A Case of Fatal Pneumonia Caused by Legionella pneumophila Serogroup 6 Developed after Drowing in a Public Bath

Abstract

A 57-year-old male was admitted to our hospital because of high fever, productive cough and dyspnea. Six days prior to admission he had an episode of drowning in a public bath. On admission chest X-ray showed wide-spread pneumonia causing severe respiratory distress for which mechanical ventilatory support was started. Despite chemotherapy including erythromycin and rifampicin his condition continued to deteriorate. Chemistry showed marked elevation of CPK and findings of acute renal failure. He eventually passed away with septic shock. During the course Legionellae remained negative with culture of broncho-alveolar lavage fluid. L. pneumophila serogroup 1 (SG1) antigen in the urine was not detected, and no elevation of serum antibody titer was noted. Culture of the material obtained from the lung abscess at autopsy revealed L. pneumophila SG6 and serum antibody titer against SG6 also was found to be extremely high. With this evidence we concluded that this case of pneumonia was caused by L. pneumophila SG6. We believe this is the first reported case of the SG6 pneumonia in Japan. Another remarkable feature of this case was massive rhabdomyolysis pathologically confirmed after autopsy. Although the pathogenesis of this process has not been clarified, there are several case reports of rhabdomyolysis complicated with Legionnair's disease in the past. Therefore, we should bear in mind and pay careful attention while coping with this disease.

Legionnaires' Disease Associated with Habitual Drinking of Hot Spring Water.

“…Similar cases of Legionnaires' disease accompanying myelodysplastic syndromeor disseminated intravascular coagulation have also been reported (8,9). Manyof the reported cases of legionellosis have been attributed either to inhalation or aspiration of legionellae into the respiratory tract (7,(10)(11)(12)(13)(14)(15). The tap water this patient had long used was found to be heavily contaminated with L. pneumophila of >104 CFU/100 ml, in contrast to the previous reports in which the quantitative culture of L. pneumophila was reportedly 103 CFU/100 ml or less (14,16).…”

Successful Liver Transplantation from Donor withPlesiomonas shigelloidesSepsis after Freshwater Drowning: Case Report and Review of Literature on Gram-Negative Bacterial Aspiration during Drowning and Utilization of Organs from Bacteremic Donors

“…Six victims from the tsunami in Thailand of December 2004 developed melioidosis; fortunately, all survived because of accurate diagnosis. In another case series, five patients developed Francisella philomiragia infection after near drowning [23][24][25][26]. One article reported a drowning victim who was evaluated for tissue donation [9].…”

“…Rosenthal et al [24] Pseudomonas putrefaciens Pathogen isolated from sputum also was isolated at drowning site Wenger et al [26] Francisella philomiragia Rare pathogen isolated from five drowning victims Tokuda et al [25] Legionella pneumophilia Fatal pneumonia and lung abscess Chierakul et al [23] Burkholderia pseudomallei Prognosis is good with early diagnosis Reines and Cook [31] A. hydrophilia In near-drownings, one survived, one died of acute respiratory distress syndrome (ARDS) and sepsis Outin et al [30] A. hydrophilia Three cases of septicemia, including 51-year-old patient who died after a few days with ARDS Gaussorgues et al [28] A. hydrophilia No details available Lecler et al [29] A. hydrophilia No details available Ender et al [18] A. hydrophilia Sepsis common in near-drowning victims; should they receive prophylactic antibiotics? Vázquez Piloto et al [32] A. hydrophilia Drunk driver nearly drowned in irrigation ditch but survived Miyake et al [19] A. hydrophilia Patient also had severe sepsis Bossi-Kupfer et al [27] A. veronii Nineteen-year-old man with tracheobronchitis after near-drowning in river known to be contaminated with A. veronii biovar sobria 116 BONATTI ET AL.…”

“…Vázquez Piloto et al [32] A. hydrophilia Drunk driver nearly drowned in irrigation ditch but survived Miyake et al [19] A. hydrophilia Patient also had severe sepsis Bossi-Kupfer et al [27] A. veronii Nineteen-year-old man with tracheobronchitis after near-drowning in river known to be contaminated with A. veronii biovar sobria 116 BONATTI ET AL. pneumophila, Shewanella putrefaciens, Burkholderia pseudomallei, Vibrio, F. philomiragia, and zygomycetes among many others [7,8,18,20,21,[23][24][25][26][73][74][75][76]. With increasing fecal pollution and global warming, many uncommon or new pathogens, such as Naegleria fowleri, may cause more waterborne illnesses [77].…”

Lung Abscess Caused by Legionella Species: Implication of the Immune Status of Hosts

“…The atypical clinical presentation might affect prompt diagnosis and eventually result in poor outcome. Certain case reports have mentioned that Legionella abscess was diagnosed at autopsies (6)(7)(8). Therefore, (9); this case was also included in our analyses.…”