/Objective The appropriate reporting and monitoring of legionella antigen and culture test volumes and results is a veteran affairs quality assurance regulatory requirement. Legionnaires disease incidence has been noted to be increasing in the United States, and it has also been documented that health care facilities are especially high- risk settings for the transmission of Legionella bacteria from the building water systems to the occupants. However, studies of Legionella test epidemiology for non-veteran hospitals is sparse in the literature. To provide perspective, here we report the total legionella antigen and culture tests from quarter 1 2016 to quarter 4 2019 to provide a regional perspective. Methods Quality assurance data on both the total number of Legionella antigen and culture tests and the recorded number of positive cases were reviewed from quarter 1 2016 to quarter 4 2019 and tabulated. This data is collected routinely as per veteran affairs regulatory directives. Results There were a total of 1613 legionella antigen tests and 1287 legionella cultures. None of the Legionella cultures were positive during the study period. Nonetheless, there were 3 positive urinary antigen tests for a total calculated percentage of 0.00002%. Conclusion The presence of positive Legionella antigen tests at a regional veteran affairs medical center indicates that a robust quality assurance program is tremendous benefit to monitoring Legionella at a major medical institution in order to prompt action to prevent hospital-based spread.

Characterization of Legionella pneumophila Populations by Multilocus Variable Number of Tandem Repeats (MLVA) Genotyping from Drinking Water and Biofilm in Hospitals from Different Regions of the West Bank

The West Bank can be considered a high-risk area for Legionnaires’ disease (LD) due to its hot climate, intermittent water supply and roof storage of drinking water. Legionella, mostly L. pneumophila, are responsible for LD, a severe, community-acquired and nosocomial pneumonia. To date, no extensive assessment of Legionella spp and L. pneumophila using cultivation in combination with molecular approaches in the West Bank has been published. Two years of environmental surveillance of Legionella in water and biofilms in the drinking water distribution systems (DWDS) of eight hospitals was carried out; 180 L. pneumophila strains were isolated, mostly from biofilms in DWDS. Most of the isolates were identified as serogroup (Sg) 1 (60%) and 6 (30%), while a minor fraction comprised Sg 8 and 10. Multilocus Variable number of tandem repeats Analysis using 13 loci (MLVA-8(12)) was applied as a high-resolution genotyping method and compared to the standard Sequence Based Typing (SBT). The isolates were genotyped in 27 MLVA-8(12) genotypes (Gt), comprising four MLVA clonal complexes (VACC 1; 2; 5; 11). The major fraction of isolates constituted Sequence Type (ST)1 and ST461. Most of the MLVA-genotypes were highly diverse and often unique. The MLVA-genotype composition showed substantial regional variability. In general, the applied MLVA-method made it possible to reproducibly genotype the isolates, and was consistent with SBT but showed a higher resolution. The advantage of the higher resolution was most evident for the subdivision of the large strain sets of ST1 and ST461; these STs were shown to be highly pneumonia-relevant in a former study. This shows that the resolution by MLVA is advantageous for back-tracking risk sites and for the avoidance of outbreaks of L. pneumophila. Overall, our results provide important insights into the detailed population structure of L. pneumophila, allowing for better risk assessment for DWDS.

Enhancement of Culture of Legionella longbeachae from Respiratory Samples by Use of Immunomagnetic Separation and Antimicrobial Decontamination.

Legionella longbeachae is the commonest Legionella species identified in patients with community-acquired pneumonia in New Zealand. Isolation of the organism on culture is the gold standard for the diagnosis of Legionnaires disease, but it has poor sensitivity (40%) compared with quantitative PCR (qPCR). We have developed a selective decontamination process using glycine, vancomycin, polymyxin, and cycloheximide (GVPC) with immunomagnetic separation (IMS) for culturing L. longbeachae A polyclonal antibody specific for L. longbeachae was produced from New Zealand White rabbits and coupled to tosyl-activated magnetic beads. Stored L. longbeachae qPCR-positive respiratory samples were retrieved from -80°C storage for testing. One portion of test samples was mixed with GVPC and the antibody bead complex, separated, washed, and cultured on modified Wadowsky and Yee agar (MWY) agar. Another portion was exposed to HCl-KCl acidic buffer (pH 2.2) before incubation on MWY agar. qPCR used probes specific for the ITS (internal transcribed spacer) region of the L. longbeachae genome. Cultures were positive in 10/53 (19%) samples after acid wash and 26/53 (49%) after GVPC-IMS (P = 0.001). Growth of contaminants was rare. The mean qPCR threshold cycle values were lower in culture-positive samples after acid wash than in the culture-negative samples (mean, 29.9 versus 34.8; difference, 4.9; 95% confidence interval [CI], ±2.9; P = 0.001) but not after GVPC-IMS (mean, 33.0 versus 34.7; difference, 1.7; 95% CI, ±2.48; P = 0.16). The sensitivity of culture for L. longbeachae in respiratory specimens may be improved by using GVPC-IMS rather than acid wash for decontamination, but this should be confirmed in a prospective study of fresh specimens.

Respiratory Distress in an Adolescent Girl.

1. Bobby Kumar, MD* 2. Katie Meyer, DO* 3. Leon Rosenberg, DO* 4. Alyson Trillo, DO* 5. Ashley Van Putten, DO, PGY3* 1. *Salah Foundation Children’s Hospital, Fort Lauderdale, FL A 17-year-old girl with past medical history of iron deficiency anemia and depression presented with 6 days of fever (maximum temperature of 103.6°F), cough, congestion, and mild shortness of breath. Other symptoms included nonbloody, nonbilious emesis, decreased appetite, diarrhea, chest pain, body aches, and abdominal pain. When her shortness of breath worsened, she presented to the emergency department for evaluation. On presentation, she was febrile, with oral temperature of 103.1°F, tachycardia, and in severe respiratory distress with subcostal and supraclavicular retractions, decreased breath sounds on the bases, and significant crackles on the right side. Initial oxygen saturation was 89% on room air, with improvement to 98% on 2 L/min of oxygen via nasal cannula. Chest radiograph shows extensive right-sided infiltrates as well as a focal patchy infiltrate on the left (Fig 1). Figure 1. Anteroposterior (a) and lateral (b) chest radiographs showing extensive right-sided infiltrates with patchy infiltrates on the left. Due to right upper quadrant abdominal pain and persistent diarrhea, an abdominal ultrasound was performed, which was unremarkable. Initial laboratory testing on admission revealed no elevated white blood cell count, mild microcytic anemia (hemoglobin 11.3 g/dL, mean corpuscular volume 60.6), hyponatremia (sodium 125 mmol/L), hypokalemia (potassium 3.3 mmol/L), elevated aspartate aminotransferase (141 units/L) and alanine aminotransferase (57 units/L), elevated γ -glutamyl transferase (52 units/L), prolonged coagulation studies (prothrombin time 17.7 seconds and partial thromboplastin time 30.0 seconds), minimally elevated lipase (200 units/L), positive toxicology for cannabis, elevated C-reactive protein of 36.6 mg/dL, negative urine pregnancy test, urinalysis with 100 mg/dL of protein, and a specific gravity of 1.024. Screening for sexually transmitted infections was negative. The …

Legionnaires' Disease on the Rise in Switzerland: A Denominator-Based Analysis of National Diagnostic Data, 2007-2016.

The risk of falling ill with Legionnaires’ disease (LD) is suggested to increase, but the global burden of disease is unknown due to a lack of appropriate diagnosis and surveillance systems. In Switzerland, the number of LD cases, captured by the National Notification System for Infectious Diseases, has more than doubled since 2008. This study aims to investigate this increase, contextualizing disease surveillance data with denominator data, which is not routinely available, i.e., the number of tests performed for Legionella spp. We collected the testing data for Legionella spp. of 14 Swiss diagnostic laboratories and calculated the positivity, defined as the proportion of the number of positive tests to the number of tests performed. The number of positive tests increased proportionally to the number of tests performed; hence, the positivity remained stable. However, the cause of the increase in test volume is unclear and has a large impact on the interpretation of the positivity curve. Further, the test outcome was found to be dependent on regional determinants, and the diagnostic method applied. The lack of understanding if and at which stage LD is considered in current case management of pneumonia patients limits the interpretation of observed heterogeneities in incidence or underestimation of LD in Switzerland. The absence of (or non-adherence to) existing guidelines and the heterogeneity in diagnostic testing hampers the comparison of data in the Swiss public health context. Therefore, diagnostic procedures should be harmonised across Switzerland and adherence to national LD management guidelines supported.

UNUSUAL PRESENTATION OF DISSEMINATED LEGIONELLA WITH HYPERTRIGLYCERIDEMIA AND MASSIVE RHABDOMYOLYSIS

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Legionella most commonly presents as pneumonia but can involve multiple organ systems. We present a case of a patient with pneumonia, rhabdomyolysis, renal failure, hypertriglyceridemia, pancreatitis, and cutaneous involvement. CASE PRESENTATION: A 41-year-old black male presented with shortness of breath requiring intubation. Pertinent labs showed elevated white blood cell count, creatinine, and CK. Chest radiograph (fig 1) showed right lower lobe airspace opacity. He was started on broad spectrum antibiotics and admitted to the intensive care unit. Despite aggressive IV fluids, his CK level peaked at 780,000. Kidney function continued to decline, ultimately requiring dialysis. Urine legionella antigen was positive otherwise work up negative. Antibiotics were switched to Levaquin. He was noted to have triglyceride level of 1800, with associated lipase elevation and imaging consistent with pancreatitis. This was managed with fluids and insulin infusion but eventually needed plasma exchange. He also had a 1cm superficial ulcer in the left groin (fig 2) and biopsy revealed a dermal microabscess favoring an underlying infectious process (fig 3). After 2 weeks of levaquin, he clinically improved, however required long-term dialysis. DISCUSSION: Legionella infection typically presents as pneumonia. Rarely, it can present as extra-pulmonary disease involving gastrointestinal, neurological, cardiac, renal, and musculoskeletal systems, and skin and soft tissues. A rare triad of pneumonia, rhabdomyolysis and renal failure has been associated with worse and sometimes fatal outcomes [1]. Our patient’s course is unique as he had severe rhabdomyolysis, renal failure, hypertriglyceridemia, pancreatitis, and cutaneous lesion associated with his legionella infection. To our knowledge this is the first case report of hypertriglyceridemia associated with legionella infection in humans. There have been reports of elevated triglyceride levels in guinea-pigs with legionella [2]. It is likely his pancreatitis was from hypertriglyceridemia, however may be from pancreatic injury due to direct cell infection, toxin release, or cytokine induced inflammation. His skin lesion was very similar to the cutaneous manifestations of legionnaire disease reported in the literature [4]. The biopsy results strongly favored an underlying infectious process and no other infection was identified with tissue stains and culture. Few case reports have described rhabdomyolysis in Legionnaires’ disease. The highest reported CK level was 165,600 [2], our patient peaked at 780,000. The mechanism of action is unclear; direct bacterial invasion into the muscle and the release of endotoxin leading to muscle damage have been postulated [3]. CONCLUSIONS: This case highlights the breath of involvement legionella can have, including the new manifestation of hypertriglyceridemia and severe rhabdomyolysis that has never been reported previously. Reference #1: T. Koufakis, I. Gabranis, M. Chatzopoulou, A. Margaritis, M. Tsiakalou. Severe Legionnaires' disease complicated by rhabdomyolysis and clinically resistant to moxifloxacin in a splenectomised patient: too much of a coincidence? Case Rep. Infect. Dis., 2015 (2015), pp. 1-4 Reference #2: Hambleton P, Bailey NE, Fitzgeorge RB, Baskerville A. Clinical chemical responses to experimental airborne legionellosis in the guinea-pig. Br J Exp Pathol. 1985;66(2):173-183. Reference #3: Johnson DA, Etter HS. Legionnaires' disease with rhabdomyolysis and acute reversible myoglobinuric renal failure. South Med J. 1984;77(6):777-779. doi:10.1097/00007611-198406000-00032 DISCLOSURES: No relevant relationships by Hadi Hatoum, source=Web Response No relevant relationships by Hamel Patel, source=Web Response No relevant relationships by Patrisha Shelley, source=Web Response

RARE ACUTE FIBRINOUS PNEUMONIA ASSOCIATED WITH LEGIONNAIRE’S DISEASE

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Acute fibrinous organizing pneumonia (AFOP) is a newly proposed, rare histological variant of subacute interstitial pneumonia, which can be fatal. This case report describes an uncommon case of AFOP. CASE PRESENTATION: A 79-year-old female presented to the emergency department (ED) with worsening shortness of breath associated with hemoptysis, fever, and chills. Past medical history of remote Stage 1B adenocarcinoma of the lung status post-definitive chemo-radiotherapy, hypertension, coronary artery disease and permanent atrial fibrillation. In ED, the patient was afebrile, tachycardic and tachypneic. Her physical examination was significant for inspiratory crackles and wheezing throughout the lung fields. Laboratory data included a WBC of 9.1 k/µL, hyponatremia (122 mmol/L). A chest CT scan showed areas of airspace opacities in the right upper and left lung base. Legionella pneumophila serogroup 1 antigen was positive, compatible with acute Legionnaires disease. The patient was treated with 8 days of Levofloxacin and discharged home. After 3 weeks, the patient reported minimal improvement of symptoms, persistence of fatigue and shortness of breath with 10 lb weight loss. Repeat CXR displayed consolidative opacities in the upper lobes bilaterally, unchanged from previous imaging. Given the persistent infiltrates, and concern for progression of her known malignancy, a CT-guided biopsy was done. It contained core fragments of lung parenchyma with interstitial fibromyxoid tissue and organizing fibrin; without evidence of granulomas/neoplasm. These findings were consistent with a diagnosis of AFOP. After 1 week of steroids, her CXR highlighted interval resolution of patchy parenchymal opacities and resolution of symptoms. DISCUSSION: AFOP is a rare pathological disease with only a few cases reported in the literature. The exact etiopathogenesis remains unknown and clinical manifestations are usually non-specific. CT findings typically consist of bilateral opacities and areas of consolidation, but a definite diagnosis is made via lung biopsy. Currently, there is no standard therapeutic regimen for AFOP and is under investigation, making it controversial. The small number of case reports have highlighted that patients respond positively with a longer course of corticosteroids and/or immunosuppressive agents(1). Our patient showed marked symptomatic and radio-graphic improvement within 1 week of steroid therapy. As such, shorter courses of prednisone treatments may be considered in the appropriate clinical setting and if associated with side effects & morbidity from steroids. CONCLUSIONS: The diagnosis of AFOB can be very challenging as the clinical picture may mimic other potential etiologies such as inflammatory lung disorders, or malignancy. The mortality rate of untreated AFOB is high and therefore, consideration of this diagnosis in the appropriate clinic context can be potentially lifesaving. Reference #1: Gomes, R., Padrão, E., Dabó, H., Soares Pires, F., Mota, P., Melo, N., Jesus, J. M., Cunha, R., Guimarães, S., Souto Moura, C., & Morais, A. (2016). Acute fibrinous and organizing pneumonia: A report of 13 cases in a tertiary university hospital. Medicine, 95(27), e4073. https://doi.org/10.1097/MD.0000000000004073 DISCLOSURES: No relevant relationships by Sanchit Chawla, source=Web Response No relevant relationships by Anu Suri, source=Web Response