Search

Omadacycline is a novel tetracycline antibiotic that has a strong in vitro antibacterial activity against atypical pathogen such as Legionella. It is approved for the treatment of adults with community-acquired bacterial pneumonia, including Legionella pneumonia. However, clinical data on the use of omadacycline in Legionella pneumonia is limited. In the present paper, we report a case of severe pneumonia induced by Legionella pneumophila (L.pneumophila) presenting with septic shock and multiple organ dysfunction including lung, liver and kidney. With omadacycline treaetment, inflammation indices of the patient markedly decreased, and the patient significantly improved with multiple organ dysfunction and was discharged from home. Due to its strong antibacterial activity against L.pneumophila, good safety profile and no dosage adjustment in patients with severe hepatic or renal impairment, omadacycline can be considered as an optimal treatment strategies for severe infections by such special pathogen. Whereas, more case reports are needed to support this conclusion., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The optimal antimicrobial regimen for adults with respiratory failure due to Legionella pneumonia remains controversial. A systematic review was performed to assess the impact on outcomes comparing quinolones versus macrolides. A literature search was conducted in PubMed, Cochrane Library and Web of Science between 2012 and 2022. It yielded 124 potentially articles and ten observational studies met the inclusion criteria. A total of 4271 patients were included, 2879 (67 %) were male. A total of 1797 (42 %) subjects required intensive care unit (ICU) admission and 942 (52 %) mechanical ventilation. Fluoroquinolones and macrolides alone were administered in 1397 (33 %) and 1500 (35 %) subjects, respectively; combined therapy in 204 (4.8 %) patients. Overall mortality was 7.4 % (319 patients), with no difference between antibiotics. When data from the three studies with severe pneumonia were pooled together, mortality with fluoroquinolones alone was statistically superior to macrolides alone (72.8 % vs 30.8 %, p value 0.027). Hospital length of stay and complications were comparable. Our findings suggest that macrolides and quinolones were comparable for hospitalized Legionella pneumonia. However, in severe pneumonia, a randomized clinical trial is an unmet clinical need. PROSPERO registration number: CRD42023389308., Competing Interests: Declarations of Competing Interest None., (Copyright © 2023 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Introduction: Severe Legionnaires' disease (LD) can lead to multi-organ failure or death in 10%-30% of patients. Although hyper-inflammation and immunoparalysis are well described in sepsis and are associated with high disease severity, little is known about the immune response in LD. This study aimed to evaluate the immune status of patients with LD and its association with disease severity., Methods: A total of 92 hospitalized LD patients were included; 19 plasmatic cytokines and pulmonary Legionella DNA load were measured in 84 patients on the day of inclusion (day 0, D0). Immune functional assays (IFAs) were performed from whole blood samples collected at D2 and stimulated with concanavalin A [conA, n = 19 patients and n = 21 healthy volunteers (HV)] or lipopolysaccharide (LPS, n = 14 patients and n = 9 HV). A total of 19 cytokines (conA stimulation) and TNF-α (LPS stimulation) were quantified from the supernatants. The Sequential Organ Failure Assessment (SOFA) severity score was recorded at D0 and the mechanical ventilation (MV) status was recorded at D0 and D8., Results: Among the 84 patients, a higher secretion of plasmatic MCP-1, MIP1-β, IL-6, IL-8, IFN-γ, TNF-α, and IL-17 was observed in the patients with D0 and D8 MV. Multiparametric analysis showed that these seven cytokines were positively associated with the SOFA score. Upon conA stimulation, LD patients had a lower secretion capacity for 16 of the 19 quantified cytokines and a higher release of IL-18 and MCP-1 compared to HV. IL-18 secretion was higher in D0 and D8 MV patients. TNF-α secretion, measured after ex vivo LPS stimulation, was significantly reduced in LD patients and was associated with D8 MV status., Discussion: The present findings describe a hyper-inflammatory phase at the initial phase of Legionella pneumonia that is more pronounced in patients with severe LD. These patients also present an immunoparalysis for a large number of cytokines, except IL-18 whose secretion is increased. An assessment of the immune response may be relevant to identify patients eligible for future innovative host-directed therapies., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Allam, Mouton, Testaert, Ginevra, Fessy, Ibranosyan, Descours, Beraud, Guillemot, Chapalain, Albert-Vega, Richard, Argaud, Friggeri, Labeye, Jamilloux, Freymond, Venet, Lina, Doublet, Ader, Trouillet-Assant and Jarraud.)

BACKGROUND Legionnaires' disease is one of the most common types of community-acquired pneumonia. It can cause acute kidney injury and also occasionally become severe enough to require continuous renal replacement therapy (CRRT). Non-occlusive mesenteric ischemia (NOMI) is a condition characterized by ischemia and necrosis of the intestinal tract without organic obstruction of the mesenteric vessels and is known to have a high mortality rate. CASE REPORT A 72-year-old man with fatigue and dyspnea was diagnosed with Legionnaires' disease after a positive result in the Legionella urinary antigen test pneumonia confirmed by chest radiography and computed tomography. He developed acute kidney injury, with anuria, rhabdomyolysis, septic shock, respiratory failure, and metabolic acidosis. We initiated treatment with antibiotics, catecholamines, mechanical ventilation, CRRT, steroid therapy, and endotoxin absorption therapy in the Intensive Care Unit. Despite ongoing CRRT, metabolic acidosis did not improve. The patient was unresponsive to treatment and died 5 days after admission. The autopsy revealed myoglobin nephropathy, multiple organ failure, and NOMI. CONCLUSIONS We report a fatal case of Legionnaires' disease complicated by rhabdomyolysis, acute kidney injury, myoglobin cast nephropathy, and NOMI. Legionella pneumonia complicated by acute kidney injury is associated with a high mortality rate. In the present case, this may have been further exacerbated by the complication of NOMI. In our clinical practice, CRRT is a treatment option for septic shock complicated by acute kidney injury. Thus, it is crucial to suspect the presence of NOMI when persistent metabolic acidosis is observed, despite continuous CRRT treatment.

Background: Infections have been recognized as an uncommon cause of rhabdomyolysis, with evidence indicating a worse prognosis when compared to rhabdomyolysis caused by other etiologies. Diseases caused by Legionella pneumophila can present variably, ranging from mild to severe illness, as is sometimes the case with pneumonia. In particular, the triad of Legionnaire's disease, rhabdomyolysis, and acute kidney injury is associated with a significant increase in the morbidity and mortality, with most patients requiring initiation of renal replacement therapy such as hemodialysis. While the exact mechanism of both the muscle and kidney injury in this setting remains unknown, several hypotheses exist, with some research suggesting multiple yet distinct processes occurring in both target organs., Case Presentation: In this case report, we describe a 53-year-old African American man who presented with Legionella pneumophila pneumonia complicated by rhabdomyolysis and acute kidney injury. He was treated with aggressive fluid resuscitation and a 2-week course of azithromycin. His clinical status improved without necessitating renal replacement therapy or mechanical ventilation. We postulate that early recognition and treatment were key to his recovery. He was discharged 10 days later without recurrence of rhabdomyolysis at the time of this report., Conclusion: While there are several well-established and more common causes of rhabdomyolysis, clinicians should recognize Legionella sp. as an etiology, given its association with significant morbidity and mortality., (© 2023. The Author(s).)

Clinically mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) is a clinicoradiologic syndrome diagnosed by temporary hyperintense lesion in the area, including the splenium of the corpus callosum, on diffusion-weighted imaging and neuropsychiatric symptoms that recover without sequelae. MERS is rare in adults, especially elderly people. We herein report a man in his 60s diagnosed with MERS caused by Legionella pneumonia. He completely recovered with only the administration of levofloxacin and azithromycin despite the risk factors of an advanced age, medical history of untreated hypertension, bilateral spontaneous pneumothoraxes, smoking and drinking habits and pulmonary emphysema. To our knowledge, this is the oldest case of MERS due to Legionella pneumonia and extremely old among total MERS cases. Our research revealed that Legionella species are the most common pathogens of adult-onset MERS, while viruses are the main causative factors in children. This case helps clarify the features of MERS in high-risk adults., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Abstract: Legionnaires disease is an important, relatively uncommon, yet well known form of atypical community-acquired pneumonia (CAP). If not appropriately treated in the early stage of infection, it can be fatal. Several factors increase the risk of contracting Legionnaires disease, including age over 50 years, chronic cardiovascular disease, underlying respiratory disease, chronic renal disease, diabetes, smoking, any immunosuppressing condition, travel history, and certain types of employment. Legionnaires disease can present without the usual symptoms associated with pneumonia. The incidence of Legionnaires disease is increasing, and because of its morbidity and mortality, clinicians should consider it in the differential when treating patients with CAP. This article reviews the pathophysiology and treatment of Legionnaires disease and when to refer patients to tertiary centers for higher levels of care, including extracorporeal membrane oxygenation., (Copyright © 2022 American Academy of Physician Associates.)

BACKGROUND We report a case of diffuse alveolar hemorrhage (DAH) caused by Legionella pneumophila serogroup (SG) 1 and review the existing literature to identify risk factors and determine the prognosis of patients with Legionella pneumonia-associated DAH. CASE REPORT A 44-year-old woman was admitted to our hospital following the presentation of dyspnea for a few days. Chest computed tomography (CT) findings revealed "crazy-paving" pattern in the right upper lobe implicating DAH and consolidation in the lower lobe. Analysis of the bronchoalveolar lavage (BAL) fluid revealed DAH, with further analyses identifying L. pneumophila SG 1 as the causative agent. The patient was successfully treated with levofloxacin and a red blood cell transfusion and discharged on the 32nd day of hospitalization. A literature review of 6 reported cases (including our case) of Legionella pneumonia-associated DAH revealed that the median age of patients with DAH was 59 years (range, 44-75 years), involving female patients in 4 cases (67%) and the use of immunosuppressive drugs in 2 cases (33%). Three cases were BAL Legionella polymerase chain reaction (PCR)-positive and 4 cases were diagnosed using a urinary Legionella antigen test (one case was simultaneously PCR-positive). These infections were caused by L. pneumophila SG 1 in three cases and SG 3 in one case. Mechanical ventilation was used in 5 cases (83%) and one patient had an unfavorable prognosis. Steroids for DAH were used in 5 cases (83%), and 2 cases responded to this treatment. CONCLUSIONS Our case highlights that clinicians should be aware of Legionella spp. as a cause of DAH in an immunocompetent host with "crazy-paving" pattern on chest CT, and perform a urinary antigen test and BAL PCR for diagnosis.

Introduction: Legionnaire's disease is a community-acquired pneumonia caused by the Gram-negative bacterium Legionella pneumophila. This disease is often associated with neurological symptoms, the clinical presentation of which can be very varied., Case Report: We report a 47-year-old female patient who developed Legionnaires' disease with cerebellar symptoms (ataxia, dysarthria and hypermetria). Laboratory tests revealed a biological inflammatory syndrome. The cerebrospinal fluid was sterile. Urinary antigen test and serology were positive for L. pneumophila. An interstitial syndrome of the right upper lobe was detected on chest computed tomography (CT) scan. Brain imaging (magnetic resonance imaging and CT angiography) showed no abnormalities. The outcome was favourable after treatment with spiramycin, levofloxacin and corticosteroids., Discussion: Few cases only (n=110) of Legionnaires' disease with cerebellar symptoms have been reported in the literature. The pathogenic mechanism behind neurological dysfunction in patients with Legionnaires' disease is unknown. Neurological symptoms improve with antibiotic therapy and corticosteroids. Extra-pulmonary forms of Legionnaires' disease are frequent, with neurological symptoms being the most common symptoms. Cerebellar dysfunction may be underestimated and requires appropriate management with antibiotic therapy and corticosteroid therapy. Recommendations for the management of Legionnaire's disease with severe extra-pulmonary symptoms are needed., (Copyright © 2022 Société Nationale Française de Médecine Interne (SNFMI). Published by Elsevier Masson SAS. All rights reserved.)

BACKGROUND Legionella infection is a common cause of atypical pneumonia, known as Legionnaires' disease when infection extends to extrapulmonary involvement, which often leads to hospitalization. The triad of Legionella pneumonia, rhabdomyolysis, and renal failure displays a rare yet fatal complication without prompt management. CASE REPORT Our patient was a 62-year-old man with no significant medical history who developed Legionnaires' disease with severely elevated creatinine phosphokinase (CPK) of 9614 mcg/L, consistent with rhabdomyolysis. He experienced severe headache, anorexia, and hematuria, which prompted him to seek medical care. Pertinent social history included recent flooding in his neighborhood, which surrounded the outer perimeter of his home. His clinical manifestations and laboratory findings were consistent with Legionella infection, with concomitant acute kidney injury. A chest X-ray revealed hazy left perihilar opacities concerning for atypical pneumonia. Immediate interventions of hydration and antigen-directed azithromycin were initiated to prevent rapid decompensation. His clinical symptoms resolved without further complications, and he was not transferred to the Intensive Care Unit (ICU). CONCLUSIONS Legionella-induced rhabdomyolysis is an uncommon association that can lead to acute kidney failure and rapid clinical deterioration. Early and aggressive management with fluid repletion and appropriate antibiotics can improve clinical manifestations and hospital length of stay. Our patient's reduction in CPK levels and clinical improvement confirmed that extrapulmonary involvement in Legionella infection can lead to rhabdomyolysis. It is important for healthcare providers to recognize the clinical triad of Legionella pneumonia, rhabdomyolysis, and renal failure as prompt and timely management to reduce associated morbidity.

Background: Acute fibrinous and organizing pneumonia (AFOP) is a rare clinicopathological condition. Studies in the literature have reported that AFOP may be associated with respiratory infections, such as respiratory syncytial virus, influenza virus, Pneumocystis jirovecii, Penicillium citrinum, and Chlamydia infections. However, AFOP associated with Legionella infection has not been reported previously. Here, we report a case of a patient with AFOP secondary to Sjögren's syndrome and Legionella infection., Case Presentation: A 47-year-old man was admitted to the hospital because of fever, expectoration, and shortness of breath. Lung imaging showed irregular patchy consolidation. A diagnosis of Legionella pneumonia was initially considered on the basis of the patient's history of exposure to soil before disease onset, signs of extrapulmonary involvement, and a positive Legionella urine antigen test result. However, the patient's symptoms and lung imaging did not improve after treatment with levofloxacin, moxifloxacin, and tigecycline for Legionella infection. In addition, Sjögren's syndrome was diagnosed on the basis of clinical manifestations and immunological indicators. Pathological changes associated with AFOP were confirmed from the results of ultrasound-guided percutaneous lung biopsy. The patient's clinical symptoms improved rapidly after a short course of low-dose corticosteroid therapy, and lung imaging showed significant improvement., Conclusions: The possibility of secondary AFOP should be considered when Legionella pneumonia does not improve after standard antibiotic therapy. Lung biopsy and histopathological examination are important for the adjustment of treatment strategy. Our case also highlights the importance of screening for autoimmune diseases in patients with AFOP., (© 2022. The Author(s).)

Coronavirus disease-2019 (COVID-19) and legionnaires disease (LD) caused by Gram-negative water-born bacteria Legionella pneumophila show certain similarities, including a predisposition to pulmonary involvement and extrapulmonary manifestations in some of the patients infected. One disease can mimic the other, both can rarely coexist., Case Series Report: The authors describe 7 such cases (5 females), aged 51-90 years (mean 69.7 years) detected while screening 133 subjects with moderate to severe pneumonia and confirmed COVID- 19, which constituted 5.3% of the patients in whom urinary antigen test (UAT) for L. pneumophila was performed. The patients had multiple concomitant disorders: hypertension (6), heart failure (4), diabetes (4), obesity (4), coronary heart disease (3), chronic kidney disease (3), chronic obstructive pulmonary disease (3), anemia (3). Positive UAT was obtained at admission in 4 patients, and on 3rd, 11th and 14th days of hospitalization in the remaining 3 patients. One patient also had positive UAT for Streptococcus pneumoniae. We analyzed: radiological imaging, laboratory data (CRP, interleukin-6, procalcitonin, troponin I, BNP), ECG, echocardiography, treatment and outcome. Three patients required a modification of initial antibiotic therapy, two developed Clostridioides difficile infection. The duration of hospitalization ranged from 13 to 59 days (mean 24.3 days); two patients died., Conclusions: The authors suggest that the coexistence of COVID- 19 and LD may result in prolonged hospitalization, in increased mortality risk and in subsequent cardiovascular complications, including takotsubo syndrome (TTS) which was found in 2 cases, both presented as focal TTS (fTTS)., (© 2022 MEDPRESS.)

A 42-year-old diabetic man presented to the hospital with severe sepsis and multiorgan dysfunction. A probable respiratory source of sepsis was suspected because of suggestive clinical and radiological findings. He was critically ill and was therefore admitted to intensive care for further management including ventilatory support and renal replacement therapy. He was also found to have marked anaemia requiring multiple blood transfusions with clinical and laboratory evidence pointing towards severe haemolysis. Further workup for the aetiology of pneumonia established a diagnosis of Legionella by confirmatory tests namely legionella antigen in the urine and exponentially rising serum antibody titres. The cause for the severe haemolysis was found to be complement-mediated autoimmune haemolysis as determined by direct antiglobulin test positive for complement components C3 and negative for IgG. Such clinically significant autoimmune haemolysis as a presenting feature, rather than a late complication, has never before been reported in the literature., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Legionella bacteria is a common cause of pneumonia, but the infection may affect several organs in the most serious cases. A systemic involvement ab initio could be non-specific, leading to a diagnostic misinterpretation., Case Presentation: A 33-year-old woman had been complaining of mental confusion, restlessness, aggressiveness, and, subsequently, hirsutism. After 3 weeks, the patient developed pneumonia and died during the hospitalization. The autopsy examination revealed a multi-organ necrotizing exudative disease involving the lung, the heart and the brain. The microbiological tests of tracheal aspirate were positive for Legionella pneumophila serotype 1., Conclusion: The Legionella infection may show a proteiform clinical course and an extra-pulmonary manifestation may be the first sign of the disease. Herein, we report a case of Legionella infection in a young female, presenting with non-specific neurological symptoms and hirsutism at onset, misdiagnosed as a metabolic disease.

Legionnaires' disease (LD) is an established cause of pneumonia, and the disease remains largely underdiagnosed. Even though LD has been reported from many parts of the world, only sporadic cases have been reported in India. During February 2015-January 2020, we enrolled 597 patients with radiographically confirmed pneumonia and tested respiratory secretions for Legionella spp. by using real-time PCR, and culture. A commercial urinary antigen test (UAT) was also used to detect the Legionella pneumophila (Lp) serogroup 1 antigen in urine. An LD case was defined as a patient with pneumonia and positive results for Legionella spp. infections determined by real-time PCR (from any respiratory specimen) or culture or UAT. Demographic data, risk factors, clinical, radiological, and outcome data of Lp-positive and Lp-negative patients were compared using logistic regression. Over the study period, 14 (2.3%) patients were positive for Legionella spp. infections by real-time PCR and UAT; eight (57%) were admitted to the intensive care unit, and four (28.6%) in-hospital deaths occurred. Bivariate analysis showed that renal disease, neurological conditions, confusion, leukocytosis, and requirement of oxygen support were more common in the Lp-positive group than in the Lp-negative group. However, multivariate analysis failed to confirm most of these differences; renal disease was the only independent variable remaining significant. All test methods have intrinsic limitations in identifying Legionella; therefore, more than one testing method should be used. Application of molecular assays including real-time PCR has great value because of its high sensitivity, specificity, and rapid diagnostic potency. Increased awareness and improved diagnostic testing could facilitate early detection of cases, pathogen-directed therapy, and improved outcomes for patients.

Introduction: Legionnaires' disease is caused by Legionella bacteria, and commonly manifests as pneumonia and has a high fatality rate., Patient Concerns: This case study reports on the fatal incident of a patient, initially diagnosed with pneumonia, and subsequently diagnosed with Legionnaires' disease caused by a new sequence type (ST) of Legionella., Diagnosis: It is speculated that the patient acquired Legionnaires' disease from a contaminated water source. Legionnaires' disease was diagnosed using the Legionella urinary antigen assay and bacterial cultures of respiratory secretions; Legionella pneumophilia Type 1 was also identified through serological testing. Sequence-based typing of the cultured bacterium revealed it to be a previously unidentified species, and it was named ST2345 new-type., Interventions: In addition to the treatment of Legionnaires' disease, blood samples taken on the second day of admission showed a co-infection of Candida tropicalis, which was treated with anti-fungal treatment. The patient improved after a week, however, on the seventh day of administration lower respiratory secretions showed the growth of Klebsiella pneumonia, indicative of ventilator-associated pneumonia., Outcomes: Despite active treatment, the patient passed away due to multiple organ failure. As this was a fatal case, further research is needed to determine whether the critical condition of this case was related to the virulence of the novel Legionella strain., Conclusion: A key finding of this study is that treatment for suspected Legionnaires' disease must be administered rapidly, as infection with Legionella may give rise to secondary pathogenic infections.

Aspergillus fumigatus can cause a wide range of diseases, from hypersensitivity to invasive infection. Invasive disease usually occurs in severely immunocompromised patients with deep and prolonged neutropenia. It is a less well-recognized complication in critically ill patients without traditional risk factors. We describe a case of early invasive pulmonary aspergillosis (IPA) secondary to Legionella pneumophila serogroup 1 pneumonia in a patient on an intensive care unit (ICU). In addition to commonly accepted risk factors for IPA in ICU patients, we hypothesis that L. pneumophilia pneumonia could enhance this type of infection. We also reviewed all published cases of coinfection with L. pneumophila and A. fumigatus to assess whether Legionnaires' disease could be a risk factor for IPA., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Objective: To summarize the clinical course, neuroimaging and cerebrospinal fluid (CSF) analyses of cerebellar dysfunction in Legionnaires' disease. Methods: A case of Legionnaires' disease with pronounced cerebellar involvement was reported. The related literatures published up to February 2019 were reviewed with "Legionella, legionellosis, legionnaires' disease, cerebellum, cerebellar" as the keywords in CNKI, Wanfang and PubMed databases. Results: A 69-year-old man complained of anorexia and diarrhea for several days. He was subsequently admitted to the hospital after he had fever, ataxia, dysarthria and involuntary tremor. Chest CT revealed right lower lobe pneumonia. Routine urinalysis showed hematuria and proteinuria. Serum alanine transaminase was 52 U/L, creatinine 137 μmol/L, sodium 128 mmol/L, and creatine kinase 6 893 U/L. Cranial CT was normal. Analysis of CSF showed mildly elevated total protein. Legionella colonies isolated from bronchoalveolar lavage fluid was positive by PCR. After initial treatment with moxifloxacin and azithromycin for 7 days, the fever and neurological symptoms persisted. Corticosteroid therapy was administered for 3 days, the fever resolved, whereas the neurological symptoms improved gradually and slowly by 4 weeks of antibiotic therapy. Finally, successive serological test confirmed Legionella pneumophila serogroups 6 and 7 by indirect immunofluorescence. Twenty-one literatures with 23 cases were reviewed, and plus our case, there were a total of 24 cases for analysis. There were 16 males and 8 females, aged from 22 to 71 years. Ataxia and dysarthria were the cerebellar symptoms most frequently reported, occurring in 22 and 18 cases, respectively. All patients had various central and peripheral neuropathies during their illness. Neuroimaging and analysis of CSF was reported in 21 cases. There were no abnormalities in 18 cases of cranial imaging, 1 case with slight hydrocephalus on cranial CT, and 3 cases with hyperintensity in the splenium of corpus callosum on cranial MRI. Eighteen cases of CSF analyses were normal, whereas 1 case with elevated lymphocytes and 3 cases with elevated proteins. Nine cases were eventually identified as Legionella pneumophila serotype 1 by urinary antigen detection, 1 case as Legionella pneumophila serogroups 6 and 7, while the remaining 14 were unknown serotype. Long-term neurologic follow-up showed that 3 cases recovered completely in the first week, while 19 cases improved slowly in the following 3 weeks, and 13 cases had persistent deficits of gait or speech after 3 months. Conclusions: Legionellosis with cerebellar insufficiency is rare. It may be misdiagnosed in the onset of illness. After treatment, there is a trend of slow recovery and neurological symptoms may persist in long-term follow-up.

A 44-year-old right-handed man with a 5-day history of non-productive cough associated with subjective fevers/chills and night sweats presented to the emergency department with slurred speech. Radiography and urine antigen testing confirmed the diagnosis of Legionella pneumonia The hospital course was complicated by acute hypoxic respiratory failure that required 7 days of invasive mechanical ventilation. Following extubation, the patient had dysarthria and developed new parkinsonism features. Brain imaging revealed a non-specific focal lesion in the left frontal lobe of unclear significance. Ciprofloxacin was decided as the final antibiotic of choice for its favourable central nervous system profile. Levodopa-carbidopa was initiated to help activate the basal ganglia. The patient had complete resolution of pneumonia and transient parkinsonism. He was able to regain most of his baseline functional status with intensive rehabilitation., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

L. pneumophila is an unusual cause of pneumonia with a prevalence of 2.7%, and it is even more uncommon in pregnancy. To date, only 11 cases of Legionnaire's Disease in pregnancy have been reported, though this small number could possibly be attributed to underdiagnoses and under documentation. Case Presentation: In this paper, we present a 31-year-old Hispanic female, gravida 4, para 1 from the southwest United States who presented with a 3-week history of fever, worsening cough, dyspnea on exertion, and hypoxemia. Chest x-ray showed bibasilar infiltrates, with positive serology for Legionella IgM and IgG (1:250 and 1:640 respectively), as well as positive urinary antigen. Despite appropriate treatment with azithromycin 500 mg, she continued to have dyspnea and mild respiratory distress. Conclusion: Upon follow up, mother and fetus initially remained stable without any signs of sequelae from Legionnaire's disease, but the patient miscarried 5 weeks after the second admission to the hospital. The chest x-ray eventually cleared up after almost 21 days of azithromycin., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Over the past decade, the reported incidence of Legionnaires' disease (LD) in the northeastern United States has increased, reaching 1-3 cases per 100,000 population. There is reason to suspect that this is an underestimate of the true burden, since LD cases may be underdiagnosed. In this analysis of pneumonia and influenza (P&I) hospitalizations, we estimated the percentages of cases due to Legionella, influenza, and respiratory syncytial virus (RSV) by age group. We fitted mixed-effects models to estimate attributable percents using weekly time series data on P&I hospitalizations in Connecticut from 2000 to 2014. Model-fitted values were used to calculate estimates of numbers of P&I hospitalizations attributable to Legionella (and influenza and RSV) by age group, season, and year. Our models estimated that 1.9%, 8.8%, and 5.1% of total (all-ages) inpatient P&I hospitalizations could be attributed to Legionella, influenza, and RSV, respectively. Only 10.6% of total predicted LD cases had been clinically diagnosed as LD during the study period. The observed incidence rate of 1.2 cases per 100,000 population was substantially lower than our estimated rate of 11.6 cases per 100,000 population. Our estimates of numbers of P&I hospitalizations attributable to Legionella are comparable to those provided by etiological studies of community-acquired pneumonia and emphasize the potential for underdiagnosis of LD in clinical settings., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Legionella pneumophila infection (legionellosis) usually presents as a multisystemic disease, predominantly affecting the lungs (Legionnaires' disease - LD). Immunodeficiency, chemotherapy or chronic steroids use increase the risk of developing LD. Extrapulmonary manifestations of LD include cardiac complications: myocarditis, pericarditis or endocarditis., A Case Report: The authors describe a case of a 51-year-old female with a history of cryoglobulinemic vasculitis, Sjögren syndrome and chronic lymphocytic leukemia who was admitted due to a high fever, fatigue, tachycardia, dyspnea and cough. Chest X-ray and CT showed bilateral pulmonary infiltrations and pleural effusion. LD was diagnosed on positive L. pneumophila urinary antigen test. Echocardiography revealed severe left ventricular (LV) dysfunction with substantially decreased ejection fraction and global longitudinal strain (GLS), with a pattern resembling reverse takotsubo syndrome (rTTS). The coronary arteries in non-invasive coronary angiography were normal. During therapy with levofloxacin and intravenous immunoglobulins as well as with carvedilol, ramipril and diuretics, gradual clinical improvement with complete normalization of LV function was observed within 5 weeks. Cardiac magnetic resonance (CMR) performed on day 35 revealed only small intramural foci of late gadolinium enhancement (LGE) with localization not corresponding to the most decreased regional longitudinal strain in the initial echocardiographic examination. The authors suggest that the mechanism of transient LV dysfunction in the case presented may have been of complex nature, including LD myocarditis and stress-induced cardiomyopathy (with the prevalence of the latter) which has not so far been reported in the literature., (© 2019 MEDPRESS.)

Legionnaires' disease is a recognised but rare cause of rhabdomyolysis. It can be further complicated with renal impairment. In this case report, we describe a previously healthy, semiactive 50-year-old man who within days was reduced to having periods of dyspnea after minutes of walking in addition to near fatal acute renal failure. He was found to have the rare triad of Legionella pneumonia, renal failure and rhabdomyolysis, which is associated with high morbidity and mortality. He was treated according to guidelines with azithromycin monotherapy and aggressive fluid hydration. 20 days after admission, the patient was walking independently and discharged home., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective:: To analyze the management and outcome of patients with refractory respiratory failure complicating severe Legionella pneumonia rescued with extracorporeal membrane oxygenation (ECMO) in our Center., Design and Setting:: Observational study of patients with refractory respiratory failure treated with ECMO in Hospital S.João (Porto, Portugal), between November 2009 and September 2016., Participants:: A total of 112 patients rescued with ECMO, of which 14 had Legionella pneumonia., Results:: Patients with Legionella pneumonia were slightly older than patients with acute respiratory failure of other etiologies (51 [48-56] vs 45 [35-54]), but with no significant differences in acute respiratory failure severity between groups: Pao 2 /Fio 2 ratio 67 (60-75) versus 69 (55-85) and Respiratory Extracorporeal Membrane Oxygenation Survival Prediction score 4 (1-5) versus 2 (-1-4), respectively. Legionella pneumonia was associated with earlier ECMO initiation (days of invasive mechanical ventilation [IMV] before ECMO: 2.0 [1.0-4.0] vs 5.0 [2.0-9.5]). After IMV adjustment to "lung rest" settings, this group presented higher respiratory system (RS) static compliance (28.7 [18.8-37.4] vs 16.0 [10.0-20.8] mL/cmH 2 O) but required higher ECMO support (blood flow 5.0 [4.3-5.4] vs 4.2 [3.6-4.8]). Patients with Legionella pneumonia had shorter IMV (16 [14-23] vs 27 [20-42] days) and lower incidence of intensive care unit nosocomial infections (35.7% vs 64.3%), with a trend to higher hospital survival (85.7% vs 62.2%; P = .13)., Conclusion:: In Legionella pneumonia complicated by refractory respiratory failure, ECMO support allowed patient stabilization under lung protective ventilation and high survival rates. Timely ECMO referral should be considered for Legionella pneumonia failing conventional treatment.

Legionella pneumonia is occasionally accompanied by renal complications; however, the cause of this remains unknown. We herein report a 70-year-old Japanese man with Legionella pneumonia who presented with hyponatremia, hypophosphatemia, and hypouricemia. The levels of urinary β2-microglobulin and N-acetyl-β-D-glucosaminidase were remarkably high, indicating severe renal tubular damage. The presence of glycosuria and aminoaciduria as well as increased fractional excretion of uric acid and decreased tubular reabsorption of phosphate indicated that the patient's condition was complicated with Fanconi syndrome. After antimicrobial therapy, the electrolyte abnormalities and renal tubular damage were completely resolved.

Background: Legionellosis is a well-known cause of pneumonia. Primary cutaneous and subcutaneous infection caused by Legionella pneumophila is rare and the diagnosis is challenging., Case Presentation: A 38-year-old Thai woman with systemic lupus erythematosus and myasthenia gravis treated with prednisolone and azathioprine presented to our hospital with low-grade fever, diarrhea, and indurated skin lesions on both thighs. Initial examination showed plaques on both inner thighs. Magnetic resonance imaging showed myositis and swelling of the skin and subcutaneous tissue. Diagnosis of panniculitis due to L. pneumophila was carried out by histopathology, Gram stain, and 16S rRNA gene sequencing method of tissue biopsy from multiple sites on both thighs. Myocarditis was diagnosed by echocardiography. The final diagnosis was disseminated extrapulmonary legionellosis. Treatment comprised intravenous azithromycin for 3 weeks and the skin lesions, myositis and myocarditis resolved. Oral azithromycin and ciprofloxacin were continued for 3 months to ensure eradication of the organism. The patient's overall condition improved., Conclusions: To our knowledge, we report the first case of L. pneumophila infection manifesting with panniculitis, possible myositis, and myocarditis in the absence of pneumonia. The diagnosis of extrapulmonary Legionella infection is difficult, especially in the absence of pneumonia. A high index of suspicion and appropriate culture with special media or molecular testing are required. Initiation of appropriate treatment is critical because delaying therapy was associated with progressive infection in our patient.

We investigate whether the clinical presentations and outcomes of Legionella pneumonia in human immunodeficiency virus (HIV)-infected patients were comparable to those seen in non-HIV-infected patients (case-control design). HIV-infected individuals presented neither a more severe disease nor a worse clinical outcome than matched HIV-negative control patients.

A 1-month-old girl developed respiratory failure due to bilateral interstitial pneumonia after bathing in reheated and reused water. A molecular test for sputum and an environmental culture detected Legionella pneumophila serotype 1. This is the first report of infantile legionellosis contracted from a bathtub at home.

An index case of Legionnaires's disease with mediastinal adenopathy prompted us to review our recent experience with Legionnaires' disease to determine the incidence of mediastinal adenopathy of this finding in Legionnaires' disease. We reviewed the radiographic findings of 90 hospitalized adults with Legionnaires' disease from 2015 to 2017. Excluded were 11 patients with mediastinal adenopathy due to non-Legionnaires' disease causes, e.g., lymphoma. Thirty-seven of the remaining patients had both chest films and chest computed tomography (CT) scans. Of the 37 Legionnaires' disease cases, 13/37 (35%) had mediastinal adenopathy and 8/27 (24%) also had unilateral hilar adenopathy. These chest CT findings were not seen on chest films. Chest CT scans are needed to detect mediastinal adenopathy in Legionnaires' disease. Mediastinal adenopathy may be due to Legionnaires' disease or a malignancy. Some findings in Legionnaires' disease are also present in mediastinal adenopathy due to lymphomas, e.g., highly elevated erythrocyte sedimentation rate (ESR), lactate dehydrogenase (LDH), and ferritin. Hospitalized adults with Legionnaires' disease and mediastinal adenopathy should have serial chest CT scans to monitor resolution of the mediastinal adenopathy. In hospitalized adults with otherwise unexplained persistent mediastinal adenopathy, they should be considered as being due to another etiology, e.g., lymphoma, until proven otherwise.

The Acute Respiratory Distress Syndrome (ARDS) is defined by hypoxemic respiratory failure due to inflammatory response within the lung usually requiring invasive mechanical ventilation. Despite more than 50 years of scientific research numerous issues especially regarding mechanical ventilation as the most important treatment option remain unclear. Most important, adjustment of mechanical ventilation is challenging due to desirable beneficial effects on pulmonary gas exchange on the one hand and deleterious effects in terms of ventilator-associated lung injury on the other. Specifically, optimal settings of positive end-expiratory pressure and the role of spontaneous breathing activity are still controversial. Because no specific pharmacological therapy revealed beneficial effects until today, adjunctive treatment is actually limited to prone positioning and restrictive fluid balance. Long-term outcome of ARDS survivors is often affected by anxiety and mental health disorders., Competing Interests: Die Autoren erklären, dass kein Interessenkonflikt vorliegt., (Georg Thieme Verlag KG Stuttgart · New York.)

Legionnaires' disease (LD) can be fatal among high-risk transplant recipients. To understand the epidemiology of LD, we reviewed 15-year longitudinal data from a center in Seattle, Washington that cares for both solid organ transplant (SOT) and hematopoietic cell transplant (HCT) recipients. We identified all laboratory-confirmed LD and extracted data on species, diagnostic modalities, clinical presentation, management, and outcomes from medical records. Among 32 patients with LD, transplant recipients made up the majority of diagnoses (22, 69%; SOT 10, HCT 12). Approximately 0.8% of transplant recipients who underwent Legionella-specific testing were positive. Non-pneumophila Legionella species (LNLP), which are not detected by urinary antigen test, accounted for half the cases, led by Legionella micdadei (32%). The severity and outcome between Legionella pneumophila and LNLP infections were similar (attributed mortality, 36% vs 27%); all LNLP deaths occurred in transplant recipients with L. micdadei. The clinical and radiological features mimicked other opportunistic pathogens; 32% (n=7) were not on empiric treatment at the time of diagnosis. These data add to the emerging literature describing the importance of LD and highlight the need for both routine Legionella testing on transplant recipients with pulmonary findings and empiric Legionella-active antibiotic therapy., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Legionnaire's disease (LD) is mainly reported in apparently immunocompetent patients. Among them, risk factors include chronic lung disease and smoking. However, LD is also well reported among immunocompromised patients, particularly those treated with anti-tumor necrosis factor alpha therapy, patients with hematological malignancy, and transplant patients. This article discusses the available data on immunity against Legionella spp, epidemiology, clinical presentation, diagnosis, and treatment of LD in immunocompromised patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: A case report of Legionella pneumophila pneumonia associated with off-label use of ustekinumab in a patient with Crohn's disease (CD) is presented., Summary: A 57-year-old man with longstanding CD was hospitalized with a four-day history of fever (38.5 °C), dyspnea, left pleuritic pain, and weight loss (more than 6 kg) about six weeks after beginning treatment with ustekinumab, a human monoclonal antibody approved in the United States for two indications (plaque psoriasis and psoriatic arthritis) and currently under investigation as a potential treatment for CD and other inflammatory disorders. During the preceding 25 years, the man had been treated for severe CD with a number of agents (e.g., infliximab, adalimumab, certolizumab); ultimately, off-label ustekinumab therapy (90 mg subcutaneously weekly) was initiated due to persistent severe CD symptoms. Chest x-ray studies at the time of admission demonstrated left upper lobar consolidation, and a urine antigen test was positive for L. pneumophila . The patient was treated with i.v. levofloxacin and methylprednisolone and discharged after two weeks. Ustekinumab was reintroduced (45 mg subcutaneously every two weeks), and the patient continued to receive the drug for 16 months, with clinical remission of CD symptoms and no further adverse events. A literature search identified two case reports of pneumonia associated with ustekinumab use, but neither case involved L. pneumophila ., Conclusion: Pneumonia caused by L. pneumophila developed in a patient with CD treated with ustekinumab. Pneumonia symptoms resolved after ustekinumab was discontinued., (Copyright © 2017 by the American Society of Health-System Pharmacists, Inc. All rights reserved.)

Objective Legionnaires' disease (LD) is a common form of lobar pneumonia, but the optimum diagnostic modality has long been a subject of debate due to incomplete sensitivity and specificity. A delay in the initiation of specific therapy for LD is associated with increased mortality. The decision to treat a patient for Legionella must be made quickly. The purpose of this study was to evaluate the ability of the modified Winthrop-University Hospital WUH system to identify LD while discriminating against pneumococcal pneumonia at the time of hospitalization for community-acquired pneumonia. Methods Five patients with LD and 13 patients with pneumococcal pneumonia were retrospectively analyzed. Results The WUH system identified 4 of 5 patients with LD (sensitivity, 80%) while excluding legionellosis in 12 of 13 patients with pneumococcal pneumonia (specificity, 92%). The positive and negative likelihood ratios were 10.4 and 0.2. The area under the receiver operating characteristic curve was 0.969. Conclusion The WUH system is useful for obtaining a rapid presumptive clinical diagnosis of LD. Further investigation with a larger number of patients is strongly recommended.

A middle-aged immunocompetent woman was diagnosed and treated for a severe pulmonary human herpesvirus 3 infection. During the treatment, an infection from Legionella pneumophila serogroup 1 was also diagnosed. This coinfection threatened the life of the patient and led to serious permanent sequelae. This report highlights the importance of preventing Legionella environmental contamination, suspecting Legionella coinfection in patients with viral pneumonia, and vaccinating susceptible adults against chickenpox., (Copyright © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

A 51-year-old man presented at the emergency department with a one-day history of fever, altered mental status, slurred speech, worsening gait instability, nausea, vomiting, and diarrhea. The patient did not have a history of alcoholism or drug abuse. On physical examination, crackles were heard over the right lower lobe. Neurological findings revealed ataxic gait, dysarthria and bilateral dysmetria upon finger-nose testing. The results of laboratory tests revealed leukocytosis, renal failure, and hyponatremia. Chest radiography and lung computed tomography (CT) revealed right lower lobe infiltrates with air bronchograms. The result of a urinary Legionella antigen test was positive. The results of brain CT and cerebrospinal fluid (CSF) analyses did not reveal any signs of infection, but brain magnetic resonance imaging (MRI) revealed a corpus callosum lesion upon admission. The patient's symptoms began to resolve after the administration of intravenous levofloxacin. A subsequent brain MRI examination performed 9 days after admission showed the complete resolution of the lesion. He was discharged 11 days after admission without any neurological sequelae. He was finally diagnosed as having clinically mild encephalitis/ encephalopathy with a reversible splenial lesion (MERS).

We present the case of a community-acquired pneumonia by Legionella Pneumophila in a 31-year-old patient with Crohn's disease under anti-TNF agents. Following this and other similar cases reported in literature, we propose to include recommendations to prevent this infection in patients starting treatment with immunosuppressant drugs through simple measures regarding the control of water in the patients' home.