Titilope Olanipekun1,2*, Chivon Stubbs1,3, Valery Effoe1,2, Leondus McIver4 and Harold Stringer1,2,5
1Department of Internal Medicine, Morehouse School of Medicine, Georgia, USA 2Department of Internal Medicine, Grady Memorial Hospital, Georgia, USA 3Department of Family Medicine, Morehouse School of Medicine, Georgia, USA 4Department of Internal Medicine, University of Louisville, Louisville, USA 5Division of Infectious Disease, Morehouse School of Medicine, Georgia, USAFulltext PDF
Background: Legionella pneumophila is a common cause of Community Acquired Pneumonia (CAP) which is often associated with a severe clinical course and a mortality rate of 5% to 25% among immunocompetent patients. Complications of Legionella infection include acute renal and respiratory failures, disseminated intravascular coagulation and septic shock which often require intensive level of medical care. Reported cases of myocardial dysfunction and acute systolic heart failure from legionella disease are rare. This case describes an atypical presentation of legionella pneumonia in a previously healthy patient complicated by multi-organ failure. Case Presentation: A 63 year old female with medical history of hypertension was admitted to the intensive care unit for acute onset of altered mental status, decreased oral intake, subjective fevers, dizziness and diarrhea. Physical exam was remarkable for temperature of 101.2 F, pulse rate 112 beats/minute, respiratory rate 22 cycles/minute and blood pressure 88/60 mmHg. Laboratory studies showed leukocytosis, markedly elevated serum Creatinine Kinase (CPK), and creatinine and lactic acid levels. Troponin was elevated; however no evidence of cardiac ischemia on electrocardiogram. Chest X-ray revealed right mid-lung opacities consistent with pneumonia. A Transthoracic Echo (TTE) showed reduced ejection fraction of 35% and urine legionella antigen test was positive for Legionella pneumophilia group 1 antigen. She was admitted to the medical Intensive Care Unit (ICU) and initiated on Intravenous (IV) fluids and empiric antibiotics for CAP (IV Ceftriaxone 2 g daily and Azithromycin 500 mg daily) and by day 5 of hospitalization, her fever had completely resolved and neurological status returned to normal. Her serum CPK and creatinine levels significantly improved and troponin levels normalized. She was discharged home to follow up with infectious disease and cardiology team outpatient. A repeat TTE six weeks later showed normal ejection fraction of 60% to 65% and a normal cardiac stress test. Conclusion: Legionella pneumohila is primarily a respiratory illness, however it has extrapulmonary manifestations. Cardiac complications of Legionella infection are uncommon. Studies have linked atypical organisms that cause CAP with cardiovascular disease through atherogenesis and atherosclerosis. Legionella infection should be considered as a possible etiology of systolic heart failure in patients with CAP and sepsis.
Infection; Cardiovascular; Critical; Heart failure; Legionella
Olanipekun T, Stubbs C, Effoe V, McIver L, Stringer H. Severe Legionnaire Disease Complicated by Multi-Organ Dysfunction: The Heart is not Spared. Int J Intern Emerg Med. 2019;2(2):1022.