A Patient with Suspected Myocarditis Associated with Legionnaires' Disease: A Case Report and Review of the Literature

Abstract

Legionnaires' disease (LD) is a systemic infectious disease caused by Legionella species. It mainly presents with lung involvement. Herein, we present a case with suspected myocarditis associated with LD and review of the relevant literature. An 81-year-old male tourist patient with high fever, cough, imbalance while walking, and confusion presented to the emergency department. The patient was diagnosed with LD based on increased density in the left lower zone on chest x-ray and a positive Legionella urine antigen test. He was administered a combination of claritromycin and levofloxacine on the day of admission. The diagnosis of acute myocarditis was made after worsening of the cardiac functions, ST elevation and troponin I positivity. The patient's symptoms regressed with antibiotic therapy and the patient was transferred to his home country by ambulance plane ten days after admission. A search of PubMed and Web of Science using the keywords "Legionella and myocarditis" revealed 15 case reports, nine of which were in English and were reviewed. There were three female and six male patients with a mean age of 44 years (range: 32-56 years). Seven were diagnosed with LD by urine antigen testing, one by serological testing and culture, and one by direct fluorescent-antibody staining and culture. Myocarditis was diagnosed by biopsy in two patients and by clinical and laboratory findings in the rest. Myocarditis without existing pneumonia was detected in one case. Electrocardiography abnormalities such as atrial flutter, atrioventricular block, torsade de pointes, sinus tachycardia, QT prolongation, ST elevation, and T wave inversion were detected in seven patients. Ventricle dysfunction on echocardiography and cardiac marker abnormality were detected in all but one of the patients (not tested in one patient). Antimicrobial monotherapy was chosen for three of the cases. One patient died due to myocarditis. In conclusion, myocarditis may develop rarely during the course of LD. Clinical suspicion is essential for the diagnosis. Early diagnosis and appropriate treatment may be life-saving. Keywords: Pneumonia, Legionella pneumophila, Legionnaires' disease, myocarditis, travel medicine Lejyoner hastalığı (LH), Legionella bakterisinin etkeni olduğu ve ön planda akciğerlerin tutulduğu sistemik bir enfeksiyon hastalığıdır. Burada LH tanısı alan ve miyokardit şüphesi olan bir olgu sunuldu ve ilgili literatür gözden geçirildi. Seksen bir yaşında turist erkek hasta yüksek ateş, öksürük, yürümede bozukluk ve bilinç değişikliği şikayeti ile acil servise başvurdu. Akciğer grafisinde sol alt zonda dansite artışı ve idrarda Legionella antijeni olumlu saptanması üzerine LH tanısı aldı. Klaritromisin ve levofloksasin tedavisine yattığı gün başlandı. Kardiyak fonksiyonların kötüleşmesi, ST elavasyonu ve troponin I değerlerinde yükseklik akut miyokardit ile uyumlu bulundu. Antibiyotik tedavisi ile şikayetleri gerileyen hasta kendi isteği üzerine yatışının onuncu günü uçak ambulansla ülkesine gönderildi. PubMed ve Web of Sciences...

Legionnaires' Disease

“…Extrapulmonary involvement: Extrapulmonary legionellosis is very rare and more common in immunosuppressed patients. Reported manifestations include myocarditis, pericarditis, and infective endocarditis due to heart involvement; cerebral abscess, meningoencephalitis, aseptic meningitis, cerebellitis, and peripheral neuropathy due to neurological involvement; rhabdomyolysis due to muscle involvement; acute kidney injury and pyelonephritis due to renal involvement; abscess and cellulitis due to skin and subcutaneous tissue involvement; and perirectal abscess, pancreatitis, and peritonitis due to gastrointestinal involvement [1,2,17,23,25,47] .…”

“…Erdogan et al [21] (n=17) aspartate aminotransferase and alanine aminotransferase. Hypophosphatemia, hyponatremia, elevated serum ferritin, elevated creatinine levels, elevated C-reactive protein, high erythrocyte sedimentation rate, microscopic hematuria, proteinuria, and creatine kinase elevation are other laboratory findings frequently seen in Legionnaires' disease [1,2,17,21,24,[43][44][45][46][47][48][49][50] . The demographic, clinical, and laboratory characteristics of Legionnaire's disease patients in some previous studies are presented in Table 2.…”