Legionnaire's Disease: Difference between revisions

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<div class="editorbox"> '''Original Editor '''- Itayi Charasika [[Pathophysiology of Complex Patient Problems|from Bellarmine University's&nbsp;Pathophysiology of Complex Patient Problems project.]] <br> '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} </div>
'''Original Editors '''- Itayi Charasika&nbsp;[[Pathophysiology of Complex Patient Problems|from Bellarmine University's&nbsp;Pathophysiology of Complex Patient Problems project.]]  
 
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp; 
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==Definition/Description==
==Definition/Description==


Legionnaire’s Disease is a deadly severe form of pneumonia. It is the cause of nosocomial pneumonia. This disease can be fatal. Legionnaire’s disease is a lung infection. It is a disease caused by a bacteria, known as ''Legionella''. This disease is often screened for whenever a person is diagnosed with pneumonia because of the close resemblance Legionnaire’s has to pneumonia. Legionnaire’s disease is commonly from inhaling the bacteria. [[Image:Lunganatomy.jpg|frame|Legionnaire's Disease]] The history of Legionnaire's Disease, can be viewed below&nbsp;under ''History of Disease''.
Legionnaires' Disease is a severe form of [[pneumonia]] (lung infection) caused by a bacteria, known as ''Legionella''. It can occur through inhalation of contaminated aerosols such as humidifiers, hot and cold water systems, air conditioning cooling towers and whirlpool spas. Infection can also occur by exposure of babies during water births or aspiration of contaminated ice or water, particularly in susceptible hospital patients.  It can be a cause of community acquired pneumonia or [[Hospital Acquired Pneumonia|hospital acquired pneumonia]]<ref>Pedro-Botet M. L., Sabria-Leal M., Haro M., Rubio C., Gimenez G., Sopena N., Tor J.Nosocomial and community-acquired Legionella pneumonia: clinical comparative analysis. ''Eur. Respir. J.''8199519291933 retrieved from https://erj.ersjournals.com/content/8/11/1929.short</ref>. This disease is often screened for whenever a person is diagnosed with pneumonia because of the close resemblance Legionnaires' has to pneumonia.


<br>The bacteria, ''Legionella'', in Legionnaire’s disease can also lead to '''[http://medical-dictionary.thefreedictionary.com/Pontiac+fever Pontiac Fever]''', which is like a milder version of Legionnaire’s disease. Pontiac Fever resembles the flu. If a person is diagnosed with both illnesses, then the <u>term</u> is Legionellosis. Unlike Legionnaire’s disease, Pontiac Fever usually clears on it own<sup>1</sup>.
<br>The bacteria, ''Legionella'', in Legionnaires' disease can also cause a milder illness called Pontiac Fever. Pontiac Fever resembles a mild and self-resolving flu-like disease.<ref name=":0">Sharma L, Losier A, Tolbert T, Dela Cruz CS, Marion CR. Atypical Pneumonia: Updates on Legionella, Chlamydophila, and Mycoplasma Pneumonia. ''Clin Chest Med''. 2017;38(1):45–58. doi:10.1016/j.ccm.2016.11.011 retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5679202/</ref>  Unlike Legionnaires' disease, Pontiac Fever usually resolves on its own after 2-5 days.<ref name=":0" />If diagnosed with both illnesses, then the term is Legionellosis.


&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; [[Image:Ld image.jpg|Image:Ld_image.jpg]]
==History of Disease==


<br>'''<u>History of Disease</u>''': Legionnaire’s disease first came about in 1967 when a group of people in Philadelphia, attending an American Legion convention meeting became exposed to this disease.&nbsp;&nbsp;View ''Legionnaire's Disease ''video below or please visit http://www.youtube.com/watch?v=8oTf2bGCt-Y<nowiki/>.&nbsp;&nbsp;
Legionnaires' disease was first discovered  about in 1967 when a group of people in Philadelphia, attending an American Legion convention meeting were exposed to this disease. Those affected suffered from a type of pneumonia, now referred to as Legionnaires’ disease.


{{#ev:youtube|8oTf2bGCt-Y|300}}
The first identified cases of Pontiac fever occurred in 1968 in Pontiac, Michigan, among people who worked at and visited the city’s health department. It wasn’t until ''Legionella'' was discovered after the 1976 Legionnaires’ disease outbreak in Philadelphia that public health officials were able to show that ''Legionella'' causes both diseases.


== Prevalence==
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;[[Image:Lunganatomy.jpg|frame|Legionnaire's Disease]] 


Accurate data reflecting the true incidence of disease are not available because of underutilization of diagnostic testing and under-reporting. It is a common cause of severe pneumonia requiring hospitalization<sup>10</sup>.<br>
[[Image:Ld image.jpg|Image:Ld_image.jpg]]


'''<u>Facts</u>''':
<br>


*Responsible for ~ 5% of all pneumonias<sup>4</sup>
== Etiology ==
*12,000 people affected yearly in the U.S.<sup>4</sup>
The pathogen causing Legionnaires' Disease came from the ''Legionellaceae'' family of bacteria. Although the family ''Legionellaceae'' now contains more than 40 species, ''L. pneumophila'' causes over 90% of human infections. ''L micdadei'', the second most frequently isolated species in human infection, evidently has lower virulence for humans than ''L. pneumophila'' as it appears to infect only immunocompromised hosts.<ref>Myerowitz RL, Pasculle AW, Dowling JN et al. (1971) Opportunistic lung infection due to “Pittsburgh Pneumonia Agent”. N Engl J Med 301: 953–958.</ref> Water is the major natural reservoir for ''Legionella'', and the pathogen is found in many different natural and artificial aquatic environments such as cooling towers or water systems in buildings, including hospitals.<ref>Cunha BA, Burillo A, Bouza E, Legionnaires' disease, The Lancet, Volume 387, Issue 10016, 2016, Pages 376-385, ISSN 0140-6736, <nowiki>https://doi.org/10.1016/S0140-6736(15)60078-2</nowiki> retrieved from https://www.sciencedirect.com/science/article/pii/S0140673615600782</ref>
*Severe, sometimes fatal disease<sup>4</sup>
*Each year an estimated 8,000-18,000 hospitalized cases occur in the U.S.<sup>10</sup>
*The majority of reported cases are sporadic<sup>10</sup>
*Travel-associated outbreaks, outbreaks in community settings, and nosocomial and occupational outbreaks are common<sup>10</sup>
*More than 20% of all cases are thought to be associated with recent travel<sup>10</sup>  
*Difficult to detect among travelers because of the low attack rate, long incubation period, and the dispersal of persons&nbsp; from&nbsp;the source of the outbreak<sup>10</sup>
*Present rate is that 80% of those contracting the disease die<sup>26</sup>


&nbsp;<br>
Common places that allow Legionella transmission:<br>1. Potable (drinking) water systems<br>2. Whirlpool spas<br>3. Cooling towers&nbsp;


For recent breaking news on Legionnaire's Disease regarding&nbsp;California health officials investigating a mystery illness at the Playboy mansion possibly caused by a fog machine, please visit [http://www.youtube.com/watch?v=xk5dEOYtPbw&feature=fvsr http://www.youtube.com/watch?v=xk5dEOYtPbw&amp;feature=fvsr].  
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;[[Image:Images7.jpg]]&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<br>Conditions for Legionella transmission:<br>1. Heat<br>2. Stasis<br>3. Aerosolization


<br>
== Prevalence==
 
♦ Legionnaire's Disease is not only found in the United States, but it is worldwide.&nbsp;♦


&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; [[Image:World images.jpg|Image:World_images.jpg]]&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;[[Image:Images3.jpg]]
Accurate data reflecting the true incidence of disease are not available because of underutilization of diagnostic testing and under-reporting.<ref>Plouffe JF, Breiman RF, Fields BS, Herbert M, Inverso J, Knirsch C, Kolokathis A, Marrie TJ, Nicolle L, Schwartz DB, Azithromycin in the Treatment of ''Legionella'' Pneumonia Requiring Hospitalization, ''Clinical Infectious Diseases'', Volume 37, Issue 11, December 2003, Pages 1475–1480, <nowiki>https://doi.org/10.1086/379329</nowiki> retrieved from https://academic.oup.com/cid/article/37/11/1475/372119</ref> It is a common cause of severe pneumonia requiring hospitalization.<br>


&nbsp;&nbsp;
'''Facts''':


==Characteristics/Clinical Presentation==
*Responsible for ~ 5% of all pneumonias
*12,000 people affected yearly in the U.S
*Each year an estimated 8,000-18,000 hospitalized cases occur in the U.S.<ref name=":1">Legionnaires' Disease available at https://emedicine.medscape.com/article/220163-overview</ref>
*The majority of reported cases are sporadic but 10-20% of them are linked to outbreaks<ref name=":1" />
*Travel-associated outbreaks, outbreaks in community settings, and nosocomial and occupational outbreaks are common
*More than 20% of all cases are thought to be associated with recent travel
*Difficult to detect among travelers because of the low attack rate, long incubation period, and the dispersal of persons&nbsp; from&nbsp;the source of the outbreak
*Present rate is that 80% of those contracting the disease die
*In 2011 California health officials reported Legionnaires disease as a potential diagnosis during a investigation of a mystery illness at the Playboy mansion possibly caused by a fog machine where a 100 people developed respiratory infections.  [http://www.youtube.com/watch?v=xk5dEOYtPbw&feature=fvsr http://www.youtube.com/watch?v=xk5dEOYtPbw&amp;feature=fvsr].


For patient stories on contracting Legionnaire's Disease, visit http://www.youtube.com/watch?v=n5tL69KVTZg.


{{#ev:youtube|n5tL69KVTZg|300}}&nbsp;


Many patients report having the following symptoms: [[Image:Images4.jpg]]&nbsp;  
'''Legionnaire's Disease is found worldwide as illustrated below'''.&nbsp;  


♦ '''<u>S/S</u>''': Fevers, chills, dry or productive cough, fatigue, anorexia, headache, myalgia, diarrhea, muscle aches, &amp; gastrointestinal symptoms<sup>4</sup> <br>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;[[Image:World images.jpg|Image:World_images.jpg]]&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;[[Image:Images3.jpg]]


==Associated Co-morbidities==
&nbsp;&nbsp;


<u>People at risk</u>:  
== Associated Comorbidities ==
People at risk:  


*Smokers (esp. Middle-aged/older adults who smoke cigarettes)  
*Smokers (current and former)  
*Chronic lung disease  
*Chronic lung disease  
*&nbsp;Advanced age  
*Advanced age (50 years and above)
*Alcohol abuse  
*Alcohol abuse  
*Surgery  
*Surgery  
Line 72: Line 62:
*Recent repairs or maintenance work on domestic plumb  
*Recent repairs or maintenance work on domestic plumb  
*Immune system compromised by
*Immune system compromised by
**DM
**Renal Failure
**Cancer (esp. hematological or pulmonary malignancy)
**AIDS


&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp;o DM<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; o Renal Failure<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; o Cancer (esp. hematological or pulmonary malignancy)<br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;o AIDS<br>
==Characteristics/Clinical Presentation==
 
'''Signs & Symptoms''':
==Medications==


► [http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000662/ '''Erythromycin'''] (the drug of choice for prolonged period) - given early
* Fever                                                                                                                   
* Dry or productive cough, 
* Fatigue 
* Anorexia 
* Headache 
* Myalgia 
* Diarrhea 
* Gastrointestinal symptoms 


► [http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000675/ '''Rifampin'''] is also a benefit
[[Image:Images4.jpg]]  &nbsp;
=== Systemic Involvement ===
*Gastrointestinal symptoms include nausea, vomiting, diarrhea, and anorexia.


<br><u>'''Newer Effective Therapeutic Options Include Antibiotics (Macrolides)'''</u>'''<sup>4</sup>''':<br>► [http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000901/ '''Clarithromycin''']
*Neurologic symptoms include headache, lethargy, altered mental status, and rarely, focal symptoms.


► [http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001009/ '''Azithromycin''']
*Musculoskeletal symptoms include arthralgias and myalgias.


► [http://medical-dictionary.thefreedictionary.com/Fluoroquinolones '''Fluoroquinolones''']<br>
*Nonpulmonary symptoms are prominent early in the disease.<br>


==Diagnostic Tests/Lab Tests/Lab Values==
==Diagnostic Tests/Laboratory Findings:==


Legionnaire’s disease is diagnosed by growing bacteria on a special medium and silver staining. The bacteria is identified in the sputum and the Legionella antigen is seen in the urine<sup>4</sup>.  
Legionnaire’s disease is diagnosed by growing bacteria on a special medium and silver staining. The bacteria is identified in the sputum and the ''Legionella'' antigen is seen in the urine.


&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp; [[Image:Images6.jpg]]&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; [[Image:Images8.jpg]]<br>What diagnostic tests can confirm Legionnaires' disease? (http://www.cdc.gov/legionella/faq.htm<sup>9</sup>)<br>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp; [[Image:Images6.jpg]]&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; [[Image:Images8.jpg]]<br>What diagnostic tests can confirm Legionnaires' disease?<ref name=":2">Legionnaires Disease- CDC available at https://www.cdc.gov/legionella/index.html</ref><br>


{| style="width: 639px; height: 366px" border="2" cellspacing="1" cellpadding="1" width="639"
{| style="width: 639px; height: 366px" border="2" cellspacing="1" cellpadding="1" width="639"
|+ '''Diagonostic Tests'''  
|+'''Diagnostic Tests'''
{| style="width: 309px; height: 149px" border="3" cellspacing="1" cellpadding="1" width="309"
|+'''Tests In Relationship to Snout/Spin'''
|-
|'''Test'''
|'''Sensitivity (%)'''
|'''Specificity (%)'''
|-
|'''Culture'''
| 80
| 100
|-
|'''Urine antigen'''
| 70
| 100
|-
|'''Paired serology*'''
| 70-80
|&gt;90
|-
|'''[http://www.nlm.nih.gov/medlineplus/ency/article/003553.htm Direct fluorescent antibody stain]'''
| 25-75%
| 95
|-
| *''Note: A single antibody titer of any level is not diagnostic of legionellosis''
|
|
|}
|-
|-
|  
|  
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|-
|-
| '''Culture'''  
|'''Culture'''
| -&nbsp;Clinical &amp; Environmental isolates can be compared<br>-&nbsp;Detects all species &amp; serogroups<br>- 100% specific<br>
| -&nbsp;Clinical &amp; Environmental isolates can be compared<br>-&nbsp;Detects all species &amp; serogroups<br>- 100% specific<br>
| - Technically difficult<br>- Slow (&gt;5 days to grow)<br>- Sensitivity highly dependent on technical skill<br>-&nbsp;May be affected by antibiotic treatment <br>
| - Technically difficult<br>- Slow (&gt;5 days to grow)<br>- Sensitivity highly dependent on technical skill<br>-&nbsp;May be affected by antibiotic treatment <br>
|-
|-
| '''Urine Antigen'''  
|'''Urine Antigen'''
| -&nbsp;&gt;99% specific...<br>-&nbsp;Rapid (same day)<br>
| -&nbsp;&gt;99% specific...<br>-&nbsp;Rapid (same day)<br>
| -&nbsp;...but only for L. pneumophila serogroup 1 (Lp1) [ which may account for up to 80% of cases]<br>-&nbsp;Limited utility when compared to environmental isolates<br>
| -&nbsp;...but only for L. pneumophila serogroup 1 (Lp1) [ which may account for up to 80% of cases]<br>-&nbsp;Limited utility when compared to environmental isolates<br>
|-
|-
| '''Serology'''  
|'''Serology'''
| -&nbsp;Not affected by antibiotic treatment<br>-&nbsp;70-80% sensitive; &gt;90% specific<br>
| -&nbsp;Not affected by antibiotic treatment<br>-&nbsp;70-80% sensitive; &gt;90% specific<br>
| -&nbsp;Must have paired sera<br>-&nbsp;5-10% of population has titer 1:≥256<br>Single acute phase antibody titers of 1:≥256 do not discriminate between cases of Legionnaires' disease and other causes of community-acquired pneumonia. <br>
| -&nbsp;Must have paired sera<br>-&nbsp;5-10% of population has titer 1:≥256<br>Single acute phase antibody titers of 1:≥256 do not discriminate between cases of Legionnaires' disease and other causes of community-acquired pneumonia. <br>
|-
|-
| '''[http://www.nlm.nih.gov/medlineplus/ency/article/003553.htm DFA]'''
| DFA
| -&nbsp;Can be performed on pathologic specimens<br>-&nbsp;95% specific<br>
| -&nbsp;Can be performed on pathologic specimens<br>-&nbsp;95% specific<br>
| -&nbsp;25-75% sensitive
| -&nbsp;25-75% sensitive
|}
|}


==Etiology/Causes==
===== Legionnaires Disease VS Pontiac Fever =====
 
Legionnaire’s disease is the cause of nosocomial pneumonia<sup>4</sup>.
 
&nbsp;<br>'''<u>Common places that allow Legionella transmission</u><sup>10</sup>''':<br>1. Potable (drinking) water systems<br>2. Whirlpool spas<br>3. Cooling towers&nbsp;
 
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;[[Image:Images7.jpg]]&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<br>'''<u>Conditions for Legionella transmission</u><sup>10</sup>''':<br>1. Heat<br>2. Stasis<br>3. Aerosolization<br>
 
==Systemic Involvement==
 
► <u>Gastrointestinal</u> symptoms include nausea, vomiting, diarrhea, and anorexia.
 
► <u>Neurologic</u> symptoms include headache, lethargy, altered mental status, and rarely, focal symptoms.
 
► <u>Musculoskeletal</u> symptoms include arthralgias and myalgias.
 
► <u>Nonpulmonary</u> symptoms are prominent early in the disease.<br>
 
==Medical Management (current best evidence)==
 
Patients diagnosed with Legionnaire's Disease are prescribed to take the various medications see above under ''Medications''.&nbsp;
 
For patients with Pontiac fever: it is a self-limited illness that does not benefit from antibiotic treatment. Complete recovery usually occurs within 1 week<sup>10</sup>.
 
==Physical Therapy Management (current best evidence)==
 
► <u>Screening Questions</u>:
 
&nbsp;&nbsp;&nbsp; - Have you traveled recently? (Patient could have traveled-associated Legionnaire’s disease (http://www.cdc.gov/legionella/faq.htm<sup>9</sup>)
 
► <u>Top 10 Things Every Clinician Needs to Know About Legionellosis</u> ([http://www.cdc.gov/legionella/top10.htm http://www.cdc.gov/legionella/top10.htm<sup>10</sup>)]
 
<br>
 
What does the diagnosis of Legionnaire’s disease include? Two clinical syndromes:
 
{| style="width: 714px; height: 260px" border="3" cellspacing="1" cellpadding="1" width="714"
{| style="width: 714px; height: 260px" border="3" cellspacing="1" cellpadding="1" width="714"
|+ '''Legionnaire's Disease vs. Pontiac Fever'''  
|+ '''Legionnaire's Disease vs. Pontiac Fever'''  
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|}
|}


<u></u>&nbsp;<u></u>&nbsp;* Percent of persons who, when exposed to the source of an outbreak, become ill. <br>** Percent of persons who die from Legionnaires' disease or Pontiac fever.  
&nbsp;&nbsp;* Percent of persons who, when exposed to the source of an outbreak, become ill. <br>** Percent of persons who die from Legionnaires' disease or Pontiac fever.
 
==Medical Management==
<br>


{| style="width: 309px; height: 149px" border="3" cellspacing="1" cellpadding="1" width="309"
== Medications ==
|+ '''Tests In Relationship to Snout/Spin'''
*Erythromycin (the drug of choice for prolonged period) - given early
|-
| '''Test'''
| '''Sensitivity (%)'''
| '''Specificity (%)'''
|-
| '''Culture'''
| 80
| 100
|-
| '''Urine antigen'''
| 70
| 100
|-
| '''Paired serology*'''
| 70-80
| &gt;90
|-
| '''[http://www.nlm.nih.gov/medlineplus/ency/article/003553.htm Direct fluorescent antibody stain]'''
| 25-75%
| 95
|-
| *''Note: A single antibody titer of any level is not diagnostic of legionellosis''
|
|
|}


<u></u>&nbsp;
*Rifampin is also a benefit


► <u>Patient Care</u>: Respiratory Therapists/PTs: O<sup>2 </sup>therapy, repositioning, postural drainage, suctioning<sup>4</sup>  
<br>Newer Effective Therapeutic Options Include Antibiotics (Macrolides):<br>
* Clarithromycin


► <u>Monitor</u>: Chest wall expansion, depth/pattern of ventilations, cough, chest pain, restlessness, &amp; hypoxemia<sup>4</sup>
*Azithromycin


► <u>Signs of Shock</u>:&nbsp;↓ blood pressure, tachycardia w/weak thread pulse, diaphoresis, clamy skin, &amp; cold<sup>4</sup>
* Fluoroquinolones


► <u>Patient Education</u>: Pulmonary hygiene, deep breathing and coughing exercises, chest physiotherapy, postural drainage, disposal of solid tissues to prevent disease transmission<sup>4<br></sup>
Patients diagnosed with Legionnaire's Disease are prescribed to take the various medications.&nbsp;


==Alternative/Holistic Management (current best evidence)==
For patients with Pontiac fever: it is a self-limited illness that does not benefit from antibiotic treatment. Complete recovery usually occurs within 1 week.


<u>'''Treatment:'''</u>&nbsp; Natural Encyclopedia recommends following remedies for Pnuemonia &amp;&nbsp; Bronchitis.
==Physical Therapy Management==


•You will want to use essentially the same treatment as outlined for bronchitis; except that, because the person's illness is so much more serious, he must be given much rest and intensified care. <br>•Rinse out the nose with saltwater, gently taking it in and blowing it out. Gargle with saltwater. Then repeat the rinsing and gargling with a goldenseal and myrrh mixture. This will help keep a cold or flu from going down into the lungs. <br>•But if the lungs are already affected, do the above treatment. Also give hot footbaths and a high herb enema at least once a day. Drink plenty of water. Take laxative herbs, to keep the bowels working properly. Give short, hot fomentations to the chest and upper back, with short cold between each hot application. <br>•Only give liquids the first few days. These should consist of fruit juices (diluted pineapple juice or orange juice) or lemon and water (without sugar), etc. Continue this until the high fever abates. Then give strained vegetable broths, whole grains (best in dry form, so it will be chewed well).&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; •
*Screening Questions:


•Stop smoking and get tobacco out of the house. If you have chronic bronchitis, do not expect much improvement as long as tobacco smoke is in the home. <br>•Do not use milk; it produces a thick phlegm which complicates healing. White-flour products and sugar foods should not be used until bronchitis is past. <br>•Drink plenty of fluids: pure water, soups, and herb teas. Vitamin C is important! Take it to bowel tolerance. <br>•Anise tea and almond milk are helpful in bronchitis. Make the almond milk by blending 6 tbsp. of almonds in a pint of water. <br>•Cayenne and lobelia will help break up the congestion. <br>•Add moisture to the air with a vaporizer or humidifier or heat a pan of water on the stove. <br>•Remain in bed as long as fever is present. Bronchitis often hangs on because people think it is about over and begin going about their everyday duties. Go to bed and get well. <br>•Deep breathing exercises should be taken 3-4 times a day. Take a deep breath, hold it a few seconds, and exhale. Do this 10-20 times. This will help air out of the infected area. <br>•Breathe deep. Blow up a balloon several times every day. This helps open up and enlarge the airways. <br>•Apply a heating compress at night. <br>•A hot footbath will help pull the blood away from the chest and reduce congestion. <br>•Hot drinks help you cough out the phlegm. Coughing is the only way the phlegm can come out. Do not use cough suppressants while you have bronchitis. <br>•Apply warm, moist heat or a hot water bottle over the chest and back before bedtime. This will help relieve congestion and aid in sleep. <br>•Avoid fatigue and chilling. Do not walk barefoot on cold floors while you are trying to get well. <br>•If the coughing gets worse, there is a high fever, wheezing sounds, lethargy, and weakness. Chest pains develop and very difficult breathing. Contact a health professional; the condition may be developing into pneumonia. <br>•If the condition persists over too long a time, there is the possibility of tuberculosis or lung cancer. <br>•A professional can use bronchoscopy instruments to examine the bronchial tubes and suction out phlegm. <br>•In recent years, a new type of bronchitis has arisen, which is contracted primarily by women. Difficult to treat, it often continues for 3 weeks to 5 months. Drinking goldenseal tea is helpful with this condition, as well as with other types of bronchitis. <br>•Other helpful herbs include pau d'arco, chickweed, ginkgo biloba, burdock, lobelia, slippery elm bark, echinacea, and wild cherry bark.
&nbsp;&nbsp;&nbsp; - Have you traveled recently? (Patient could have traveled-associated Legionnaire’s disease<ref name=":2" />  


Data taken from [http://www.naturalencyclopedia.com/Pneumonia ''Natural Encyclopedia'']<sup>26</sup>.<br>
* Patient Care: Respiratory Therapists/PTs: O<sub>2</sub> therapy, repositioning, postural drainage, suctioning 
* Monitor: Chest wall expansion, depth/pattern of ventilations, cough, chest pain, restlessness, &amp; hypoxemia
* Signs of Shock:&nbsp;↓ blood pressure, tachycardia w/weak thread pulse, diaphoresis, clamy skin, &amp; cold
* Patient Education: Pulmonary hygiene, deep breathing and coughing exercises, chest physiotherapy, postural drainage, disposal of solid tissues to prevent disease transmission<sup><br></sup><br>  


==Differential Diagnosis<sup>'''25'''</sup>  ==
==Differential Diagnosis==


*Adult Respiratory Distress Syndrome (ARDS)  
*Adult Respiratory Distress Syndrome (ARDS)  
Line 269: Line 241:
==Case Reports/ Case Studies==
==Case Reports/ Case Studies==


•[https://newyorkmedicaljournal.org/articles/atypical-presentation-of-legionnaires-disease/ Atypical Presentation of Legionnaire’s Disease: A Case Report and Review] <br>•[https://casesjournal.biomedcentral.com/articles/10.1186/1757-1626-2-9151 Severe Legionnaires disease complicated by multi-organ dysfunction in a previously healthy patient: a case report] [7]<br>•[http://ajcc.aacnjournals.org/content/12/3/234.full Legionnaires Disease: A Case Study]   
•[https://newyorkmedicaljournal.org/articles/atypical-presentation-of-legionnaires-disease/ Atypical Presentation of Legionnaire’s Disease: A Case Report and Review] <br>•[https://casesjournal.biomedcentral.com/articles/10.1186/1757-1626-2-9151 Severe Legionnaires disease complicated by multi-organ dysfunction in a previously healthy patient: a case report]<br>•[http://ajcc.aacnjournals.org/content/12/3/234.full Legionnaires Disease: A Case Study]   


==Resources  ==
==Resources  ==
* [https://www.cdc.gov/legionella/index.html Legionella(Legionnaire' Disease and Pontiac Fever)- Centers for Disease Control and Prevention]
* [https://www.cdc.gov/legionella/index.html Legionella(Legionnaire' Disease and Pontiac Fever)- Centers for Disease Control and Prevention]
* [http://legionella.org/ Legionella.org]
* [http://legionella.org/ Legionella.org]
 
* [https://thesureword.org/wp-content/uploads/2016/11/The-Natural-Remedies-Encyclopedia.pdf Natural Remedies Encyclopedia]
1.http://www.cdc.gov/legionella/patient_facts.htm 2. http://www.osha.gov/SLTC/legionnairesdisease/index.html 3. OSHA eTool: http://www.osha.gov/dts/osta/otm/legionnaires/index.html 4. Taber’s Cyclopedic Medical Dictionary. F.A. Davis Company. Phildelphia. Edition 19. 2001. Pg.121 5. Atypical Presentation of Legionnaire’s Disease: A Case Report and Review. Sophie Kay1, DO, Christopher Grantham2, MD, Michelle Dahdouh3, MD. http://newyorkmedicaljournal.org/index.php/articles/atypical_presentation_of_legionnaires_disease_a_case_report_and_review 6. Legionnaires Disease: A Case Study. By Melinda Cramer, RN, BSN. From School of Nursing, University of Pennsylvania, Philadelphia, Pa. American Journal of Critical Care. 2003;12: 234-238. http://ajcc.aacnjournals.org/content/12/3/234.full 7. Severe Legionnaires disease complicated by multi-organ dysfunction in a previously healthy patient: a case report. Kays Kassha1, Issam Abuanza2, Samer A Hadi3 and Roy Hilton2. http://casesjournal.com/content/2/1/9151 8. Legionnaires' Disease with Facial Nerve Palsy. Case Reports in Medicine. Volume 2011 (2011), Article ID 916859, 4 pgs. Shailesh R. Basani, Salwa Mohamed Ahmed, and Eyassu Habte-Gabr. Received 20 September 2010; Accepted 16 January 2011. http://www.hindawi.com/journals/crim/2011/916859/ 9. http://www.cdc.gov/legionella/faq.htm<br>10. http://www.cdc.gov/legionella/top10.htm<br>
* [https://www.who.int/news-room/fact-sheets/detail/legionellosis Legionellosis- WHO]<br>
 


==References==
==References==
<references />
<references />


17. http://www.suntimes.com/news/nation/4080689-418/legionnaires-disease-found-at-playboy-mansion.html<br>18. http://www.nbcchicago.com/news/local/Bacteria-that-Causes-Legionnaires-Disease-Found-at-Playboy-Mansion-117204503.html<br>19. http://www.dailymail.co.uk/news/article-1361964/Playboy-Mansion-illness-Legionnaires-disease-bacteria-water-source.html<br>20. http://www.mayoclinic.com/health/legionnaires-disease/DS00853<br>21.http://www.nlm.nih.gov/medlineplus/legionnairesdisease.html &amp; picture<br>22. http://www.nlm.nih.gov/medlineplus/ency/article/000616.htm<br>23. http://www.legionella.org/<br>24. http://emedicine.medscape.com/article/783656-overview<br>25. http://www.mdguidelines.com/legionnaires-disease/differential-diagnosis<br>26. http://www.naturalencyclopedia.com/Legionnaire's_Disease
<br>


  [[Category:Cardiopulmonary]]
  [[Category:Cardiopulmonary]]
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[[Category:Respiratory Disease]]
[[Category:Respiratory Disease]]
[[Category:Communicable Diseases]]
[[Category:Communicable Diseases]]
[[Category:Infectious Diseases]]

Latest revision as of 16:21, 3 March 2023

Original Editor - Itayi Charasika from Bellarmine University's Pathophysiology of Complex Patient Problems project.
Top Contributors - Itayi Charasika, Donald John Auson, Kim Jackson, Kalyani Yajnanarayan, Admin, Elaine Lonnemann, WikiSysop, Adam Vallely Farrell and Nupur Smit Shah

Definition/Description[edit | edit source]

Legionnaires' Disease is a severe form of pneumonia (lung infection) caused by a bacteria, known as Legionella. It can occur through inhalation of contaminated aerosols such as humidifiers, hot and cold water systems, air conditioning cooling towers and whirlpool spas. Infection can also occur by exposure of babies during water births or aspiration of contaminated ice or water, particularly in susceptible hospital patients. It can be a cause of community acquired pneumonia or hospital acquired pneumonia[1]. This disease is often screened for whenever a person is diagnosed with pneumonia because of the close resemblance Legionnaires' has to pneumonia.


The bacteria, Legionella, in Legionnaires' disease can also cause a milder illness called Pontiac Fever. Pontiac Fever resembles a mild and self-resolving flu-like disease.[2] Unlike Legionnaires' disease, Pontiac Fever usually resolves on its own after 2-5 days.[2]If diagnosed with both illnesses, then the term is Legionellosis.

History of Disease[edit | edit source]

Legionnaires' disease was first discovered about in 1967 when a group of people in Philadelphia, attending an American Legion convention meeting were exposed to this disease. Those affected suffered from a type of pneumonia, now referred to as Legionnaires’ disease.

The first identified cases of Pontiac fever occurred in 1968 in Pontiac, Michigan, among people who worked at and visited the city’s health department. It wasn’t until Legionella was discovered after the 1976 Legionnaires’ disease outbreak in Philadelphia that public health officials were able to show that Legionella causes both diseases.

                     

Legionnaire's Disease

Image:Ld_image.jpg


Etiology[edit | edit source]

The pathogen causing Legionnaires' Disease came from the Legionellaceae family of bacteria. Although the family Legionellaceae now contains more than 40 species, L. pneumophila causes over 90% of human infections. L micdadei, the second most frequently isolated species in human infection, evidently has lower virulence for humans than L. pneumophila as it appears to infect only immunocompromised hosts.[3] Water is the major natural reservoir for Legionella, and the pathogen is found in many different natural and artificial aquatic environments such as cooling towers or water systems in buildings, including hospitals.[4]

Common places that allow Legionella transmission:
1. Potable (drinking) water systems
2. Whirlpool spas
3. Cooling towers 

                                                                        Images7.jpg                                                                                          
Conditions for Legionella transmission:
1. Heat
2. Stasis
3. Aerosolization

Prevalence[edit | edit source]

Accurate data reflecting the true incidence of disease are not available because of underutilization of diagnostic testing and under-reporting.[5] It is a common cause of severe pneumonia requiring hospitalization.

Facts:

  • Responsible for ~ 5% of all pneumonias
  • 12,000 people affected yearly in the U.S
  • Each year an estimated 8,000-18,000 hospitalized cases occur in the U.S.[6]
  • The majority of reported cases are sporadic but 10-20% of them are linked to outbreaks[6]
  • Travel-associated outbreaks, outbreaks in community settings, and nosocomial and occupational outbreaks are common
  • More than 20% of all cases are thought to be associated with recent travel
  • Difficult to detect among travelers because of the low attack rate, long incubation period, and the dispersal of persons  from the source of the outbreak
  • Present rate is that 80% of those contracting the disease die
  • In 2011 California health officials reported Legionnaires disease as a potential diagnosis during a investigation of a mystery illness at the Playboy mansion possibly caused by a fog machine where a 100 people developed respiratory infections. http://www.youtube.com/watch?v=xk5dEOYtPbw&feature=fvsr.


Legionnaire's Disease is found worldwide as illustrated below. 

                                          Image:World_images.jpg                        Images3.jpg

  

Associated Comorbidities[edit | edit source]

People at risk:

  • Smokers (current and former)
  • Chronic lung disease
  • Advanced age (50 years and above)
  • Alcohol abuse
  • Surgery
  • Recent travel with an overnight stay outside of the home
  • Exposure to whirlpool spas
  • Recent repairs or maintenance work on domestic plumb
  • Immune system compromised by
    • DM
    • Renal Failure
    • Cancer (esp. hematological or pulmonary malignancy)
    • AIDS

Characteristics/Clinical Presentation[edit | edit source]

Signs & Symptoms:

  • Fever
  • Dry or productive cough,
  • Fatigue
  • Anorexia
  • Headache
  • Myalgia
  • Diarrhea
  • Gastrointestinal symptoms

Images4.jpg  

Systemic Involvement[edit | edit source]

  • Gastrointestinal symptoms include nausea, vomiting, diarrhea, and anorexia.
  • Neurologic symptoms include headache, lethargy, altered mental status, and rarely, focal symptoms.
  • Musculoskeletal symptoms include arthralgias and myalgias.
  • Nonpulmonary symptoms are prominent early in the disease.

Diagnostic Tests/Laboratory Findings:[edit | edit source]

Legionnaire’s disease is diagnosed by growing bacteria on a special medium and silver staining. The bacteria is identified in the sputum and the Legionella antigen is seen in the urine.

          Images6.jpg                Images8.jpg
What diagnostic tests can confirm Legionnaires' disease?[7]

Diagnostic Tests
Tests In Relationship to Snout/Spin
Test Sensitivity (%) Specificity (%)
Culture 80 100
Urine antigen 70 100
Paired serology* 70-80 >90
Direct fluorescent antibody stain 25-75% 95
*Note: A single antibody titer of any level is not diagnostic of legionellosis

Test

Advantages

Disadvantages

Culture - Clinical & Environmental isolates can be compared
- Detects all species & serogroups
- 100% specific
 - Technically difficult
- Slow (>5 days to grow)
- Sensitivity highly dependent on technical skill
- May be affected by antibiotic treatment
Urine Antigen - >99% specific...
- Rapid (same day)
 - ...but only for L. pneumophila serogroup 1 (Lp1) [ which may account for up to 80% of cases]
- Limited utility when compared to environmental isolates
Serology - Not affected by antibiotic treatment
- 70-80% sensitive; >90% specific
 - Must have paired sera
- 5-10% of population has titer 1:≥256
Single acute phase antibody titers of 1:≥256 do not discriminate between cases of Legionnaires' disease and other causes of community-acquired pneumonia.
DFA - Can be performed on pathologic specimens
- 95% specific
 - 25-75% sensitive
Legionnaires Disease VS Pontiac Fever[edit | edit source]
Legionnaire's Disease vs. Pontiac Fever
Legionnaires' disease Pontiac fever
Clinical Features Pneumonia: cough, fever, chest pain Flu-like illness (fever, chills, malaise) without pneumonia
Radiographic pneumonia Yes No
Incubation period 2-14 days after exposure 24-48 hours after exposure
Etiologic agent Legionella species Legionella species
Attack rate* < 5% > 90%
Isolation of organism Possible Virtually never
Outcome Hospitalization common
Case-fatality rate: 5-40%**
 Hospitalization uncommon
Case-fatality rate: 0%
Additional Below*

  * Percent of persons who, when exposed to the source of an outbreak, become ill.
** Percent of persons who die from Legionnaires' disease or Pontiac fever.

Medical Management[edit | edit source]

Medications[edit | edit source]

  • Erythromycin (the drug of choice for prolonged period) - given early
  • Rifampin is also a benefit


Newer Effective Therapeutic Options Include Antibiotics (Macrolides):

  • Clarithromycin
  • Azithromycin
  • Fluoroquinolones

Patients diagnosed with Legionnaire's Disease are prescribed to take the various medications. 

For patients with Pontiac fever: it is a self-limited illness that does not benefit from antibiotic treatment. Complete recovery usually occurs within 1 week.

Physical Therapy Management[edit | edit source]

  • Screening Questions:

    - Have you traveled recently? (Patient could have traveled-associated Legionnaire’s disease[7]

  • Patient Care: Respiratory Therapists/PTs: O2 therapy, repositioning, postural drainage, suctioning
  • Monitor: Chest wall expansion, depth/pattern of ventilations, cough, chest pain, restlessness, & hypoxemia
  • Signs of Shock: ↓ blood pressure, tachycardia w/weak thread pulse, diaphoresis, clamy skin, & cold
  • Patient Education: Pulmonary hygiene, deep breathing and coughing exercises, chest physiotherapy, postural drainage, disposal of solid tissues to prevent disease transmission

Differential Diagnosis[edit | edit source]

  • Adult Respiratory Distress Syndrome (ARDS)
  • Bronchitis
  • Congestive heart failure
  • Gastroenteritis
  • HIV infection and AIDS
  • Inflammation of the rib cartilage (costochondritis)
  • Meningitis
  • Non-Legionnaire's pneumonia
  • Pleural effusion
  • Pneumonia caused by other organisms
  • Prostatitis
  • Septic shock
  • Tuberculosis

Case Reports/ Case Studies[edit | edit source]

•Atypical Presentation of Legionnaire’s Disease: A Case Report and Review
•Severe Legionnaires disease complicated by multi-organ dysfunction in a previously healthy patient: a case report
•Legionnaires Disease: A Case Study

Resources[edit | edit source]

References[edit | edit source]

  1. ↑ Pedro-Botet M. L., Sabria-Leal M., Haro M., Rubio C., Gimenez G., Sopena N., Tor J.Nosocomial and community-acquired Legionella pneumonia: clinical comparative analysis. Eur. Respir. J.8199519291933 retrieved from https://erj.ersjournals.com/content/8/11/1929.short
  2. ↑ 2.0 2.1 Sharma L, Losier A, Tolbert T, Dela Cruz CS, Marion CR. Atypical Pneumonia: Updates on Legionella, Chlamydophila, and Mycoplasma Pneumonia. Clin Chest Med. 2017;38(1):45–58. doi:10.1016/j.ccm.2016.11.011 retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5679202/
  3. ↑ Myerowitz RL, Pasculle AW, Dowling JN et al. (1971) Opportunistic lung infection due to “Pittsburgh Pneumonia Agent”. N Engl J Med 301: 953–958.
  4. ↑ Cunha BA, Burillo A, Bouza E, Legionnaires' disease, The Lancet, Volume 387, Issue 10016, 2016, Pages 376-385, ISSN 0140-6736, https://doi.org/10.1016/S0140-6736(15)60078-2 retrieved from https://www.sciencedirect.com/science/article/pii/S0140673615600782
  5. ↑ Plouffe JF, Breiman RF, Fields BS, Herbert M, Inverso J, Knirsch C, Kolokathis A, Marrie TJ, Nicolle L, Schwartz DB, Azithromycin in the Treatment of Legionella Pneumonia Requiring Hospitalization, Clinical Infectious Diseases, Volume 37, Issue 11, December 2003, Pages 1475–1480, https://doi.org/10.1086/379329 retrieved from https://academic.oup.com/cid/article/37/11/1475/372119
  6. ↑ 6.0 6.1 Legionnaires' Disease available at https://emedicine.medscape.com/article/220163-overview
  7. ↑ 7.0 7.1 Legionnaires Disease- CDC available at https://www.cdc.gov/legionella/index.html
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