Casi comunitari (aprile 2003 - aprile 2012)

Legionella pneumophila community-acquired pneumonia (CAP) in a post-splenectomy patient with myelodysplastic syndrome (MDS)

Cunha BA, Hage JE.

Infectious Disease Division, Winthrop-University Hospital, Mineola, New York 11501, USA. bacunha@winthrop.org

Heart Lung. 2012 Sep-Oct;41(5):525-7.

ABSTRACT: Legionnaire's disease is a cause of community-acquired pneumonia (CAP) in normal hosts, but those with impaired cell-mediated immunity (CMI) and T-lymphocyte function are particularly predisposed to Legionella species CAP. Myelodysplastic syndrome (MDS) is a disorder of the elderly that is associated with impaired CMI. Cases of MDS or Legionella species CAP are rare. Splenectomized patients primarily have impaired humoral immunity and B-lymphocyte function, and, to a lesser extent, some decrease in CMI. For this reason, Legionnaire's disease has rarely been reported in splenectomized patients. We believe this to be the first reported case of Legionella pneumophila CAP in an asplenic patient with MDS.

 

Epidemiology of respiratory infections caused by atypical bacteria in two Kenyan refugee camps

Kim C, Nyoka R, Ahmed JA, Winchell JM, Mitchell SL, Kariuki Njenga M, Auko E, Burton W, Breiman RF, Eidex RB.

U.S. Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA. reidex@ke.cdc.gov

J Immigr Minor Health. 2012 Feb;14(1):140-5.

ABSTRACT: Chlamydia pneumoniae, Mycoplasma pneumoniae, and Legionella spp. are common causes of atypical pneumonia; however, data about these atypical pathogens are limited in the refugee setting. Paired nasopharyngeal and oropharyngeal specimens were collected from patients with respiratory illness presenting to healthcare centers in two refugee camps in Kenya. The specimens were tested for C. pneumoniae, M. pneumoniae, and Legionella spp. as well as eight respiratory viruses. Atypical pathogens were detected in 5.5% of the specimens of which 54% were co-infected with at least one of the eight viruses tested. Patients positive for atypical bacteria co-infected with virus were significantly more likely to have severe acute respiratory illness than patients infected with only atypical bacteria (P = 0.04). While the percentage of atypical pathogens identified was lower than expected, we found a significant relationship between atypical bacterial-viral co-infection and severity of disease in this refugee population.

 

Legionella longbeachae serogroup 1 infections linked to potting compost

Lindsay DS, Brown AW, Brown DJ, Pravinkumar SJ, Anderson E, Edwards GF.

Scottish Haemophilus, Legionella, Meningococcus and Pneumococcus Reference Laboratory, Stobhill Hospital, Glasgow G21 3UW, UK. diane.lindsay@ggc.scot.nhs.uk

J Med Microbiol. 2012 Feb;61(Pt 2):218-22.

ABSTRACT: Four cases of legionellosis caused by Legionella longbeachae serogroup (sg) 1 were identified in Scotland from 2008 to 2010. All case patients had exposure to commercially manufactured growing media or potting soils, commonly known as multipurpose compost (MPC), in greenhouse conditions, prior to disease onset. Two patients had been using the same brand of MPC but the clinical isolates were distinct genotypically by amplified fragment length polymorphism (AFLP) analysis. However, an indistinguishable AFLP profile was also found in an environmental isolate from the supply of MPC used by each patient. The third patient was diagnosed by immunofluorescent antibody serology only; however, the MPC to which this patient was exposed contained L. longbeachae sg 1 in large quantities (80000 c.f.u. g(-1)). The fourth patient was L. longbeachae sg 1 culture-positive, but L. longbeachae was not identified from 10 samples of garden composting material. As compost is commonly used, but L. longbeachae infection seemingly rare, further work is required to ascertain (i) the prevalence and predictors of L. longbeachae in compost and (ii) the conditions which facilitate transmission and generate an aerosol of the bacteria. As most cases of legionellosis are diagnosed by urinary antigen that is Legionella pneumophila-specific and does not detect infection with L. longbeachae, patients in cases of community-acquired pneumonia with a history of compost exposure should have serum and respiratory samples sent to a specialist Legionella reference laboratory for analysis.

 

Pneumonia associated with a dental unit waterline

Ricci ML, Fontana S, Pinci F, Fiumana E, Pedna MF, Farolfi P, Sabattini MA, Scaturro M.

Department of Infectious Parasitic and Immune-Mediated Diseases, Istituto Superiore di Sanità, Rome, Italy. marialuisa.ricci@iss.it

Lancet. 2012 Feb 18;379(9816):684.

NO ABSTRACT

 

Wellness centres: an important but overlooked source of Legionnaires disease. Eight years of source investigation in the Netherlands, 1 August 2002 to 1 August 2010

Euser SM, Bruin JP, van der Hoek W, Schop WA, den Boer JW.

Regional Public Health Laboratory Kennemerland, Haarlem, the Netherlands. s.euser@streeklabhaarlem.nl

Euro Surveill. 2012 Feb 23;17(8).

ABSTRACT: Visiting wellness centres is considered safe and relaxing and might provide health benefits for visitors with certain cardiovascular, dermatological or respiratory diseases. On the other hand, wellness centres could pose health risks, especially with respect to Legionnaires’ disease. We investigated the role of wellness centres in the occurrence of Legionnaires’ disease by analysing the data of eight years (2002–2010) of source investigation in the Netherlands. There were 15 wellness centres identified as potential sources of infection for a total of 35 Legionnaires’ disease patients. Twelve of these centres were positive for Legionella spp.: six for Legionella pneumophila, six for non-pneumophila Legionella spp.. Of the 65 positive environmental samples found during the wellness centre investigations, 41 were derived from shower heads. For two centres, the Legionella pneumophila strains in the collected samples had a genotype that was indistinguishable from the patient isolates. These results show that wellness centres are potential sources of Legionnaires’ disease.

 

Legionella longbeachae and endocarditis

Leggieri N, Gouriet F, Thuny F, Habib G, Raoult D, Casalta JP.

Laboratoire de Microbiologie, Centre Hospitalier Universitaire de La Timone, 264 Rue Saint Pierre, 13385 Marseille Cedex 5, France. didier.raoult@gmail.com

Emerg Infect Dis. 2012 Jan;18(1):95-7.

ABSTRACT: We report a case of infectious endocarditis attributable to Legionella longbeachae. L. longbeachae is usually associated with lung infections. It is commonly found in composted waste wood products. L. longbeachae should be regarded as an agent of infectious endocarditis, notably in the context of gardening involving handling of potting soils.

 

Community-acquired versus nosocomial Legionella pneumonia: Lessons learned from an epidemiologic investigation

Cunha BA, Thekkel V, Schoch PE.

Hospital Epidemiologist Chief, Infectious Disease Division, Winthrop-University Hospital, Mineola, NY 11501. bacunha@winthrop.org

Am J Infect Control. 2011 Dec;39(10):901-3

NO ABSTRACT.

 

Legionellosis must be kept in mind in case of pneumonia with lung abscesses in children receiving therapeutic steroids

Heine S, Fuchs A, von Müller L, Krenn T, Nemat S, Graf N, Simon A.

Department of Paediatric Oncology and Haematology, Children's Hospital Medical Centre, University Hospital of Saarland, Kirrberger Straße, Homburg, Saarland, Germany. sabine.heine@uks.eu

Infection. 2011 Oct;39(5):481-4.

ABSTRACT: A 10-year-old boy, who had received recurrent short-course treatments with steroids to control severe autoimmune thrombocytopaenia, developed Legionnaires' disease as community-acquired pneumonia. Legionella pneumophila pneumonia was complicated by an extended abscess of the right inferior lobe, leading to residual lung cavities. Legionellosis must be kept in mind as the differential diagnosis in the case of severe pneumonia and with lung abscesses in children receiving therapeutic steroids. Legionella-specific diagnostic tests (polymerase chain reaction [PCR] in respiratory samples or urine antigen assay) and, also, specific empirical antibiotic combination therapy are required for the early detection and treatment of L. pneumophila pneumonia in childhood.

 

Cluster of travel-associated Legionnaires disease in Lazise, Italy, July to August 2011

Rota M, Scaturro M, Fontana S, Foroni M, Boschetto G, Trentin L, Blengio G, Bandettini G, Buratto T, Caporali M, Napoli C, Ricci M.

National Centre for Epidemiology, Surveillance and Health Promotion, Istituto Superiore di Sanita, Rome, Italy. mariacristina.rota@iss.it

Euro Surveill. 2011 Oct 6;16(40). pii: 19982.

ABSTRACT: Since 18 August 2011, 17 cases of travel-associated Legionnaires' disease have been reported. They were tourists from five European countries who had stayed in five accommodation sites in Lazise, Italy. The dates of symptom onset ranged from 18 July to 25 August 2011. Control measures were implemented and no further cases associated with stays at the sites have been reported after disinfection. Timely notification of any further cases potentially associated with stay in Lazise is recommended.

 

Respiratory failure presenting in H1N1 influenza with Legionnaires disease: two case reports

Iannuzzi M, De Robertis E, Piazza O, Rispoli F, Servillo G, Tufano R.

Dipartimento di Scienze Chirurgiche Anestesiologiche Rianimatorie e dell' Emergenza- Dipartimento di Anestesia e Rianimazione, Facoltà di Medicina e Chirurgia Federico II, Napoli, Italy. michele.iannuzzi@unina.it

J Med Case Reports. 2011 Oct 21;5(1):520.

ABSTRACT: Introduction: Media sensationalism on the H1N1 outbreak may have influenced decisional processes and clinical diagnosis. Case presentation: We report two cases of patients who presented in 2009 with coexisting H1N1 virus and Legionella infections: a 69-year-old Caucasian man and a 71-year-old Caucasian woman. In our cases all the signs and symptoms, including vomiting, progressive respiratory disease leading to respiratory failure, refractory hypoxemia, leukopenia, lymphopenia, thrombocytopenia, and elevated levels of creatine kinase and hepatic aminotransferases, were consistent with critical illness due to 2009 H1N1 virus infection. Other infectious disorders may mimic H1N1 viral infection especially Legionnaires' disease. Because the swine flu H1N1 pandemic occurred in Autumn in Italy, Legionnaires disease was to be highly suspected since the peak incidence usually occurs in early fall. We do think that our immediate suspicion of Legionella infection based on clinical history and X-ray abnormalities was fundamental for a successful resolution. Conclusion: Our two case reports suggest that patients with H1N1 should be screened for Legionella, which is not currently common practice. This is particularly important since the signs and symptoms of both infections are similar.

 

Post-infection immunocomplex glomerulonephritis and Legionnaires' disease in a patient with adult Still's disease during treatment with interleukin 1 receptor antagonist anakinra: a case report

Scholtze D, Varga Z, Imhof A.

Department of Internal Medicine, University Hospital Zürich, Raemistrasse 100, CH-8091 Zürich, Switzerland. dieter.scholtze@gmx.net

J Med Case Reports. 2011 Jul 9;5:299.

ABSTRACT: INTRODUCTION: Legionellosis is a systemic disease that primarily affects the lungs. However, dysfunction in many organ systems, including the kidneys, has also been described. There are only a few reported cases of renal dysfunction in patients with legionellosis. CASE PRESENTATION: A 27-year-old Caucasian woman with known adult Still's disease was admitted to our hospital for community-acquired pneumonia, due to Legionella infection, with acute renal failure. Although her respiratory symptoms responded well to antibiotic treatment, her renal function worsened, with severe proteinuria and edema. A renal biopsy showed extracapillary and endocapillary proliferative glomerulonephritis with accompanying chronic and acute interstitial nephritis. This was consistent with a post-infection immunocomplex glomerulonephritis. After initiation of steroid therapy, her renal function improved. Additionally, therapy with diuretics and an angiotensin-converting enzyme inhibitor was initiated because of persistent proteinuria. Under this treatment regimen, her severe edema and proteinuria disappeared. CONCLUSION: To the best of our knowledge, there is only a handful of reported cases of post-infection glomerulonephritis with a nephrotic syndrome in a patient with legionellosis. Our findings suggest that, in patients with Legionnaires' disease with renal failure, post-infection immunocomplex glomerulonephritis should be considered and steroid therapy may be an effective modality to treat the renal complication.

 

High ferritin and myoglobin level in legionella pneumonia: a case report and review of literature

Karabay O, Tuna N, Ogutlu A, Gozdas HT.

Department of Infectious Diseases and Clinical Microbiology, Sakarya Training and Research Hospital, Turkey. drkarabay@yahoo.com

Indian J Pathol Microbiol. 2011 Apr-Jun;54(2):381-3.

ABSTRACT: Legionella pneumophila is a cause of both community- and hospital-acquired pneumonia and might cause high morbidity and mortality. Therefore, early diagnosis and treatment with appropriate antibiotics is crucial. Many clinical and laboratory abnormalities can be observed in the course of Legionella pneumonia. In this study, we aimed to present simultaneously increased serum ferritin and myoglobin level in a legionella case with reference to the relevant literature.

 

Combined Legionella and Escherichia coli lung infection after a tsunami disaster

Ebisawa K, Yamada N, Okada S, Suzuki Y, Satoh A, Kobayashi M, Morikawa N.

South Miyagi Medical Center, Japan. s.okada@southmiyagi-mc.jp

Intern Med. 2011;50(19):2233-6.

ABSTRACT: Pulmonary infection after a tsunami is often polymicrobial and tends to form chronic pyogenic lung disease, necrotizing pneumonia, and empyemas. We report a combined pulmonary infection of Legionella and multiple antibiotic-resistant Escherichia coli in a previously well 75-year-old woman following immersion in tsunami waters 1 km inland from the Pacific coastline following the Tohoku Region Pacific Coast Earthquake of 2011. She needed drainage several times and the long-term use of multiple antibiotics according to the type of bacteria found and antibiotic susceptibility. We should be mindful of infections caused by multiple pathogens in the environment in Japan as a consequence of a tsunami disaster.

 

Two Legionnaires' disease cases associated with industrial waste water treatment plants: a case report.

Kusnetsov J, Neuvonen LK, Korpio T, Uldum SA, Mentula S, Putus T, Tran Minh NN, Martimo KP.

National Institute for Health and Welfare (THL), Water and Health Unit, P,O,Box 95, FI-70701 Kuopio, Finland. jaana.kusnetsov@thl.fi.

BMC Infect Dis. 2010 Dec 2;10:343.

ABSTRACT: BACKGROUND: Finnish and Swedish waste water systems used by the forest industry were found to be exceptionally heavily contaminated with legionellae in 2005.

CASE PRESENTATION: We report two cases of severe pneumonia in employees working at two separate mills in Finland in 2006. Legionella serological and urinary antigen tests were used to diagnose Legionnaires' disease in the symptomatic employees, who had worked at, or close to, waste water treatment plants. Since the findings indicated a Legionella infection, the waste water and home water systems were studied in more detail. The antibody response and Legionella urinary antigen finding of Case A indicated that the infection had been caused by Legionella pneumophila serogroup 1. Case A had been exposed to legionellae while installing a pump into a post-clarification basin at the waste water treatment plant of mill A. Both the water and sludge in the basin contained high concentrations of Legionella pneumophila serogroup 1, in addition to serogroups 3 and 13. Case B was working 200 meters downwind from a waste water treatment plant, which had an active sludge basin and cooling towers. The antibody response indicated that his disease was due to Legionella pneumophila serogroup 2. The cooling tower was the only site at the waste water treatment plant yielding that serogroup, though water in the active sludge basin yielded abundant growth of Legionella pneumophila serogroup 5 and Legionella rubrilucens. Both workers recovered from the disease.

CONCLUSION: These are the first reported cases of Legionnaires' disease in Finland associated with industrial waste water systems.

 

Case of Legionella pneumonia complicated with pulmonary thromboembolism

Rókusz L.

Military Hospital - State Health Centre 1st Department of Medicine Budapest Hungary.

Acta Microbiol Immunol Hung. 2010 Dec;57(4):401-6.

ABSTRACT: We report a patient with community acquired Legionella pneumonia, complicated with pulmonary embolism. The patient was cured by levofloxacin and anticoagulant therapy. We performed laboratorial control and we excluded the thrombophilia and antiphospholipid syndrome. Our case report draws attention to the possible association between Legionella infection and pulmonary embolism.

 

Outbreak of Legionnaires' disease associated with a supermarket mist machine

Barrabeig I, Rovira A, Garcia M, Oliva JM, Vilamala A, Ferrer MD, Sabrià M, Domínguez A.

Epidemiological Surveillance Unit of Costa Ponent, Department of Health, Generalitat of Catalonia, Barcelona, Spain. ibarrabeig@catsalut.cat

Epidemiol Infect. 2010 Dec;138(12):1823-8.

ABSTRACT: An outbreak of Legionnaires' disease affected 12 customers of a supermarket in a town in Catalonia, Spain, between August and November 2006. An epidemiological and environmental investigation was undertaken. Preliminary investigation showed that all patients had visited the same supermarket in this town where a mist machine was found in the fish section. Water samples were collected from the machine and from the supermarket's water distribution system when high-risk samples were excluded. Environmental samples from the mist machine and clinical samples from two patients tested positive for L. pneumophila serogroup 1 and had the same molecular pattern. The PFGE pattern detected in the clinical and mist-machine isolates had never previously been identified in Catalonia prior to the outbreak and has not been identified since. Four days after turning off the machine, new cases ceased appearing. Molecular study supports the hypothesis that the mist machine from the fish section of the supermarket was the source of infection. We believe it is essential to include exposure to mist machines in any legionellosis epidemiological survey.

 

Legionella pneumophila pneumonia in a pregnant woman treated with anti-TNF-α antibodies for Crohn's disease: a case report

Epping G, van der Valk PD, Hendrix R.

Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, The Netherlands. G.Epping@mst.nl

J Crohns Colitis. 2010 Dec;4(6):687-9.

ABSTRACT: Anti-TNF-α antibodies are widely used. The indications for their usage are still increasing. With their emerging use, their infectious complications are seen more often. We describe the first case of a pneumonia with Legionella pneumophila in a pregnant women with Crohn's disease, during treatment with anti-TNF-α antibodies. She was treated with erythromycin and made a full recovery.

 

Relapsing Legionella pneumophila cellulitis: a case report and review of the literature

Han JH, Nguyen JC, Harada S, Baddour LM, Edelstein PH.

Division of Infectious Diseases, Department of Medicine, University of Pennsylvania School of Medicine, 3400 Spruce St., 3 Silverstein, Ste. E, Philadelphia, PA 19104, USA. jennifer.han@uphs.upenn.edu

J Infect Chemother. 2010 Dec;16(6):439-42.

ABSTRACT: Legionella spp. rarely cause soft tissue infections, with only a few cases reported and usually in the setting of immunocompromise. We report a case of L. pneumophila cellulitis, without pneumonia, in a 65-year-old immunocompromised woman. The patient had a history of interstitial lung disease and idiopathic thrombocytopenic purpura, for which she was receiving high-dose corticosteroids, and had recently experienced an episode of L. pneumophila cellulitis of the lower extremity, which responded to an extended course of levofloxacin. She was initially transferred to this institution for definitive workup of presumed B cell lymphoma and, during her hospital course, suffered a relapse of L. pneumophila-associated cellulitis that responded promptly to azithromycin. More unusual organisms such as Legionella spp. should be considered in the etiology of cellulitis, particularly in the setting of immunocompromise, in cases that are refractory to conventional antibiotics routinely administered for skin and soft tissue infections.

 

Legionnaires' disease and Pontiac fever after using a private outdoor whirlpool spa

Euser SM, Pelgrim M, den Boer JW.

Regional Public Health Laboratory Kennemerland, Haarlem, the Netherlands. s.euser@streeklabhaarlem.nl

Scand J Infect Dis. 2010 Dec;42(11-12):910-6.

ABSTRACT: Pontiac fever and Legionnaires' disease are regarded as clinically and epidemiologically distinct diseases, caused by bacteria of the genus Legionella. Although several outbreaks of either Pontiac fever or Legionnaires' disease have been reported, they are rarely seen simultaneously. In this report we describe such a simultaneous outbreak of Pontiac fever and Legionnaires' disease that occurred in the Netherlands. In August 2009, 1 patient with Legionnaires' disease and 3 patients with Pontiac fever, all from a single family, were reported to the Municipal Health Service. All family members had been exposed to the private whirlpool spa in the garden of their home. A sampling investigation by the Legionella Source Identification Unit (LSIU) showed that a sample from the whirlpool spa, as well as a sample from the garden shower and 2 samples from a garden hose were positive for Legionella pneumophila serogroup 1, and genotyping results indicated the AFLP-type 004 Lyon (ST47) to be present in these samples.

 

Eosinophilic infiltrate in a patient with severe Legionella pneumonia as a levofloxacin-related complication: a case report

Facciolongo N, Menzella F, Castagnetti C, Cavazza A, Piro R, Carbonelli C, Zucchi L.

Department of Pneumology, S, Maria Nuova Hospital, 42123 Reggio Emilia, Italy. nicola.facciolongo@asmn.re.it.

J Med Case Reports. 2010 Nov 11;4:360.

ABSTRACT: INTRODUCTION: Legionella pneumonia can appear with different levels of severity and it can often present with complications such as acute respiratory distress syndrome.

CASE PRESENTATION: We report the case of a 44-year-old Caucasian man with Legionella pneumonia with successive development of severe acute respiratory distress syndrome. During his stay in intensive care the clinical and radiological situation of the previously observed acute respiratory distress syndrome unexpectedly worsened due to acute pulmonary eosinophilic infiltrate of iatrogenic origin.

CONCLUSION: Levofloxacin treatment caused the occurrence of acute eosinophilic infiltrate. Diagnosis was possible following bronchoscopic examination using bronchoaspirate and transbronchial biopsy.

 

Outbreak of Legionnaires' disease in a nursing home, Slovenia, August 2010: preliminary report

Trop Skaza A, Beskovnik L, Storman A, Ursic S, Groboljsek B, Kese D.

Institute of Public Health Celje, Slovenia. alenka.skaza@zzv-ce.si

Euro Surveill. 2010 Sep 30;15(39):19672.

ABSTRACT: We report an outbreak of Legionnaires' disease ina nursing home in Slovenia in August 2010 affecting 15 of 234 residents. To date, Legionnaires' disease has been confirmed in four patients. Further serum analyses and genotyping of isolates are ongoing. The building's water distribution system with dead end sections has been identified as the probable source of infection.

 

Investigation of Pontiac-like illness in office workers during an outbreak of Legionnaires' disease, 2008

Nicolay N, Boland M, Ward M, Hickey L, Collins C, Lynch M, McCarthy M, O'Donnell J.

Health Protection Surveillance Centre, Dublin, Ireland. mairin.boland@gmail.com

Epidemiol Infect. 2010 Nov;138(11):1667-73.

ABSTRACT: In July 2008, office workers in Dublin complained of influenza-like illness preceding and interspersing two cases of notified Legionnaires' disease. Legionella pneumophila serogroup 1 was identified in both cooling towers supplying the office. A retrospective cohort study was undertaken to investigate possible Pontiac fever (PF). Forty-seven employees (23%) met the clinical case definition for PF but confirmatory testing was negative. Exposure to the smoking area situated beside the cooling towers was associated with an increased risk of PF (RR 2.4, 95% CI 1.5-3.8). The diagnosis of PF should be considered when many persons exposed to a possible reservoir of Legionella spp. present with flu-like symptoms. More sensitive microbiological tests would allow better confirmation and more comprehensive reporting of PF. Early detection is vital to prevent potentially severe illness and outbreaks of PF or Legionnaires' disease.

 

Isolation of Legionella rubrilucens from a pneumonia patient co-infected with Legionella pneumophila

Matsui M, Fujii S, Shiroiwa R, Amemura-Maekawa J, Chang B, Kura F, Yamauchi K.

1Medical Corporation Matsui Internal Clinic, Iwate, Japan. kyamauch@iwate-med.ac.jp

J Med Microbiol. 2010 Oct;59(Pt 10):1242-6.

ABSTRACT: We report what we believe to be the first clinical isolation of Legionella rubrilucens from a pneumonia patient co-infected with Legionella pneumophila. L. rubrilucens strains were found in both a patient's sputum and the water of a hot spring in which the patient bathed, and DNA analysis by PFGE showed that they were indistinguishable.

 

A preliminary assessment of the occupational risk of acquiring Legionnaires' disease for people working in telephone manholes, a new workplace environment for Legionella growth

Ricci ML, Fontana S, Bella A, Gaggioli A, Cascella R, Cassone A, Scaturro M; Microbiologists of the Regional Agency for Environmental Protection of Novara.

Department of Infectious, Parasitic, and Immune-Mediated Diseases, Istituto Superiore di Sanità, Rome, Italy. marialuisa.ricci@iss.it

Am J Infect Control. 2010 Sep;38(7):540-5.

ABSTRACT: BACKGROUND: Telephone manholes (TMs) are underground wells, used in Italy by the telecommunication companies to locate telephone networks. Following a fatal case of Legionnaires' disease (LD), acquired during working activity in a TM, we investigated whether Legionella was present in TMs and could be a risk for manhole workers (MWs).

METHODS: Three hundred fifty-three environmental samples were collected from 100 TMs, and serum antibody titer against Legionella pneumophila and Legionella species non-pneumophila was determined from both MWs and control non-manhole workers.

RESULTS: L pneumophila and Legionella species non-pneumophila were detected in 28% of water samples, in 8% of the biofilm, and in 6% of sediment matrices taken in TMs, in a concentration range of 10(2) to 10(4) colony-forming units/L. No Legionella was found in TM air samples. Although there was a statistically significant difference (P = .027) in antibody titer to L pneumophila serogroup 1 (Lp1) between MWs and non-manhole workers, a multivariate logistic regression analysis showed a significant association between antibody against Lp1 and both age group and the practice of aquatic sports.

CONCLUSION: Although further investigations will be performed to quantify the risk of acquiring legionellosis, this preliminary study demonstrates for the first time the presence of Legionella, including human pathogenic species, in a working environment such as TM.

 

Legionellosis outbreak associated with asphalt paving machine, Spain, 2009

Coscollá M, Fenollar J, Escribano I, González-Candelas F.

Universidad de Valencia/Instituto Cavanilles de Biodiversidad y Biologia Evolutiva, Valencia, Spain. mireia.coscolla@uv.es

Emerg Infect Dis. 2010 Sep;16(9):1381-7.

ABSTRACT: From 1999 through 2005 in Alcoi, Spain, incidence of legionellosis was continually high. Over the next 4 years, incidence was lower, but an increase in July 2009 led health authorities to declare an epidemic outbreak. A molecular epidemiology investigation showed that the allelic profiles for all Legionella pneumophila samples from the 2009 outbreak patients were the same, thus pointing to a common genetic origin for their infections, and that they were identical to that of the organism that had caused the previous outbreaks. Spatial-temporal and sequence-based typing analyses indicated a milling machine used in street asphalt repaving and its water tank as the most likely sources. As opposed to other machines used for street cleaning, the responsible milling machine used water from a natural spring. When the operation of this machine was prohibited and cleaning measures were adopted, infections ceased.

 

Windscreen wiper fluid without added screenwash in motor vehicles: a newly identified risk factor for Legionnaires' disease

Wallensten A, Oliver I, Ricketts K, Kafatos G, Stuart JM, Joseph C.

Health Protection Agency, South West, Stonehouse, United Kingdom. anders.wallensten@smi.se

Eur J Epidemiol. 2010 Sep;25(9):661-5.

ABSTRACT: A source of infection is rarely identified for sporadic cases of Legionnaires' disease. We found that professional drivers are five times more commonly represented among community acquired sporadic cases in England and Wales than expected. We therefore investigated possible risk exposures in relation to driving or spending time in a motor vehicle. A case control study including all surviving community acquired sporadic cases in England and Wales with onset between 12 July 2008 and 9 March 2009 was carried out. Cases were contacted by phone and controls were consecutively recruited by sequential digital dialling matched by area code, sex and age group. Those who consented were sent a questionnaire asking questions on driving habits, potential sources in vehicles and known risk factors. The results were analysed using logistic regression. 75 cases and 67 controls were included in the study. Multivariable analysis identified two exposures linked to vehicle use associated with an increased risk of Legionnaires' disease: Driving through industrial areas (OR 7.2, 95%CI 1.5-33.7) and driving or being a passenger in a vehicle with windscreen wiper fluid not containing added screenwash (OR 47.2, 95%CI 3.7-603.6). Not adding screenwash to windscreen wiper fluid is a previously unidentified risk factor and appears to be strongly associated with community acquired sporadic cases of Legionnaires' disease. We estimated that around 20% of community acquired sporadic cases could be attributed to this exposure. A simple recommendation to use screenwash may mitigate transmission of Legionella bacteria to drivers and passengers.

 

Severe Legionnaires disease complicated by multi-organ dysfunction in a previously healthy patient: a case report

Kassha K, Abuanza I, Hadi SA, Hilton R.

Surgical Department, Glan Clwyd Hospital, Rhuddlan Road, Rhyl, LL18 5UJ, UK.

Roy.hilton@cd-tr.wales.nhs.uk

Cases J. 2009 Dec 7;2:9151.

ABSTRACT: A case of a previously healthy lady with community-acquired pneumonia who progressed to severe acute respiratory distress syndrome, acute renal failure, disseminated intravascular coagulation and sepsis is reported. Treatment with antibiotics and various modes of mechanical ventilation in the intensive care unit were successful. A urinary legionella antigen test was positive for Legionella pneumophila.

 

First reported United States case of Legionella pneumophila serogroup 1 pneumonia in a patient receiving anti-tumor necrosis factor-alpha therapy

Jinno S, Pulido S, Pien BC.

University Hospitals of Cleveland Case Medical Center, Cleveland, OH 44118, USA. sadaoj@gmail.com

Hawaii Med J. 2009 Jun;68(5):109-12.

ABSTRACT: Legionellosis has been reported to be an extremely rare disease in Hawai'i. The authors report a case of a 67-year-old woman with a history of rheumatoid arthritis treated with long-term adalimumab who developed severe right-sided community-acquired pneumonia and a parapneumonic effusion. Legionella pneumophila serogroup 1 was confirmed as the microbiologic cause based on a positive urine Legionella antigen as well as direct fluorescent antibody and Legionella culture of bronchoalveolar lavage. This is the first reported case of Legionella pneumonia associated with anti-tumor necrosis factor (TNF)-alpha therapy in the United States. There have been several reports of an increased association between legionellosis and treatment with a TNF-alpha antagonist. With the increasing use of TNF-alpha antagonists, Legionella pneumophila should be recognized as a potential re-emerging pathogen. Clinicians should particularly consider the diagnosis of legionellosis in patients who are immunocompromised, including those who receive anti-TNF-alpha therapy, or who have severe pneumonia. In such cases, there should be a low threshold for including empiric Legionella antimicrobial coverage until the diagnosis can be confirmed or reasonably excluded.

 

Legionnaires' disease cluster linked to a metal product aqueous pre-treatment process, Staffordshire, England, May 2008

Coetzee N, Liu WK, Astbury N, Williams P, Robinson S, Afza M, Duggal HV.

Health Protection Agency, West Midlands North, Stafford, United Kingdom. nic.cortzee@hpa.org.uk

Euro Surveil.2009 Oct 8;14(40). pii: 19348.

In May 2008, a report of two workers from the same construction equipment manufacturing plant who were admitted to hospital with Legionnaires disease confirmed by urine antigen prompted an outbreak investigation. Both cases were middle aged men, smokers, and with no travel, leisure or other common community exposure to Legionella sources. There were no wet cooling towers at the plant or in the surrounding area. No increase in respiratory disease or worker absenteeism occurred at the plant during the preceding month. Wider case ascertainment including alerts to hospitals and medical practitioners yielded no further cases. The environmental investigation (and sampling of water systems for Legionella) identified a Legionella pneumophila serogroup1 (Mab 2b) count of >3.0x10(4)cfu/l in water samples from an aqueous metal pre-treatment tunnel, which generates profuse water aerosol. Drainage, cleaning and biocide treatment using thiazalone eliminated Legionella from the system.

 

Host-related risk factors and clinical features of community-acquired legionnaires disease due to the Paris and Lorraine endemic strains, 1998-2007, France

Ginevra C, Duclos A, Vanhems P, Campèse C, Forey F, Lina G, Che D, Etienne J, Jarraud S.

Faculté Laennec, Université de Lyon, Lyon, France. christophe.ginevra@univ-lyon1.fr

Clin Infect Dis. 2009;49(2):184-91.

ABSTRACT: BACKGROUND: In France, Legionnaires disease is mainly caused by Legionella pneumophila. Here, we investigated possible host factors associated with susceptibility to community-acquired Legionnaires disease caused by the endemic Paris and Lorraine strains. METHODS: We conducted a double-nested exploratory case-control study with use of data from the French national surveillance network of incident Legionnaires disease cases notified from 1998 through 2007. Patients with community-acquired Legionnaires disease and an L. pneumophila serogroup 1 isolate were eligible. Case patients were patients infected by the Paris or Lorraine strain, and control patients were those infected by sporadic strains. Epidemiological and clinical factors associated with infection with the Paris and Lorraine strains were assessed by calculating adjusted odds ratios (aOR) in multivariate logistic regression models. RESULTS: We studied 1090 patients infected by sporadic strains (n = 920), the Paris strain (n = 80), or the Lorraine strain (n = 90). Infection with the Paris strain was significantly associated with female sex (aOR, 1.98; 95% confidence interval [CI], 1.19-3.28), steroid therapy (aOR, 3.16; 95% CI, 1.76-5.68), and a history of cancer or hematologic malignancies (aOR, 2.08; 95% CI, 1.15-3.76). In addition, the mortality rate was higher among patients infected with the Paris strain than in the control group (38% vs. 25.5%). The Lorraine strain was associated with smoking (aOR, 1.82; 95% CI, 1.14-2.91) and reduced mortality (9.9%). . CONCLUSION: Several host characteristics were associated with the risk of infection by endemic strains of L. pneumophila serogroup 1. These findings may help to guide preventive measures. Factors predisposing patients to infection by specific strains need to be explored further.

 

Bathwater-associated cases of legionellosis in Japan, with a special focus on Legionella concentrations in water

Kuroki T, Ishihara T, Ito K, Kura F.

Department of Microbiology, Kanagawa Prefectural Institute of Public Health, Kanagawa 253-0087, Japan. kuroki.gcg3@pref.kanagawa.jp

Jpn J Infect Dis. 2009 May;62(3):201-5.

ABSTRACT: To evaluate the relationship between the incidence of legionellosis and Legionella concentrations in bathwater, we sent a questionnaire to 76 prefectural and municipal public health laboratories in Japan and found that 35 had encountered cases of legionellosis and had implemented investigations to determine the sources of the infections. Based on the results of the questionnaire, we were able to analyze various characteristics of the patients, of the facilities that were thought to be associated with the cases, and of the species and serogroups of the isolates and concentrations of Legionella. Ninety-six cases were included in this study. The median age was 67 years (range, 13-89 years). The most prevalent underlying medical condition among patients was diabetes, and the second most prevalent was high blood pressure. Concentrations of Legionella in bathwater ranged from 10 to 160,000 CFU/100 ml. Ten episodes were selected in which causative strains were found in the suspected source environment, and were then confirmed by pulsed-field gel electrophoresis analysis, enabling us to provide an estimated infectious concentration range of Legionella of 90 to 140,000 CFU/100 ml. It was thus suggested that the current Japanese regulatory safety level for Legionella in bathwater, which is set below the detection limit of culture techniques (10 CFU/100 ml), should be appropriate to prevent bathwater-associated legionellosis. In tandem with the above-mentioned research, a review of literature concerning bathwater-associated legionellosis and typical cases was undertaken.

 

Legionnaires disease in a neonatal unit of a private hospital, Cyprus, December 2008: preliminary outbreak report

Unit for Surveillance and Control of Communicable Diseases.

Medical and Public Health Services, Ministry of Health, Nicosia, Cyprus.

Euro Surveill. 2009 Jan 15;14(2). pii: 19090.

ABSTRACT: We report an outbreak of Legionnaires disease in neonates, affecting 11 newborn babies. The case fatality rate is currently 27%. The outbreak has been confirmed by detection of Legionella pneumophila antigen in eight of the 11 cases. Tests are in progress to determine the source of infection.

 

A Case of Legionella pneumophila Pneumonia Followed by Invasive Aspergillosis

Saijo T, Izumikawa K, Takazono T, Kosai K, Kurihara S, Nakamura S, Imamura Y, Miyazaki T, Seki M, Kakeya H, Yamamoto Y, Yanagihara K, Miyazaki Y, Fukushima K, Kohno S.

Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki 852-8501, Japan. koizumik@nagasaki-u.ac.jp.

Jpn J Infect Dis. 2008 Sep;61(5):379-81.

ABSTRACT: We report a rare case of Legionella pneumophila pneumonia followed by invasive aspergillosis (IA). Legionellosis was ameliorated by the administration of ciprofloxacin, erythromycin, and corticosteroid as adjunctive therapy. Although intravenous administration of the corticosteroid was effective at reducing severe inflammation due to legionellosis, IA occurred at 12 days after admission. Combination therapy with micafungin and voriconazole was effective in this case; however, it remains necessary to exercise caution when making decisions regarding indications for corticosteroid use and observation in the treatment of severe pneumonia patients.

 

A large Legionnaires' disease outbreak in Pamplona, Spain: early detection, rapid control and no case fatality

Castilla J, Barricarte A, Aldaz J, García Cenoz M, Ferrer T, Pelaz C, Pineda S, Baladrón B, Martín I, Goñi B, Aratajo P, Chamorro J, Lameiro F, Torroba L, Dorronsoro I, Martínez-Artola V, Esparza MJ, Gastaminza MA, Fraile P, Aldaz P.

CIBER de Epidemiología y Salud Pública (CIBERESP), Spain.jcastilc@navarra.es

Epidemiol Infect 2008 Jun;136(6):823-32.

SUMMARY: An outbreak of Legionnaire's disease was detected in Pamplona, Spain, on 1 June 2006. Patients with pneumonia were tested to detect Legionella pneumophila antigen in urine (Binax Now; Binax Inc., Scarborough, ME, USA), and all 146 confirmed cases were interviewed. The outbreak was related to district 2 (22 012 inhabitants), where 45% of the cases lived and 50% had visited; 5% lived in neighbouring districts. The highest incidence was found in the resident population of district 2 (3/1000 inhabitants), section 2 (14/1000). All 31 cooling towers of district 2 were analysed. L. pneumophila antigen (Binax Now) was detected in four towers, which were closed on 2 June. Only the strain isolated in a tower situated in section 2 of district 2 matched all five clinical isolates, as assessed by mAb and two genotyping methods, AFLP and PFGE. Eight days after closing the towers, new cases ceased appearing. Early detection and rapid coordinated medical and environmental actions permitted immediate control of the outbreak and probably contributed to the null case fatality.

 

Community-acquired Legionella pneumonia: new insights from the German competence network for community acquired pneumonia

von Baum H, Ewig S, Marre R, Suttorp N, Gonschior S, Welte T, Lück C; Competence Network for Community Acquired Pneumonia Study Group.

Institute for Medical Microbiology and Hygiene, University Hospital of Ulm, Germany. heike.von-baum@uniklinik-ulm.de

Clin Infect Dis 2008 May 1;46(9):1356-64.

ABSTRACT: BACKGROUND: The Competence Network for Community Acquired Pneumonia (CAPNETZ) offers a unique opportunity to study the epidemiology of legionellosis throughout Germany, applying sophisticated diagnostic tools. METHODS: The incidence, clinical characteristics, and outcome of Legionella pneumonia in 2503 adult patients with community-acquired pneumonia, participating in the German Multicenter Study of the CAPNETZ, were studied. RESULTS: Legionella pneumonia was diagnosed in 94 patients (3.8%), thus identifying Legionella species as one of the most common pathogens to cause community-acquired pneumonia. It was equally common among ambulatory and hospitalized patients (3.7% and 3.8%, respectively). The predominant species causing community-acquired pneumonia was Legionella pneumophila; however, 10% of cases were caused by other species not detectable by the urinary antigen test. Patients whose disease was diagnosed by urinary antigen testing experienced a more severe clinical course. Compared with hospitalized patients, ambulatory patients with Legionella pneumonia showed an equal sex distribution, were younger, had fewer comorbidities, fewer cases of discordant initial antimicrobial treatment, and a milder clinical course without fatalities. Thirty percent of patients with Legionella pneumonia received discordant initial antimicrobial treatment without increased mortality. CONCLUSIONS: Legionella is a leading cause of community-acquired pneumonia in Germany. It needs to be considered equally in hospitalized and ambulatory patients. A positive result of a urine antigen test is associated with a more severe clinical course and leads to a potentially relevant underrecognition of species other than L. pneumophila. Legionella pneumonia in outpatients differs significantly from that in hospitalized patients in terms of clinical presentation and outcome. There was an unacceptably high rate of discordant initial antimicrobial treatment.

 

Legionnaires' disease in immunocompromised patients: a case report of Legionella longbeachae pneumonia and review of the literature

Kümpers P, Tiede A, Kirschner P, Girke J, Ganser A, Peest D.

1Department of Internal Medicine, Hannover Medical School, Hannover, Germany. kuempers.philipp@mh-hannover.de

J Med Microbiol 2008 Mar;57(Pt 3):384-7.

ABSTRACT: In addition to Legionella pneumophila, about 20 Legionella species have been documented as human pathogens. The majority of infections by non-pneumophila Legionella species occur in immunocompromised and splenectomized patients. Here, we report a case of 'classical' lobar pneumonia caused by Legionella longbeachae in a splenectomized patient receiving corticosteroids for chronic immune thrombocytopenia. Tests for Legionella antigen were negative. L. longbeachae was immediately detected in bronchoalveolar fluid by PCR and subsequently confirmed by culture on legionella-selective media. The features of Legionnaires' disease in immunocompromised patients with special emphasis on significance and detection of non-pneumophila species are reviewed.

 

Fatal coinfection with Legionella pneumophila serogroup 8 and Aspergillus fumigatus

Guillouzouic A, Bemer P, Gay-Andrieu F, Bretonnière C, Lepelletier D, Mahé PJ, Villers D, Jarraud S, Reynaud A, Corvec S.

Laboratoire de Bactériologie-Hygiène, CHU de Nantes, 44093 Nantes Cedex, France. stephane.corvec@chu-nantes.fr

Diagn Microbiol Infect Dis. 2008 Feb;60(2):193-5.

ABSTRACT: Legionella pneumophila is an important cause of community-acquired and nosocomial pneumonia. We report on a patient who simultaneously developed L. pneumophila serogroup 8 pneumonia and Aspergillus fumigatus lung abscesses. Despite appropriate treatments, Aspergillus disease progressed with metastasis. Coinfections caused by L. pneumophila and A. fumigatus remain exceptional. In apparently immunocompetent patients, corticosteroid therapy is a key risk factor for aspergillosis.

 

Outbreak of Legionnaires' disease in West Fife: Review of environmental guidelines needed

Hyland JM, Hamlet N, Saunders C, Coppola J, Watt J.

Public Health Department, NHS Fife, Cameron House, Cameron Hospital, Windygates KY8 5RG, UK. Jackie.hyland@nhs.net

Public Health. 2008 Jan;122(1):79-83.

ABSTRACT: The objectives of this study were to investigate the source of and outbreak of Legionnaires' disease in West Fife in 2004; to control the spread of legionella from this source; and to make recommendations for future practice based on the findings from the investigation. STUDY DESIGN: Outbreak investigation. METHODS: A multi-agency team investigated links between the cases of legionellosis using detailed interviews, movement mapping, a timeline and extensive environmental sampling. RESULTS: The investigation found evidence that individuals affected by legionella during this outbreak had been in, or near (within 800m), sullage tanks in Rosyth Dockyard within a period of 4 months. CONCLUSIONS: In the absence of laboratory isolation of Legionella spp. from the human cases, it was impossible to state definitely that a previously unrecognized source of environmental legionella aerosolization was responsible for the outbreak. However, strong epidemiological and environmental evidence would support this hypothesis.

 

Restaurant outbreak of Legionnaires' disease associated with a decorative fountain: an environmental and case-control study

O'Loughlin RE, Kightlinger L, Werpy MC, Brown E, Stevens V, Hepper C, Keane T, Benson RF, Fields BS, Moore MR.

Respiratory Diseases Branch, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA. ROLoughlin@cdc.gov

BMC Infect Dis. 2007 Aug 9;7:93.

ABSTRACT: BACKGROUND: From June to November 2005, 18 cases of community-acquired Legionnaires' disease (LD) were reported in Rapid City South Dakota. We conducted epidemiologic and environmental investigations to identify the source of the outbreak. METHODS: We conducted a case-control study that included the first 13 cases and 52 controls randomly selected from emergency department records and matched on underlying illness. We collected information about activities of case-patients and controls during the 14 days before symptom onset. Environmental samples (n = 291) were cultured for Legionella. Clinical and environmental isolates were compared using monoclonal antibody subtyping and sequence based typing (SBT). RESULTS: Case-patients were significantly more likely than controls to have passed through several city areas that contained or were adjacent to areas with cooling towers positive for Legionella. Six of 11 case-patients (matched odds ratio (mOR) 32.7, 95% CI 4.7-infinity) reported eating in Restaurant A versus 0 controls. Legionella pneumophila serogroup 1 was isolated from four clinical specimens: 3 were Benidorm type strains and 1 was a Denver type strain. Legionella were identified from several environmental sites including 24 (56%) of 43 cooling towers tested, but only one site, a small decorative fountain in Restaurant A, contained Benidorm, the outbreak strain. Clinical and environmental Benidorm isolates had identical SBT patterns. CONCLUSION: This is the first time that small fountain without obvious aerosol-generating capability has been implicated as the source of a LD outbreak. Removal of the fountain halted transmission.

  

Investigation of an outbreak of Legionnaires' disease: Hereford, UK 2003

Kirrage D, Reynolds G, Smith GE, Olowokure B; Hereford Legionnaires Outbreak Control Team.

Health Protection Agency, Hereford and Worcestershire Health Protection Unit, Issac Maddox House, Shrub Hill Road, Worcester WR4 9RW, UK. babatunde.olowokure@hpa.org.uk

Respir Med. 2007 Aug;101(8):1639-44.

ABSTRACT: This report describes the investigation and control of a community outbreak of Legionnaires' disease in Hereford, UK, in November 2003. Outbreak investigation consisted of epidemiological survey, identification and environmental investigation of potential sources, microbiological analysis of clinical and environmental samples and mapping the location of potential sources and the movement and residence of cases. Each identified source was allocated a 'composite score' based on different zones of exposure and wind direction. Altogether, 28 cases were identified, with an overall case fatality rate of 7%. All cases had epidemiological links to Hereford city centre. The 'composite score' identified a cluster of cooling towers as being the most likely source of the outbreak. Environmental samples from one of the cooling towers in the cluster and clinical samples from two patients were positive for Legionella pneumophilia serogroup 1 and were indistinguishable by molecular sub-typing. In this outbreak, the use of microbiological, environmental and epidemiological techniques facilitated the rapid identification of a cooling tower as the source of this outbreak. This study illustrates the continuing importance of cooling towers as a source of Legionnaires' disease and the utility of obtaining and comparing both clinical and environmental samples.

 

Legionnaires' disease outbreak associated with a cruise liner, August 2003: epidemiological and microbiological findings

Beyrer K, Lai S, Dreesman J, Lee JV, Joseph C, Harrison T, Surman-Lee S, Lück C, Brodhun B, Buchholz U, Windorfer A.

Governmental Institute of Public Health of Lower Saxony, Hannover, Germany. konrad.beyrer@nlga.niedersachsen.de

Epidemiol Infect. 2007 Jul;135(5):802-10.

ABSTRACT: Eight cases of Legionnaires' disease were identified among the 215 German passengers after a cruise to the Nordic Sea in August 2003. An unmatched case-control study was conducted to identify risk factors and the source of infection. In total, eight passengers fulfilled the case definition, one of these died. Forty-two passengers served as controls. The attack rate was 4%. The mean age was 60 years for cases and 62 years for controls. Prolonged exposure to the spa pool seemed to be a risk factor of infection (OR 4.85, P=0.09). Legionella pneumophila serogroup 1, monoclonal antibody (mAb) subgroup 'Knoxville' was isolated from clinical and environmental samples. DNA sequence-based typing revealed that these isolates were indistinguishable from each other. The investigation showed the importance of an interdisciplinary approach of microbiology and epidemiology as not all sites on the ship that tested positive for L. pneumophila actually posed a relevant risk for the passengers.

 

Legionella jordanis lower respiratory tract infection: case report and review

Vinh DC, Garceau R, Martinez G, Wiebe D, Burdz T, Reimer A, Bernard K.

Department of Medical Microbiology, McGill University Health Centre, Montreal, Quebec, Canada. Kathy_Bernard@phac-aspc.gc.ca

J Clin Microbiol. 2007 Jul;45(7):2321-3.

ABSTRACT: Legionella jordanis was first described in 1982 after isolation from environmental sources and is otherwise a very rare human pathogen. Here, we report the recovery of L. jordanis from a bronchoalveolar lavage specimen from a patient who presented with an indolent lower respiratory tract infection associated with constitutional symptoms. This case is the first culture-positive case of infection involving this species in Canada.

 

Legionnaires' disease among residents of a long-term care facility: the sentinel event in a community outbreak

Phares CR, Russell E, Thigpen MC, Service W, Crist MB, Salyers M, Engel J, Benson RF, Fields B, Moore MR.

Epidemic Intelligence Service Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA. cphares@cdc.gov

Am J Infect Control. 2007 Jun;35(5):319-23.

BACKGROUND: A long-term care facility (LTCF) reported an outbreak of Legionnaires' disease (LD) in September 2004. METHODS: We conducted case finding through enhanced surveillance, medical record review (n = 131), and community surveys (n = 258). We cultured water samples from the LTCF and assayed their outdoor air-intake filters for Legionella DNA. We also investigated a cooling tower, the only nearby outdoor aerosol source. RESULTS: Among 7 confirmed cases, 2 LTCF residents never exited, and 2 community residents never entered the LTCF during the incubation period. Among 63 water and biofilm samples collected from throughout the LTCF, we found no evidence of Legionella colonization, either in the potable water or air-handling systems. Conversely, we isolated a common outbreak-causing strain of Legionella pneumophila serogroup 1 from an industrial cooling tower located 0.4 km from the LTCF and recovered L pneumophila DNA from the LTCF's outdoor air-intake filters, suggesting that aerosolized Legionella from the cooling tower most likely entered the LTCF through the air-intake system or, possibly, through open windows. CONCLUSION: Residents of LTCFs can acquire LD from community sources. A cluster of LD cases among LTCF residents does not necessarily indicate transmission from within the LTCF.

 

Legionella bozemanii, an elusive agent of fatal cavitary pneumonia

Widmer A, Hohl P, Dirnhofer S, Bassetti S, Marsch S, Frei R.

Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, 4031 Basel, Switzerland. awidmer@uhbs.ch

Infection. 2007 Jun;35(3):180-1.

ABSTRACT: A 67-year-old patient died of Legionella bozemanii pneumonia with negative urinary antigen and negative serology. Cystic lesions in pneumonia of unknown origin should lead to the differential diagnosis of L. bozemanii infections.

 

A cluster of Legionella-associated pneumonia cases in a population of military recruits

McDonough EA, Metzgar D, Hansen CJ, Myers CA, Russell KL.

Department of Defence Center for Deployment Health Research, Naval Health Research Center, San Diego, CA 92186-5122, USA. metzgar@nhrc.navy.mil

J Clin Microbiol. 2007 Jun;45(6):2075-7.

ABSTRACT: A Legionella cluster was identified through retrospective PCR analysis of 240 throat swab samples from X-ray-confirmed pneumonia cases. These were identified among young and otherwise healthy U.S. military recruits during population-based surveillance for pneumonia pathogens. Results were confirmed by sequence analysis. Cases clustered tightly, suggesting a local environmental etiology.

 

Severe sepsis and acute respiratory distress syndrome from community-acquired legionella pneumonia: case report

Demello D, Kierol-Andrews L, Scalise PJ.

University of Connecticut in Farmington, CT, USA. landrews02@snet.net

Am J Crit Care. 2007 May;16(3):320, 317.

ABSTRACT: A case of a young man with community-acquired pneumonia, severe acute respiratory distress syndrome, and sepsis is reported. Treatment with antibiotics and various modes of mechanical ventilation in the intensive care unit were unsuccessful. A urinary legionella antigen test was positive for Legionella pneumophila

 

Community outbreak of Legionnaires disease in Vic-Gurb, Spain in October and November 2005

Sala MR, Arias C, Oliva JM, Pedrol A, Roura P, Domínguez A.

Epidemiological Surveillance Unit of the Central Region, Health Department of the Generalitat de Catalunya, Terrassa, Spain. rsala@sapcll.scs.es

Euro Surveill. 2007 Mar 1;12(3):223.

ABSTRACT: This paper reports the investigation of a community-acquired outbreak of Legionnaires' disease in the municipalities of Vic and Gurb (Central Region of Catalonia, Spain). There were 55 cases reported in October and November 2005. An epidemiological and environmental investigation was undertaken. Thirty-five case patients (64%) lived in Vic or Gurb, while 36% had visited or worked in Vic or Gurb during the 10 days before onset of symptoms, but no commonly frequented building could be identified. Water probes for culture were obtained from 30 cooling towers. In five cooling towers of two industrial settings in Gurb (plants A and B), Legionella pneumophila (Lp) serogroup 1 was present. Two Lp-1 strains were recovered from cooling towers in plants A and B. The Lp-1 strain from plant A showed a PGFE profile identical with those obtained from three patients. The exposure to Legionella pneumophila apparently occurred in a large area, since 43 of the 55 cases lived, visited or worked within a distance of 1,800 m from plant A, and six cases in a distance between 2,500 and 3,400 m. The inspections of cooling towers in plant A revealed inadequate disinfectant doses of biocide, non-existent maintenance records on weekends and wrong sample points for routine microbial check-ups. Weather conditions in October 2005 template temperature and high humidity (wind conditions are unappreciable) could have been favourable factors in this outbreak together with the flat terrain of Gurb and Vic area, explaining the extensive horizontal airborne dissemination of contaminated aerosols. The outbreak could have been prevented by proper and correct maintenance of the cooling tower at plant A.

 

Sporadic and epidemic community legionellosis: two faces of the same illness

Sopena N, Force L, Pedro-Botet ML, Barrufet P, Sauca G, García-Núñez M, Tolchinsky G, Capdevila JA, Sabrià M.

Infectious Diseases Unit, Germans Trias i Pujol University Hospital, Badalona, Spain.

nsopena.germanstrias@gencat.net

Eur Respir J. 2007 Jan;29(1):138-42.

ABSTRACT: The present study compares the risk factors, presentation and outcome of community-acquired Legionella pneumophila pneumonia in 138 sporadic-case patients (1994-2004) and 113 outbreak-case patients (2002) treated in two hospitals in Catalonia (Spain) since urinary antigen assays were adopted. Univariate and multivariate analysis were performed to compare epidemiological and clinical features, blood chemistry values, radiological findings and outcome of sporadic and epidemic legionnaires' disease. Univariate analysis showed that male sex, chronic lung disease, HIV infection and immunosuppressive therapy prevailed in sporadic cases. Presentation with respiratory symptoms, confusion and blood chemistry alterations, such as hyponatraemia, aspartate aminotransferase and blood urea nitrogen elevation, and partial pressure of oxygen P(O)(2) <7.98 KPa (60 mmHg) were also more frequent in sporadic cases, while headache prevailed in outbreak cases. Sporadic cases had a greater delay in treatment, were more severe and had a worse outcome than epidemic cases. Multivariate analysis showed significant differences in sex, chronic lung disease, HIV infection and headache. The clinical and outcome differences between the two groups may be explained by the detection of milder forms of legionnaires' disease, the earlier treatment and the lower severity of underlying disease in the outbreak cases.

 

Clinical characteristics of 8 sporadic cases of community-acquired Legionella pneumonia in advanced age

Sugihara E, Dambara T, Aiba M, Okamoto M, Yonemitsu J, Sonobe S, Koga H, Inui A, Hada N, Matsumoto N, Goto Y, Naito T, Isonuma H, Hayashida Y.

Department of General Medicine, Juntendo University School of Medicine, Tokyo. es66@med.juntendo.ac.jp

Intern Med. 2007;46(8):461-5.

ABSTRACT: Legionella spp are well recognized as one of the etiologic factor in pneumonia, but it is difficult to distinguish the clinical features of Legionella infection from pneumonia due to other causes. The objective of the present study was to examine the clinical characteristics of community-acquired Legionella pneumonia in elderly patients. We reviewed the clinical, laboratory and radiographic findings in 8 patients diagnosed as having pneumonia caused by Legionella. The diagnosis was confirmed by the presence of urinary antigen, bacterial culture, polymerase chain reaction (PCR) and serum antibody. There were 6 men and 2 women, whose ages ranged from 76 to 85 years. All patients had fever and hypoxia, four patients had respiratory symptoms. The initial chest X-ray findings were varied--consolidation, ground glass opacity, pleural effusion and linear shadow. Urinary antigen was positive in 4 patients, bacterial culture in 2, PCR on the sputum in 3 and serum antibody in 2 patients. As pneumonia caused by Legionella often becomes life-threatening, especially in elderly people, it is imperative to diagnose it at the initial stage. In this study, urinary antigen proved to be the most useful diagnostic means. However, it is important to confirm the diagnosis through plural examinations.

 

Community-acquired legionella pneumonia in elderly patients: characteristics and outcome

Sopena N, Pedro-Botet L, Mateu L, Tolschinsky G, Rey-Joly C, Sabrià M.

Infectious Diseases Unit, Germans Trias i Pujol Hospital (Badalona), Autonomous University of Barcelona, Barcelona, Spain. nsopena.germanstrias@gencat.net

J Am Geriatr Soc. 2007 Jan;55(1):114-9.

OBJECTIVES: To compare the risk factors, clinical and laboratory features, and outcome of community-acquired pneumonia (CAP) caused by Legionella pneumophila in elderly (aged > or =65) and younger patients. DESIGN: Prospective enrollment of subjects with retrospective data analysis. SETTING: A 630-bed tertiary center in Badalona (Barcelona), Spain. PARTICIPANTS: A total of 158 patients diagnosed with CAP caused by L. pneumophila from 1994 to 2004: 104 younger than 65 and 54 aged 65 and older. MEASUREMENTS: Epidemiological, clinical, laboratory, and radiological data and the outcome of the two groups were compared using univariate and multivariate analysis. RESULTS: Underlying diseases, such as chronic pulmonary diseases, diabetes mellitus, neuromuscular diseases, and heart failure; risk of aspiration; and therapy with corticosteroids were significantly more frequent in patients aged 65 and older. Patients younger than 65 were more likely to be male and have toxic habits (cigarette smoking, alcoholism) and human immunodeficiency virus infection than older patients. Fever, nonrespiratory symptoms (diarrhea and headache), and some laboratory abnormalities (hyponatremia (serum sodium concentration <130 mmol/L) and high aspartate aminotransferase and creatinine kinase levels) were significantly less frequent in patients aged 65 and older than in younger patients. No significant differences were observed between the two groups in the frequency of higher-severity risk classes and intensive care unit admission or in outcome (complications and mortality). CONCLUSION: Elderly patients with CAP caused by L. pneumophila had a higher frequency of underlying comorbidities and presented less frequently with fever and classical nonrespiratory symptoms and laboratory abnormalities of Legionnaires' disease than younger patients, although greater severity of illness at onset and higher mortality were not significantly different between the two age groups.

 

A community outbreak of Legionnaires' disease from an industrial cooling tower: assessment of clinical features and diagnostic procedures

Hugosson A, Hjorth M, Bernander S, Claesson BE, Johansson A, Larsson H, Nolskog P, Pap J, Svensson N, Ulleryd P.

Department of Medicine, Uppsala University Hospital. Uppsala, Sweden.martinhjort@vgregion.se

Scand J Infect Dis. 2007;39(3):217-24.

ABSTRACT: An outbreak of Legionnaires' disease (LD) occurred in Lidköping, Sweden, in August 2004. A cooling tower was identified as the probable source of infection. During the outbreak period an unexpected 3-6-fold increase in pneumonia patients was noted at the local hospital. During 7 weeks LD was diagnosed in 15 patients by urinary antigen and/or sputum culture. Additionally, 15 LD patients were diagnosed later by serology. Patients with LD were generally younger, more healthy, and more often smokers compared to other pneumonia patients. On admittance they had more severe symptoms with high fever and raised CRP levels, and more often hyponatraemia, gastrointestinal and CNS symptoms. A causative agent besides Legionella was found in 2 patients only. A significant titre rise for Mycoplasma and/or Chlamydophila pneumoniae was found in 13 of 29 tested patients with confirmed LD. We conclude that the clinical diagnosis of LD is difficult and that available diagnostic methods detect only a minority of patients in the acute phase. Therefore in severe pneumonia, empirically targeted therapy should be instituted on clinical grounds irrespective of the results of diagnostic tests. The observation of increased antibody levels for M. and C. pneumoniae suggests an unspecific immune reaction and merits further study.

 

Legionnaires' disease: when an 'outbreak' is not an outbreak

Pereira AJ, Broadbent J, Mahgoub H, Morgan O, Bracebridge S, Reacher M, Ibbotson S, Lee JV, Harrison TG, Nair P.

Great Yarmouth and Waveney Primary Care Trust, Beccles, Suffolk, United Kingdom. augustine.pereira@nhs.net

Euro Surveill. 2006 Nov 30;11(11):E061130.3.

ABSTRACT: During August 2006, there was a large increase in non-travel related legionella cases throughout England and in the Netherlands.

 

An outbreak of Legionella pneumophila suspected to be associated with spa pools on display at a retail store in New Zealand

Ruscoe Q, Hill S, Blackmore T, McLean M.

Regional Public Health, Hutt Valley DHB, Lower Hutt. quentin.ruscoe@huttvalleydhb.org.nz

N Z Med J. 2006 Oct 13;119(1243):U2253.

ABSTRACT: AIM: To investigate and characterise a cluster of six cases of severe pneumonia in the Wellington region notified to Regional Public Health in November 2003. And to describe the public health response to an identified subgroup of Legionella infections. METHODS: The case definition was "a person admitted to Wellington or Hutt Hospital between 29 October 2003 and 9 November 2003 with severe pneumonia". The cluster was initially investigated by interviewing patients to obtain histories of activities and exposures, and by reviewing medical notes. Medical teams sent further clinical specimens for testing (sputum for polymerase chain reaction [PCR], convalescent Legionella serology, and urine for Legionella antigen testing). Further investigation of Legionella pneumophila cases involved obtaining detailed exposure histories, environmental investigations at the suspect source of infection, and taking water and biofilm swabs for Legionella detection and serotyping. RESULTS: Three cases from the cluster were confirmed as, or compatible with, Legionella pneumophila serogroup 2. With the other three cases there was evidence of infection with L. longbeachae (two cases) or respiratory syncytial virus (one case). Exposure histories for the L. pneumophila cases revealed that the three cases had visited a Lower Hutt retail outlet with operating spa pools on display. Legionella pneumophila serogroup 1 was cultured from one of three pools. All pools were positive for Legionella on direct fluorescent antibody testing. CONCLUSIONS: Although unproven, the display spa pools were considered to be the most likely source of Legionella infection in the three cases that had visited the retail outlet. Although Legionella isolated from the pools was a different serogroup from that identified in two cases, the pools were considered to be the most likely source of infection in view of inadequate chlorination of the waters. Public health intervention to address the immediate and longer-term health risks from the pools is described. This is the second outbreak of Legionella pneumophila linked to operating display spa pools in New Zealand and it appears to be the fourth recorded outbreak of Legionnaires' disease associated with operating spa pools on display.

 

Retrospective study of 30 cases of Legionella pneumonia in the Kansai region

Maniwa K, Taguchi Y, Ito Y, Mishima M, Yoshida S.

Department of Respiratory Medicine, Japanese Red Cross Society, Wakayama Medical Center, 4-20 Komatsubara-dori, Wakayama, 640-8558, Japan.

komaniwa@wakayama.email.ne.jp

J Infect Chemother. 2006 Oct;12(5):272-6.

ABSTRACT: Thirty Legionella pneumonia cases were clinically investigated retrospectively from 1999 to 2005 at the Respiratory Medicine Department of Kyoto University and affiliated hospitals. Twenty-eight cases were sporadic and two cases were part of an outbreak. The patients consisted of 28 men and 2 women, with a mean age of 58.8 years (range 25-87). Nineteen cases were smokers and 19 had some underlying disease. The mean period from the disease occurrence to presenting at a hospital was 4.8 days (range 1-15). The mean period from presenting at hospital to Legionella pneumonia diagnosis was 4.6 days (range 0-22). Urinary antigen detection tests for Legionella pneumophilla were performed for 25 cases, and resulted in the diagnosis of 22 cases. Other diagnostic tests with positive findings were culture (buffered charcoal-yeast extract agar, BCYE), the polymerase chain reaction (PCR) test, and serological diagnosis (enzyme immunoassay and microagglutination test). Legionella species diagnosis was obtained by culture and serology for 13 cases: 10 cases had Legionella pneumophila serogroup 1, 2 cases had Legionella pneumophila serogroup 6, and 1 case had Legionella longbeachea. Fluoloquinolones (Fq) are most often used for therapy, especially in recent cases, and were predominantly the chosen treatment (70%). Death due to Legionella pneumonia occurred in 4 cases: 3 cases had severe underlying diseases, and 1 case took 18 days to diagnose (doctors' delay). To detect the majority of Legionella pneumonia cases, a combination of diagnostic examinations is still needed. Regarding the management of community-acquired pneumonia, both the cost and the indication of diagnostic examinations for Legionella infection should be considered simultaneously.

 

Biochemical and immunologic features of an outbreak of Legionnaires disease: comparative study between community-acquired pneumonias

Agulló-Ortuño MT, García-Mancebo ML, Montes-Ares O, Noguera-Velasco JA.

Servicio de Análisis Clínicos, Hospital Universitario Virgen de la ARRIXACA, Ctra. Madrid-Cartagena S/N, 30120 El Palmar, Murcia, Spain. teresa.agullo@arrakis.es

Diagn Microbiol Infect Dis. 2006 Sep;56(1):7-11.

ABSTRACT: Legionella pneumophila has been recognized as an important cause of community- and hospital-acquired pneumonia. This study evaluates the interrelationship between that patients group with Legionnaires disease (LD) and the possible factors that may predispose hosts to acquire this infection. Likewise, we search for preliminary biochemical and immunologic evidences that could help physicians to differentiate between LD and other pneumonias. We analyzed biochemical parameters and immunoglobulin levels in 61 LD patients and a control group (n = 30) who were non-Legionella pneumonia diagnosed. We observed statistically significant differences in LD patients versus control group in serum sodium, albumin, gamma-band, IgG levels, (P < .01) and for total proteins, aspartate aminotransferase (AST), and lactate dehydrogenase (LDH) (P < .05). Our study shows a trend between the presence of LD and immunoglobulin deficiencies in the group studied. Deficit in IgG or IgG plus IgM, during the exposure period, may predispose individuals to suffer legionellosis (P < .05). Overall, hypoalbuminemia, hyponatremia, and high AST and LDH levels can represent a useful prognostic marker in patients with severe pulmonary infection suspected to be legionellosis.

 

Legionnaire's disease complicated by acute renal failure due to rhabdomyolosis: a case report

Labidi J, Fdhila W, Battikh R, Ellouze S, Ben Abdelhafidh N, Louzir B, M'sadek F, Othmani S.

Service de Médecine Interne, Hôpital Militaire de Tunis, Mont Fleury, 1008 Tunis, Tunisie. battikh_riadh@yahoo.fr

Med Mal Infect. 2006 Sep;36(9):476-8.

ABSTRACT: The infectious origin of non-traumatic rhabdomyolysis is rare (5% of cases). An elevated muscle enzyme level is often reported in the legionnaire's disease. We report the case of a 39-year-old male, with no previous medical history, admitted for renal failure (creatininemia=977 micromol/l) secondary to rhabdomyolysis and a twelve-day history of infectious syndrome with pneumonia in the left base. Legionella pneumophila was considered responsible for these symptoms because of a positive serology. The other microbial assessments were negative. After rehydration and three weeks of antibiotics, the outcome was favorable: the renal failure resolved completely and the muscle enzyme level returned to normal.

 

Outbreak of Legionnaires' disease on a cruise ship linked to spa-bath filter stones contaminated with Legionella pneumophila serogroup 5

Kura F, Amemura-Maekawa J, Yagita K, Endo T, Ikeno M, Tsuji H, Taguchi M, Kobayashi K, Ishii E, Watanabe H.

Department of Bacteriology, National Institute of Infectious Diseases, Tokyo, Japan.

ABSTRACT: In January 2003, two cases of Legionnaires' disease associated with a ship's cruise were registered in the database of National Epidemiological Surveillance of Infectious Diseases. A 70-year-old male heavy smoker with mild emphysema contracted the disease during a cruise. Legionella pneumophila serogroup (sg) 5 was isolated from the patient's sputum and the ship's indoor spa. The isolate from the spa matched the patient's isolate by genotyping performed by pulsed-field gel electrophoresis (PFGE). The second case was in a 73-year-old female. During epidemiological investigation, a third case of Legionnaire's disease in a 71-year-old male was subsequently diagnosed among passengers on the same ship on the following cruise. Environmental investigation revealed that porous natural stones (Maifanshi) in the filters of the spas had harboured L. pneumophila, a phenomenon which has not been reported except in Japan. This is the first documented evidence of L. pneumophila sg 5 infection on a ship and of porous stones as a source of Legionella infection.

 

A community outbreak of Legionnaires' disease: evidence of a cooling tower as the source

Sabria M, Alvarez J, Dominguez A, Pedrol A, Sauca G, Salleras L, Lopez A, Garcia-Nunez MA, Parron I, Barrufet MP.

Hospital Universitario Germans Trias I Pujol, Infectious Diseases, Badalona, Barcelona, Spain.

Clin Microbiol Infect. 2006 Jul;12(7):642-7.

ABSTRACT: A community outbreak of Legionella pneumonia in the district of Cerdanyola, Mataro (Catalonia, Spain) was investigated in an epidemiological, environmental and molecular study. Each patient was interviewed to ascertain personal risk-factors and the clinical and epidemiological data. Isolates of Legionella from patients and water samples were subtyped by pulsed-field gel electrophoresis. Between 7 August and 25 August 2002, 113 cases of Legionella pneumonia fulfilling the outbreak case definition criteria were reported, with 84 (74%) cases being located within a 500-m radius of the suspected cooling tower source. In this area, the relative risk of being infected was 54.6 (95% CI 25.3-118.1) compared with individuals living far from the cooling tower. Considering the population residing in the Cerdanyola district (28 256 inhabitants) as a reference population, the attack rate for the outbreak was 399.9 cases/100 000 inhabitants, and the case fatality rate was 1.8%. A single DNA subtype was observed among the ten clinical isolates, and one of the subtypes from the cooling tower matched exactly with the clinical subtype. Nine days after closing the cooling tower, new cases of pneumonia caused by Legionella ceased to appear. The epidemiological features of the outbreak, and the microbiological and molecular investigations, implicated the cooling tower as the source of infection.

 

Severe community-acquired pneumonia due to Legionella pneumophila Serogroup 6

Chen CY, Chen KY, Hsueh PR, Yang PC.

Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan. kuanyu@ha.mc.ntu.edu.tw

J Formos Med Assoc. 2006 Mar;105(3):256-62.

ABSTRACT: Legionella pneumophila is a common cause of sporadic community-acquired pneumonia, but culture-proven legionellosis is rarely diagnosed. There is no laboratory test for Legionnaires' disease that can detect all patients with the disease. Culture is the standard diagnostic method and should be initiated as soon as possible in suspected cases. We describe a rare case of community-acquired pneumonia caused by L. pneumophila serogroup 6. A 77-year-old man was admitted to a tertiary care hospital because of high fever, productive cough, and progressive dyspnea. Chest radiography showed bilateral pneumonia, which led to respiratory failure necessitating mechanical ventilatory support. Despite antibiotic therapy, his condition continued to deteriorate and acute renal failure also developed. Urine was negative for L. pneumophila. Culture of the sputum yielded L. pneumophila serogroup 6, although there was no elevation of the serum antibody titer. Pneumonia resolved gradually and he was extubated after treatment with levofloxacin followed by erythromycin. L. pneumophila other than serogroup 1 should be included in the differential diagnosis of patients with suspected atypical community-acquired pneumonia.

 

The public health implications of a sporadic case of culture-proven Legionnaires' disease

Young M, Smith H, Gray B, Huang B, Barten J, Towner C, Plowman S, Afshar B, Fry N, Blair B, Savill J, McCall B.

Brisbane Southside Public Health Unit, Queensland Health.

Aust N Z J Public Health. 2005 Dec;29(6):513-7.

ABSTRACT: Legionella pneumophila is an important cause of community-acquired pneumonia. Domestic sources of infection have been increasingly recognised among community-acquired cases. This report summarises the public health investigations and management of a single community-acquired case of Legionnaires' disease in Queensland, commenced in the context of a suspected outbreak. Legionellae from the case's domestic water supply were indistinguishable from the clinical isolate. The implications for future investigation of sporadic cases are discussed.

 

A community-wide outbreak of legionnaires disease linked to industrial cooling towers--how far can contaminated aerosols spread?

Nguyen TM, Ilef D, Jarraud S, Rouil L, Campese C, Che D, Haeghebaert S, Ganiayre F, Marcel F, Etienne J, Desenclos JC.

Institut de Veille Sanitaire and European Programme for Intervention Epidemiology Training, Saint-Maurice, France.

J Infect Dis. 2006 Jan 1;193(1):102-11.

ABSTRACT: A community-wide outbreak of legionnaires disease occurred in Pas-de-Calais, France, in November 2003-January 2004. Eighteen (21%) of 86 laboratory-confirmed cases were fatal. A case-control study identified smoking, silicosis, and spending >100 min outdoors daily as risk factors for acquiring the disease. Legionella pneumophila strain Lens was isolated from cooling towers, wastewater, and air samples from plant A. This unique strain matched all 23 clinical isolates, as assessed by pulsed-field gel electrophoresis subtyping. Modeling of atmospheric dispersion of aerosols emitted from plant A cooling towers showed good coverage of the communes where patients lived and showed that the dispersion extended over a distance of at least 6 km from plant A. No other aerosol-producing installation was identified as a plausible source, and no common source of indoor exposure was found. These findings implicate plant A as the most likely outbreak source and suggest that the distance of airborne transmission of L. pneumophila may be greater than previously reported.

 

Cruise-ship--associated Legionnaires disease, November 2003-May 2004

Centers for Disease Control and Prevention (CDC).

MMWR Morb Mortal Wkly Rep. 2005 Nov 18;54(45):1153-5.

ABSTRACT: More than 9.4 million passengers traveled on pleasure cruises departing from North American ports in 2004, an increase of 13% since 2003 and 41% since 2001. Cruise ships typically transport closed populations of thousands of persons, often from diverse parts of the world. Travelers are at risk for becoming ill while on board, most commonly from person-to-person spread of viral gastrointestinal illnesses. Certain environmental organisms, such as Legionella spp., pose a risk to vulnerable passengers. During November 2003-May 2004, eight cases of Legionnaires disease (LD) among persons who had recently traveled on cruise ships were reported to CDC. This report describes these cases to raise clinician awareness of the potential for cruise-ship--associated LD and to emphasize the need for identification and reporting of cases to facilitate investigation.

 

Legionella pneumophila pneumonia during pregnancy: a case report

Gaillac N, Floccard B, Ould T, Benatir F, Levrat A, Meunier P, Allaouchiche B.

Departement d'Anesthesie Reanimation, Centre Hospitalier Universitaire Edouard Herriot, 5 place d'Arsonval 69437 Lyon, France.

J Infect. 2005 Oct 21; [Epub ahead of print]

Legionella pneumophila pneumonia during pregnancy can have serious consequences for the mother and lead to fetal distress. We report a case of L. pneumophila pneumonia in a pregnant woman at 31 weeks gestation. With early diagnosis and appropriate treatment, the outcome was favorable with delivery of a healthy infant at 40 weeks gestation.

 

Legionnaires' disease outbreak in Rome, Italy

Rota MC, Pontrelli G, Scaturro M, Bella A, Bellomo AR, Trinito MO, Salmaso S, Ricci ML.

Centro Nazionale Epidemiologia, Sorveglianza e Promozione della Salute, Istituto Superiore di Sanità, Rome, Italy.

Epidemiol Infect. 2005 Oct;133(5):853-9.

ABSTRACT: Between August and October 2003, 15 cases of Legionnaires' disease were detected in the 9th district of Rome. To identify possible sources of Legionella exposure, a matched case-control study was conducted and environmental samples were collected. Hospital discharge records were also retrospectively analysed for the period July-November 2003, and results were compared with the same period during the previous 3 years. The case-control study revealed a significantly increased risk of disease among those frequenting a specific department store in the district (OR 9.8, 95% CI 2.1-46.0), and Legionella pneumophila was isolated from the store's cooling tower. Genotypic and phenotypic analysis of human and environmental isolates demonstrated that the cluster was caused by a single strain of L. pneumophila serogroup 1, and that the cooling tower of the store was the source of infection. The increased number of hospital admissions for microbiologically undiagnosed pneumonia during the study period may indicate that some legionellosis cases were not identified.

 

Legionellosis from Legionella pneumophila Serogroup 13

Faris B.

North Glasgow University NHS Trust, Glasgow, Scotland, United Kingdom.

Emerg Infect Dis. 2005 Sep;11(9):1407-11.

ABSTRACT: We describe 4 cases of Legionella pneumophila serogroup 13-associated pneumonia. These cases originate from a broad geographic range that includes Scotland, Australia, and New Zealand. L. pneumophila serogroup 13 pneumonia has a clinically diverse spectrum that ranges from relatively mild, community-acquired pneumonia to potentially fatal severe pneumonia with multisystem organ failure. All cases were confirmed by culture and direct fluorescent antibody staining or indirect immunofluorescent antibody tests. Proven or putative sources of L. pneumophila serogroup 13 infections in 2 patients included a contaminated whirlpool spa filter and river water. An environmental source was not found in the remaining 2 cases; environmental cultures yielded only other L. pneumophila serogroups or nonpneumophila Legionella species. We describe the clinical and laboratory features of L. pneumophila serogroup 13 infections. L. pneumophila serogroup 13 pneumonia is rarely reported, but it may be an underrecognized pathogenic serogroup of L. pneumophila.

 

Community-acquired pneumonia caused by Legionella longbeachae in an immunocompetent patient

Diederen BM, van Zwet AA, van der Zee A, Peeters MF.

Laboratory of Medical Microbiology and Immunology, St. Elisabeth Hospital, P.O. Box 747, 5000, AS Tilburg, The Netherlands.

Eur J Clin Microbiol Infect Dis. 2005 Aug;24(8):545-8.

ABSTRACT: Reported here is the case of a previously healthy 67-year-old man who was admitted to the intensive care unit with pneumonia caused by Legionella longbeachae. The organism was identified in sputum and serum by 16S rRNA-based PCR assay and sequence-based typing. One acute serum sample produced a single elevated IgM antibody titer of 1:512 against non-pneumophila Legionella spp. The patient fully recovered following the initiation of appropriate antibiotic treatment. Since most current laboratory tests for Legionella spp. cannot detect infections caused by non-pneumophila Legionella spp., culture on Legionella-selective media or PCR should be considered when diagnosing severe pneumonia of unknown etiology.

 

Outbreak of travel-related pontiac fever among hotel guests illustrating the need for better diagnostic tests

Huhn GD, Adam B, Ruden R, Hilliard L, Kirkpatrick P, Todd J, Crafts W, Passaro D, Dworkin MS.

Illinois Department of Public Health, Chicago, IL, USA.

J Travel Med. 2005 Jul-Aug;12(4):173-9.

BACKGROUND: Pontiac fever (PF), a legionellosis with influenza-like symptoms and high attack rates, is rarely reported. Travel-related outbreaks can elude detection because infected persons are often widely removed geographically from the transmission source before illness onset. Thirty-one persons staying at an Illinois hotel during August 9 to 11, 2002, reported influenza-like symptoms to local health departments within 24 to 48 hours of checkout. We investigated to identify the cause and source of illness to guide control measures. METHODS: Hotel water samples were collected for culture. A telephone questionnaire detailing illness symptoms and exposures was administered to all who were guests at the hotel from August 9 to 15 (n = 380). A case was defined as onset of fever, headache, and myalgia in a guest in the 14 days following the hotel stay. Patient sera were tested by hemagglutination assay for antibodies to Legionella species. RESULTS: Among 204 questionnaire respondents from 15 states and Canada, 50 met the case definition. Among persons exposed to the swimming pool/whirlpool spa area, 63% (47 of 75) became ill versus 3% (3 of 110) of unexposed persons (relative risk 23.0, 95% CI 7.4-71.1). Illness risk increased with increasing time exposed to the pool/spa. Approximately 95 to 115 bathers per day, two to three times above the usual number, used the spa during August 9 to 11. Three Legionella species, L. dumoffii, L. maceachernii, and L. micdadei, were isolated from spa filter backwash cultures. Two of 15 ill persons with acute- and convalescent-phase sera had a greater than fourfold rise in antibody titer to L. micdadei. CONCLUSIONS: PF was associated with exposure to a hotel pool/spa area. Heavy bather usage likely contributed to a decreased effectiveness of the disinfectant in the whirlpool spa, possibly promoting bacterial aerosolization. Linking case information from many states is essential in identifying and eliminating the source of disease transmission in travel-related outbreaks of PF. Clinicians should be aware of PF in the differential diagnosis of patients with influenza-like symptoms following recent travel, particularly with exposure to a communal-use whirlpool spa.

 

An outbreak of Legionella pneumonia originating from a cooling tower

Isozumi R, Ito Y, Ito I, Osawa M, Hirai T, Takakura S, Iinuma Y, Ichiyama S, Tateda K, Yamaguchi K, Mishima M.

From the Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.

Scand J Infect Dis. 2005;37(10):709-11.

ABSTRACT: We report 2 cases of Legionella pneumonia in individuals who were exposed to aerosols during maintenance of a cooling tower at a waste processing plant. This report documents the first known occupation-related outbreak of Legionella pneumonia in Japan.

 

Persistent culture-positive Legionella infection in an immunocompromised host

O'Reilly KM, Urban MA, Barriero T, Betts RF, Trawick DR.

Department of Medicine and Therapeutics, St. Vincent's University Hospital, Dublin, Ireland.

Clin Infect Dis. 2005 May 15;40(10):e87-9.

ABSTRACT: Legionella pneumophila is an important cause of community-acquired and nosocomial pneumonia. We describe an immunocompromised patient with severe pneumonia from whom Legionella species were isolated from sputum samples by culture for 30 days, despite administration of treatment with appropriate antimicrobial agents. However, clear improvement in the patient's respiratory condition was evident, and he subsequently recovered completely.

 

Recurrence of legionnaires disease at a hotel in the United States Virgin Islands over a 20-year period

Cowgill KD, Lucas CE, Benson RF, Chamany S, Brown EW, Fields BS, Feikin DR.

Epidemic Intelligence Service, Epidemiology Program Office, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.

Clin Infect Dis. 2005 Apr 15;40(8):1205-7.

ABSTRACT: We investigated 3 cases of legionnaires disease (LD) that developed in travelers who stayed at a hotel in the United States Virgin Islands where cases of LD occurred in 1981-1982 and in 1998. The temperature of the potable water at the hotel was in a range that could optimally support the growth of Legionella species, and the potable water was colonized with Legionella pneumophila in 1981-1982 and in 2002-2003.

 

Legionella pneumonia associated with adult respiratory distress syndrome caused by Legionella pneumophila serogroup 3

Nozue T, Chikazawa H, Miyanishi S, Shimazaki T, Oka R, Shimazaki S, Miyamoto S.

Department of Internal Medicine, Yokohama Sakae Kyosai Hospital, 132 Katsura-cho, Sakae-ku, Yokohama 247-8581.

Intern Med. 2005 Jan;44(1):73-8.

ABSTRACT: A 68-year-old man developed pneumonia 2 days after nearly drowning in a bathtub of a hot spring spa. Chest radiography revealed bilateral consolidation shadows associated with adult respiratory distress syndrome. Initial treatment with antibiotics and pulse therapy with methylprednisolone was not effective. The patient died on the 4th hospital day. A urinary antigen test for Legionella was positive. Legionella pneumophila serogroup 3 was recovered from an intratracheal specimen. The same serotype of Legionella was isolated from the hot spring water. Restriction enzyme analysis by pulse-field gel electrophoresis revealed identical restriction fragments. We conclude that the water at the hot spring spa could have been the source of infection.

 

Impact of positive legionella urinary antigen test on patient management and improvement of antibiotic use

Garbino J, Bornand JE, Uckay I, Fonseca S, Sax H.

Division of Infectious Diseases, Department of Internal Medicine, University of Geneva Hospitals, 1211 Geneva 14, Switzerland. jorge.garbino@hcuge.ch

J Clin Pathol. 2004 Dec;57(12):1302-5.

ABSTRACT: AIM: To assess the incidence of legionella infection over a 27 month period at a large university hospital. MATERIAL AND METHODS: The present retrospective cohort study enrolled patients with legionellosis, defined as those presenting a positive urinary antigen for legionella together with a medical history, clinical findings, and radiological findings consistent with pneumonia. These patients were evaluated to determine the relation between their test results and changes in treatment modalities. A control group of patients with pneumonia but a negative urinary antigen test for legionella were also analysed. RESULTS: Twenty seven of 792 assessed patients tested positive for legionella. In 22 of these patients, legionella active antibiotics were administered empirically. In seven patients, the test results prompted a legionella specific treatment, whereas in 12 cases, non-specific antibiotics were stopped within 24 hours. Overall, treatment was altered in more than half of the patients as a result of the test results. CONCLUSIONS: The urinary antigen may have a direct impact on clinical management of pulmonary legionellosis. However, patient comorbidities and individual clinical judgment are still important for determining the best treatment to be given in each individual case.

 

Legionella maceachernii pneumonia in a patient with HIV infection

Dumoff K, McGovern PC, Edelstein PH, Nachamkin I.

Department of Pathology and Laboratory Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA. nachamki@mail.med.upenn.edu

Diagn Microbiol Infect Dis. 2004 Oct;50(2):141-5.

ABSTRACT: We report a case of fatal Legionella maceachernii pneumonia in a 49 year-old man with HIV infection and review the 3 previous reported cases, all of which occurred in individuals with underlying immune defects. Infection with L. maceachernii was attributable to the deaths of all cases. Issues related to the clinical aspects, laboratory identification of this unusual species, and detection of Legionnaires' diseases are discussed.

Severe Legionella pneumophila pneumonia associated with the public bath on a cruise ship in Japan

Kobayashi A, Yamamoto Y, Chou S, Hashimoto S.

Department of Anesthesiology and Intensive Care, Saiseikai Suita Hospital, 1-2 Kawazono-cho, Suita, 564-0013, Japan.

J Anesth. 2004;18(2):129-31.

NO ABSTRACT  

Comparative study of community-acquired pneumonia caused by Streptococcus pneumoniae, Legionella pneumophila or Chlamydia pneumoniae

Sopena N, Pedro-Botet ML, Sabria M, Garcia-Pares D, Reynaga E, Garcia-Nunez M.

Infectious Diseases Unit, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain. nsopena@ns.hugtip.scs.es

Scand J Infect Dis. 2004;36(5):330-4.

ABSTRACT: The objective of this study was to compare epidemiological data and clinical presentation of community-acquired pneumonia (CAP) caused by Streptococcus pneumoniae, Legionella pneumophila or Chlamydia pneumoniae. From May 1994 to February 1996, 157 patients with S. pneumoniae (n = 68), L. pneumophila (n = 48) and C. pneumoniae (n = 41) pneumonia with definitive diagnosis, were prospectively studied. The following comparisons showed differences at a level of at least p < 0.05. Patients with S. pneumoniae pneumonia had more frequently underlying diseases (HIV infection and neoplasm) and those with C. pneumoniae pneumonia were older and had a higher frequency of chronic obstructive pulmonary disease (COPD), while L. pneumophila pneumonia prevailed in patients without comorbidity, but with alcohol intake. Presentation with cough and expectoration were significantly more frequent in patients with S. pneumoniae or C. pneumoniae pneumonia, while headache, diarrhoea and no response to betalactam antibiotics prevailed in L. pneumophila pneumonia. However, duration of symptoms > or = 7 d was more frequent in C. pneumoniae pneumonia. Patients with CAP caused by L. pneumophila presented hyponatraemia and an increase in CK more frequently, while AST elevation prevailed in L. pneumophila and C. pneumoniae pneumonia. In conclusion, some risk factors and clinical characteristics of patients with CAP may help to broaden empirical therapy against atypical pathogens until rapid diagnostic tests are available.  

Diagnosis of atypical pathogens in patients hospitalized with community-acquired respiratory infection

Schneeberger PM, Dorigo-Zetsma JW, van der Zee A, van Bon M, van Opstal JL.

Laboratory of Medical Microbiology Jeroen Bosch Ziekenhuis, Den Bosch, The Netherlands. p.schneeberger@jbz.nl

Scand J Infect Dis. 2004;36(4):269-73.

ABSTRACT: The object of our study was to determine the proportion of atypical respiratory pathogens among patients hospitalized with a community-acquired respiratory infection. From September 1997 to May 1999, 159 patients (57% male, median age 55, range 1-88 y) admitted to 3 regional hospitals for a community acquired respiratory infection, were enrolled in the study. Microbiological diagnosis for the atypical pathogens Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella pneumophila was performed with PCR on a throat swab, sputum and/or broncho alveolar lavage (BAL). In addition, Legionella species other than L. pneumophila (L. non-pneumophila species) were detected by PCR. Two serum samples were collected and processed for M. pneumoniae and C. pneumoniae serology. In total, 27 patients (17%) were diagnosed with an atypical pathogen. Infection with M. pneumoniae was detected in 19 patients (12%) (PCR positive n = 7), with C. pneumoniae in 5 patients (3%) (PCR positive n = 0) and with L. pneumophila in 4 patients (2.5%) (PCR positive n = 4). In 54 (34%) patients routine microbiological investigations revealed aetiological agents other than the 3 atypical pathogens, the most frequently diagnosed pathogens being Streptococcus pneumoniae (n = 18), Haemophilus influenzae (n = 17), Gram-negative rods (n = 13), Moraxella catarrhalis (n = 6) and Staphylococcus aureus (n = 6). More than 1 pathogen was found in 13 patients. Atypical pathogens were found more often in the young age group (0-18 y), in contrast to bacterial pathogens that were found more often in the older age groups (> or = 65 y). Atypical pathogens were found less often in patients with a clinical presentation of atypical pneumonia. Legionella species other than L. pneumophila were found by PCR in 13 patients (8%), and in 6 patients in combination with another pathogen. An atypical pathogen (M. pneumoniae, C. pneumoniae or L. pneumophila) was found in 17% of the patients hospitalized with a community acquired respiratory infection, predominantly in the young age group. The role of Legionella non-pneumophila species as pathogen in community acquired respiratory infection needs to be determined. The clinical presentation does not predict the type of pathogen found.  

 

A case of breathlessness, confusion and diarrhoea

Chrysochou C, Mahto R, Klass D, Mohan D, Kodali VR.

Department of Medicine, Furness General Hospital, Barrow-in-Furness, UK. kodali@doctors.org.uk

Eur J Emerg Med. 2004 Aug;11(4):225-7.

ABSTRACT: A 61-year-old woman presented to the emergency department with acute-onset breathlessness, fever, sore throat and confusion. Her initial investigations revealed hyponatremia and middle lobe consolidation. In view of the atypical symptoms and signs, erythromycin was commenced. Urinary legionella antigen was requested and that tested positive. She was one of the first few patients whose findings alerted us to a possible outbreak of legionnaire' disease. We drew the following conclusions from our experience with this and other cases that we saw during the legionnaires' outbreak: an atypical presentation is common, as seen in this lady with confusion. If two cases of atypical pneumonias test positive for legionella within a period of a week, we suggest that public health authorities should be notified to identify the source and contain it. There is a need for continuous and high vigilance for legionnaires' disease.  

 

Legionnaires' disease in Europe 2000-2002

Joseph CA; European Working Group for Legionella Infections.

Respiratory Diseases Department, Health Protection Agency, Communicable Disease Surveillance Centre, 61 Colindale Avenue, London NW9 5EQ. cjoseph@phls.org.uk

Epidemiol Infect. 2004 Jun;132(3):417-24.

ABSTRACT: Each year, countries that participate in the European Surveillance Scheme for Travel Associated Legionnaires' Disease (EWGLINET) are requested to complete a set of standardized reporting forms that provide epidemiological and microbiological information on the total number of cases (non-travel as well as travel-related cases) detected in their country. Trends at the national and aggregated European level have been analysed for 2000-2002. For this period, 10,322 cases of Legionnaires' disease were reported and national infection rates ranged from 0 to 34.1 cases per million population. A total of 189 outbreaks were associated with nosocomial infection, community exposure or travel. The upward trend in diagnosis through the urinary antigen detection test has resulted in a higher ascertainment of cases in many countries. However, the decline in diagnosis by culture of the organism is likely to severely hamper outbreak investigations in the future if fewer clinical isolates are available for matching with environmental isolates. This important data-set has been used for studying the effectiveness of surveillance and legionella control and prevention programmes within Europe .

 

An outbreak of Legionnaires' disease at the Melbourne Aquarium, April 2000: investigation and case-control studies

Greig JE, Carnie JA, Tallis GF, Ryan NJ, Tan AG, Gordon IR, Zwolak B, Leydon JA, Guest CS, Hart WG.

Department of Human Services, Melbourne , VIC, Australia . graham.tallis@dhs.vic.gov.au

Med J Aust. 2004 Jun 7;180(11):566-72.

ABSTRACT: OBJECTIVE: To investigate the source and risk factors associated with Australia 's largest outbreak of Legionnaires' disease. DESIGN AND SETTING: Epidemiological and environmental investigation of cases of Legionnaires' disease associated with visits to the Melbourne Aquarium; two case-control studies to confirm the outbreak source and to investigate risk factors for infection, respectively. PARTICIPANTS: Patients with confirmed Legionnaires' disease who visited the Melbourne Aquarium between 11 and 27 April 2000 were compared (i) with control participants from the community, and (ii) with control participants selected from other visitors to the Aquarium during this period. MAIN OUTCOME MEASURES: Risk factors for acquiring Legionnaires' disease. RESULTS: There were 125 confirmed cases of Legionnaires' disease caused by Legionella pneumophila serogroup 1 associated with the Aquarium; 76% of patients were hospitalised, and four (3.2%) died. The Aquarium cooling towers were contaminated with this organism. Visiting the Aquarium was significantly associated with disease (odds ratio [OR], 207; 95% CI, 73-630). The case-control study indicated that current smoking was a dose-dependent risk (multivariable OR for currently smoking > 70 cigarettes/week, 13.5; 95% CI, 5-36), but chronic illness and duration of exposure at the site were not significant risks. CONCLUSIONS: This study showed an association between poorly disinfected cooling towers at the Aquarium and Legionnaires' disease in visitors, and confirmed current smoking as a critical risk factor. The rapid response, publicity, and widespread urinary antigen testing may have resulted in detection of milder cases and contributed to the relatively low apparent morbidity and mortality rates. The urinary antigen test allows rapid identification of cases and may be changing the severity of illness recognised as Legionnaires' disease and altering who is considered at risk. 

Need for national level outbreak control in Austria

Schmid D, Wewalka G, Allerberger F.

Austrian Agency for Health and Food Safety (AGES), Spargelfeldstrasse 191, A-1226, Vienna , Austria . Franz.Allerberger@ages.at

Lancet. 2004 Jun 12;363(9425):2002.

NO ABSTRACT  

 

Legionella pneumonia: the spectrum continues to expand

Brown RB.

Infectious Disease Division, Baystate Medical Center , 759 Chestnut St , Springfield , MA 01107 . richard.brown@bhs.org

Chest. 2004 Jun;125(6):1979-80

NO ABSTRACT

 

Legionella pneumonia and HIV infection: a case report

Stroup JS, Hendrickson SE, Neil M.

Department of Pharmacy, University of Oklahoma College of Pharmacy, Tulsa, Oklahoma, USA.

AIDS Read. 2004 May;14(5):267-70.

ABSTRACT: Legionella pneumonia is commonly diagnosed in patients who are chronically immunosuppressed, but it is rarely diagnosed in patients who have HIV/AIDS. We report the successful diagnosis and treatment of Legionella pneumonia in a patient with HIV infection that was diagnosed at the same admission.  

 

Pneumonia among travelers returning from abroad

Ansart S, Pajot O, Grivois JP, Zeller V, Klement E, Perez L, Bossi P, Bricaire F, Caumes E.

Service des Maladies Infectieuses et Tropicales, Groupe Hospitalier Pitie Salpetriere, Paris, France.

J Travel Med. 2004 Mar-Apr;11(2):87-91.

ABSTRACT: BACKGROUND: Although respiratory tract infections represent a frequent cause of morbidity in travelers, and pneumonia a frequent cause of medical consultation among febrile travelers returning home, the etiologic spectrum of pneumonia in travelers has not been specifically studied. METHODS: We reviewed the medical charts of all travelers hospitalized during a 12-month period in our department with pneumonia after returning home. RESULTS: Seventeen patients (nine men, eight women, mean age 44 years, range 26 to 67 years) were included in this study. The etiology of pneumonia was established in 13 patients. Bacterial pneumonia was documented in 10 cases and was due to Streptococcus pneumoniae (n=2), Mycoplasma pneumoniae (n=2), Legionella pneumophila (n=1), Coxiella burnetti (n=1), Leptospira sp. (n=1) or Mycobacterium tuberculosis (n=3). Other etiologies included histoplasmosis, invasive schistosomiasis and dengue fever (one case each). CONCLUSION: These results show the wide range of causes of pneumonia among travelers returning from abroad.

 

Clusters of travel associated legionnaires' disease in France, September 2001- August 2003

Decludt B, Campese C, Che D, Jarraud S, Etienne J.

Institut de Veille Sanitaire, Saint Maurice, France. sophie.jarraud@univ-lyon1.fr

Euro Surveill. 2004 Feb;9(2):12-3.

ABSTRACT: Clusters of travel associated legionnaires' disease warrant urgent attention, and are detected by the French national surveillance system and the European network EWGLINET. Between September 2001 and August 2003, 37 clusters were identified in French tourist accommodation: 27 hotels and 10 campsites. The number of clinical cases per cluster was as follows: 30 clusters of 2 cases (81%), 6 clusters of 3 cases (16%) and one cluster of 4 cases (3%), a total of 82 cases. The local health authorities performed environmental investigations for 36 of the 37 clusters. Among the 36 clusters investigated, water samples were collected for 35. At 16 (46%) sites, Legionella pneumophila was found at a level of more than 103 cfu/litre. In all of the accommodation where risk assessment was found to be inadequate- control measures were implemented immediately. Six hotels were closed immediately following cluster alerts. Comparison of clinical and environmental isolates by pulsed field gel electrophoresis (PFGE) was possible in 3 clusters and identical genomic profiles of the isolates were found in all. During this two year period of surveillance, we found that on many sites there has been a risk of exposure to Legionella. This reinforces the importance of the European surveillance network and the timely notifications of all the cases to EWGLINET.

 

Fatal Case of Community-Acquired Pneumonia Caused by Legionella longbeachae in a Patient with Systemic Lupus Erythematosus

Garcia C, Ugalde E, Campo AB, Minambres E, Kovacs N.

Department of Microbiology, Hospital Universitario "Marques de Valdecilla", Avenida Valdecilla s/n, 39008, Santander, Spain. mic002@humv.e

Eur J Clin Microbiol Infect Dis. 2004 Feb;23(2):116-8.

ABSTRACT: Reported here is a rare case of atypical pneumonia due to a non- pneumophila Legionella sp. that occurred in a young patient with systemic lupus erythematosus. In spite of aggressive treatment, the patient died 24 h following admission to the intensive care unit. Legionella longbeachae was cultured from respiratory tract specimens and identified to the genus level by PCR and to the species level by an immunofluorescence test. Since most current laboratory tests for Legionella spp., including urinary antigen and serology, cannot detect infections caused by non- pneumophila Legionella spp., culture on legionella-selective media should be strongly considered when diagnosing immunosuppressed patients with pneumonia.

 

Community-acquired Legionnaires' disease in Nottingham--too many cases?

Lim WS, Slack R, Goodwin A, Robinson J, Lee JV, Joseph C, Neal K.

Respiratory Medicine, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB.

Epidemiol Infect. 2003 Dec;131(3):1097-103.

ABSTRACT: The aim of this study was to compare the incidence of community-acquired Legionnaires' Disease in Nottingham with England and Wales and to explore reasons for any difference observed. Based on data from the National Surveillance Scheme for Legionnaires' Disease (1980-1999), the rate of infection in England and Wales was 1.3 per million/year compared with 6.6 per million/ year in Nottingham. Domestic water samples were obtained from 41 (95%) of 43 Nottingham cases between 1997 and 2000. In 16 (39%) cases, Legionella sp. were cultured in significant quantities. Proximity to a cooling tower was examined using a 1:4 case-controlled analysis. No significant difference in the mean distance between place of residence to the nearest cooling tower was noted (cases 2.7 km vs. controls 2.3 km; P = 0.5). These data suggest that Nottingham does have a higher rate of legionella infection compared to national figures and that home water systems are a source.

 

Community-acquired pneumonia

File TM.

Northeastern Ohio Universities College of Medicine, Rootstown, Ohio, and Infectious Disease Service, Summa Health System, Akron, Ohio, USA. filet@summa-health.org

Lancet. 2003 Dec 13;362(9400):1991-2001.

ABSTRACT: This seminar reviews important features and management issues of community-acquired pneumonia (CAP) that are especially relevant to immunocompetent adults in light of new information about cause, clinical course, diagnostic testing, treatment, and prevention. Streptococcus pneumoniae remains the most important pathogen; however, emerging resistance of this organism to antimicrobial agents has affected empirical treatment of CAP. Atypical pathogens have been quite commonly identified in several prospective studies. The clinical significance of these pathogens (with the exception of Legionella spp) is not clear, partly because of the lack of rapid, standardised tests. Diagnostic evaluation of CAP is important for appropriate assessment of severity of illness and for establishment of the causative agent in the disease. Until better rapid diagnostic methods are developed, most patients will be treated empirically. Antimicrobials continue to be the mainstay of treatment, and decisions about specific agents are guided by several considerations that include spectrum of activity, and pharmacokinetic and pharmacodynamic principles. Several factors have been shown to be associated with a beneficial clinical outcome in patients with CAP. These factors include administration of antimicrobials in a timely manner, choice of antibiotic therapy, and the use of a critical pneumonia pathway. The appropriate use of vaccines against pneumococcal disease and influenza should be encouraged. Several guidelines for management of CAP have recently been published, the recommendations of which are reviewed.

 

Epidemiologic investigation of a restaurant-associated outbreak of Pontiac fever

Jones TF, Benson RF, Brown EW, Rowland JR, Crosier SC, Schaffner W.

Tennessee Department of Health, Nashville, TN 37247, USA. tim.f.jones@state.tn.us

Clin Infect Dis. 2003 Nov 15;37(10):1292-7.

ABSTRACT: This case-control study investigated a cluster of respiratory illness among patrons of a restaurant. Of 173 patrons interviewed, 117 (68%) were ill. Symptoms included myalgias (93%), headache (87%), and fatigue (79%). The mean incubation period was 49 h and the mean duration of illness was 71 h. Patrons aged >15 years were more likely to have been ill than younger patrons (odds ratio [OR], 2.96; P=.002); 58% of persons who were ill sat near a large fountain, compared with 18% of respondents who were not ill (OR, 7.5; P=.005). Legionella anisa was cultured from water samples obtained from the fountain pool. Of 22 individuals who were ill, 11 (50%) had a > or =4-fold increase in the titer of antibody to that strain of L. anisa from acute-phase to convalescent-phase serum samples; 3 others (14%) had persistently elevated titers of > or =512; of a group of 20 individuals who had not been exposed to the restaurant, none had titers of >128. Pontiac fever should be considered as a diagnosis during acute outbreaks of influenza-like illness with a high attack rate and no other identified etiology.

 

A large outbreak of Legionnaires' disease due to an inadequate circulating and filtration system for bath water-epidemiologic manifestations

Nakamura H, Yagyu H, Kishi K, Tsuchida F, Oh-Ishi S, Yamaguchi K, Matsuoka T.

Fifth Department of Internal Medicine, Tokyo Medical University, Inashiki, Ibaraki. junnki@dg.mbn.or.jp

Intern Med. 2003 Sep;42(9):806-11.

ABSTRACT: OBJECTIVE: To study the epidemiologic manifestations of a large outbreak of Legionnaires' disease due to an inadequate circulating and filtration system for bath water. PATIENTS: In June 2000 at Ishioka City, Ibaraki Prefecture, a large outbreak of Legionnaire's disease occurred, as a result of an inadequate circulating and filtration system for communal bath water. This outbreak was the worst ever experienced in Japan, involving a total of 34 patients (20 confirmed, 14 probable), 3 of whom died. MEASUREMENTS AND RESULTS: Legionella pneumophila serogroup 1 was isolated from sputum culture in two patients. Bacteriological culture of the public bath water subsequently yielded large numbers of Legionella species. Cleavage of genomic DNA showed that restriction fragment patterns coming from clinical and environmental isolates of L. pneumophila serogroup 1 were closely related, focusing the inquiry to a public bathhouse where a circulating filtration system was suspected as the source of infection. CONCLUSIONS: It was later concluded that the circulating filtration system adopted for bath water was marred by a serious design flaw that subsequently caused the mass outbreak. Specifically, a line of the bath water was being returned to the bath without undergoing heat exchange or sterilization by chlorine; and the Legionella species that had proliferated in the filter and the bright stone filtration unit were allowed to return to the bath, eventually culminating in a mass infection.

 

Legionnaires' disease outbreak in Murcia, Spain

Garcia-Fulgueiras A, Navarro C, Fenoll D, Garcia J, Gonzales-Diego P, Jimenez-Bunuelas T, Rodriguez M, Lopez R, Pacheco F, Ruiz J, Segovia M, Balandron B, Pelaz C.

Regional Health Council of Murcia, Murcia, Spain. anam.garcia9@carm.es

Emerg Infect Dis. 2003 Aug;9(8):915-21.

ABSTRACT: An explosive outbreak of Legionnaires' disease occurred in Murcia, Spain, in July 2001. More than 800 suspected cases were reported; 449 these cases were confirmed, which made this the world's largest outbreak of the disease reported to date. Dates of onset for confirmed cases ranged from June 26 to July 19, with a case-fatality rate of 1%. The epidemic curve and geographic pattern from the 600 competed epidemiologic questionnaires indicated an outdoor point-source exposure in the northern part of the city. A case-control study matching 85 patients living outside the city of Murcia with two controls each was undertaken to identify to outbreak source; the epidemiologic investigation implicated the cooling towers at a city hospital. An environmental isolate from these towers with an identical molecular pattern as the clinical isolates was subsequently identified and supported that epidemiologic conclusion.

 

Clinical diagnosis of Legionella pneumonia revisited: evaluation of the Community-Based Pneumonia Incidence Study Group scoring system

Fernandez-Sabe N, Roson B, Carratala J, Dorca J, Manresa F, Gudiol F.

Infectious Disease Service, Hospital Universitari de Bellvitge, University of Barcelona, Barcelona, Spain.

Clin Infect Dis. 2003 Aug 15;37(4):483-9.

ABSTRACT: This prospective case-control study sought to identify differences in presentation between Legionella pneumonia (LP) diagnosed by urinary antigen and bacteremic pneumococcal pneumonia (PP), with the aim of assessing the ability of physicians to recognize such differences at admission and validating the Community-Based Pneumonia Incidence Study (CBPIS) Group scoring system for LP diagnosis. Significant differences in presentation were found: male sex, previous receipt of beta-lactam therapy, and temperature >39 degrees C were positively associated with LP; purulent sputum, pleuritic chest pain, and previous upper respiratory tract infection were negatively associated with LP. Physicians considered Legionella to be the most likely diagnosis in 52 (64%) of 81 LP cases and in 8 (6%) of 136 PP cases. Initial administration of a macrolide and rifampin and requests for urinary antigen testing for Legionella at admission were significantly more frequent among patients with LP. Overall, the CBPIS score did not differentiate reliably between LP and PP. Although certain presenting clinical features may allow recognition of LP, it is difficult to express them in a reliable scoring system.

 

Outbreak of Legionnaires' disease on a cruise ship: lessons for international surveillance and control

Regan CM, McCann B, Syed Q, Christie P, Joseph C, Colligan J, McGaffin A.

Liverpool Health Authority. martyn.regan@hpa.org.uk

Commun Dis Public Health. 2003 Jun;6(2):152-6.

ABSTRACT: A sporadic case of Legionnaires' disease was linked to travel on a cruise ship. Investigation identified two further cases of Legionnaires' Disease and one case of non-pneumonic Legionella infection. An Incident Team confirmed the source to be the ship's water system and control measures were instituted that included pasteurisation, super chlorination and chlorine dioxide dosing. The Public Health Laboratory Service (PHLS) Communicable Disease Surveillance Centre (CDSC), through the European Surveillance Scheme for Travel Associated Legionnaires' Disease, identified three previous cases associated with the same ship's water system including one fatality. Lessons for the international surveillance and control of Legionnaires' disease on cruise ships are discussed.

 

A case of Legionella pneumophila pneumonia complicated by miliary tuberculosis

Uchida K, Aoike N, Yoshida K, Koya A, Takai Y, Tateda K, Yamaguchi K.

Second Department of Internal Medicine, Toho University School of Medicine, Tokyo, Japan.

Respirology. 2003 Jun;8(2):249-51.

ABSTRACT: A 47-year-old woman was admitted to hospital with severe Legionella pneumonia. The respiratory symptoms improved dramatically and the X-rays revealed a decrease in the diffuse chest infiltrates after treatment with erythromycin and rifampicin. However, chest CT scans showed that the reticulonodular opacities persisted for several weeks after the onset of pneumonia. Two months after admission, the chest X-rays showed the progression of small nodules in both lungs and there was increasing respiratory distress. A diagnosis of miliary tuberculosis was confirmed. The present case should alert physicians to this potentially confusing combination of respiratory pathogens.

 

Community-acquired pneumonia in southeast Asia: the microbial differences between ambulatory and hospitalized patients

Wattanathum A, Chaoprasong C, Nunthapisud P, Chantaratchada S, Limpairojn N, Jatakanon A, Chanthadisai N.

Division of Pulmonary, Phramongkutklao Hospital , Bangkok , Thailand.

wattanathum@hotmail.com

Chest. 2003 May; 123(5): 1512-9.

ABSTRACT: STUDY OBJECTIVES: To determine microbial agents causing community-acquired pneumonia (CAP) in Southeast Asia. DESIGN: A prospective study. SETTING: Three general hospitals in Thailand. PATIENTS: Two hundred forty-five adult patients fulfilling the clinical criteria of CAP from September 1998 to April 2001. INTERVENTIONS: Investigations included sputum Gram stain and culture, blood culture, pleural fluid culture (if presented), urine antigen for Legionella pneumophila and Streptococcus pneumoniae, and serology for Mycoplasma pneumoniae, Chlamydia pneumoniae, and L pneumophila. RESULTS: There were 98 outpatients and 147 hospitalized patients included in the study, and an organism was identified in 74 of 98 outpatients (75.5%) and 105 of 147 of the hospitalized patients (71.4%). C pneumoniae (36.7%), M pneumoniae (29.6%), and S pneumoniae (13.3%) were the most frequent causative pathogens found in outpatients, while S pneumoniae (22.4%) and C pneumoniae (16.3%) were the most common in hospitalized patients. There was a significantly higher incidence of C pneumoniae (36.7% vs 16.3%, respectively; p < 0.001) and M pneumoniae (29.6% vs 6.8%; p < 0.001, respectively) in the outpatients than in the hospitalized patients. The incidence of S pneumoniae, L pneumophila, and mixed infections was not different between the groups. Mixed infections were presented in 13 of 98 outpatients (13.3%) and 9 of 147 hospitalized patients (6.1%), with C pneumoniae being the most frequent coinfecting pathogen. CONCLUSIONS: The data indicate that the core organisms causing CAP in Southeast Asia are not different from those in the Western countries. The guidelines for the treatment of patients with CAP, therefore, should be the same.

 

Neonatal sudden death due to Legionella pneumonia associated with water birth in a domestic spa bath

Nagai T, Sobajima H, Iwasa M, Tsuzuki T, Kura F, Amemura-Maekawa J, Watanabe H.

Department of Pediatrics. Department of Pathology, Nagoya Daini Red Cross Hospital , Nagoya 466-8650. Department of Bacteriology, National Institute of Infectious Diseases, Tokyo 162-8640, Japan.

fkura@nih.go.jp

J Clin Microbiol. 2003 May; 41(5): 2227-9

ABSTRACT: We report the first case of neonatal Legionnaires' disease associated with water birth in a spa bath at home. Legionella pneumophila serogroup 6 was detected from postmortem lung tissue.

 

Legionnaires disease: a case study

Cramer M.

School of Nursing , University of Pennsylvania, Philadelphia, Pa., USA.

Am J Crit Care. 2003 May; 12(3): 234-8.

NO ABSTRACT

 

Innocent victim of a localised outbreak: legionella endocarditis

Massey R, Kumar P, Pepper JR.

Department of Cardiothoracic Surgery, Royal Brompton Hospital , Sydney Street , London , UK .

rmmassey@yahoo.co.uk

Heart. 2003 May; 89(5): e16.

ABSTRACT: Legionella pneumophila endocarditis is extremely rare. The case of a fit 26 year old man who had previously undergone homograft aortic root replacement is reported. He was admitted with legionella pneumonia during the recent localised outbreak but went on to develop endocarditis. His aortic valve was replaced with a mechanical valve and he made an uneventful recovery. Public health issues and diagnosis in susceptible patients during localised outbreaks are discussed.

 

C-reactive protein levels in community-acquired pneumonia

Garcia Vazquez E, Martinez JA, Mensa J, Sanchez F, Marcos MA, de Roux A, Torres A.

Dept of Infectious Diseases, Hospital Clinic, Barcelona, Spain. egarciav@clinic.ub.es

Eur Respir J. 2003 Apr; 21(4): 702-5.

ABSTRACT: The diagnostic value of C-reactive protein (CRP) admission serum levels as an indicator of the aetiology of community-acquired pneumonia (CAP) was evaluated. A cohort of 1,222 patients with CAP was assessed. CRP levels were analysed in 258 patients with a single aetiological diagnosis. The mean CRP values in patients with pyogenic, atypical, viral and Legionella pneumophila pneumonia were: 16 mg x dL(-1), 13 mg x dL(-1), 14 mg x dL(-1) and 25 mg x dL(-1), respectively. CRP levels were not significantly different among patients outcome research team (PORT) groups (19 mg x dL(-1) in groups I-II, 16 mg x dL(-1) in group III and 16 mg x dL(-1) in groups IV-V). A cut-off point of 25 mg x dL(-1) had a sensibility, specificity, positive predictive value and negative predictive value of 0.6, 0.83, 0.3, and 0.94, respectively. After controlling for age and PORT score, the odds of having a CRP level >25 mg x dL(-1) was 6.9 times higher in patients with L. pneumophila pneumonia than in those with non-L. pneumophila pneumonia. Patients with Legionella pneumophila pneumonia had higher C-reactive protein levels than those with pneumonia of any other aetiology, independently of severity of infection. Being a cheap and readily available test, C-reactive protein may be a useful adjunctive procedure in the diagnosis of community-acquired pneumonia.