Pathology of five Scottish deaths from pneumonic illnesses acquired in Spain due to Legionnaires' disease agent.

Abstract

The pathology and histology are reported of five Scots who died of severe pneumonic illnesses after holidays in Spain, three in 1973 and two in 1977. There is strong evidence in favour of all the deaths having been due to the newly discovered Legionnaires' disease (LD) agent. The agent (or its soluble antigen) has been visualised in sections of lung tissue by fluorescent-antibody tests in all cases, and the agent has been identified by the Dieterle silver staining method in small numbers in all cases. Serological testing was possible in three of the patients, and two had very high antibody titres against the LD agent. Apart from the extensive and severe nature of the pathological process there is no feature to distinguish pulmonary infection by this agent from that due to more commonly known bacteria capable of causing lobar pneumonia. The severity and extensive nature of the process is partly a reflection of neglect in seeking treatment until late in the infection, and partly a reflection, as revealed in retrospect, on the use of the wrong antibiotic combination during treatment. Erythromycin has been recommended by other workers as the drug of choice against the LD agent. Infection by this organism is not confined to the USA or to Spain and is indigenous also in the United Kingdom.

Acute renal failure complicating Legionnaires’ disease

“…In other respects, reports from Britain do not suggest that advanced age, underlying chronic lung disease or cigarette smoking are encountered as frequently as in the U.S.A. (Jenkins et al, 1979). In common with several other British patients (Boyd et al, 1978), the present patient returned from holiday at an hotel in Spain. The isotonic urine and high urinary sodium concentration in this patient suggested a diagnosis of 'acute tubular necrosis' and the clinical course was consistent with this.…”

“…Although Legionnaires' disease was first described in the United States in 1977 (Fraser et al, 1977;Kirby et al, 1978) several outbreaks have now been recorded in the United Kingdom (Boyd et al, 1978;Jenkins et al, 1979). Acute oliguric renal failure requiring haemodialysis is associated with a high mortality although one elderly patient with moderately severe acute renal failure not requiring dialysis improved slowly but incompletely over many months (Kerr, Brewis and MacRae, 1978).…”

A fatal case of Legionnaires' disease originating in Scotland

“…These authors refer to outbreaks in the Washington area and Pontiac (Michigan) while Macrae and Lewis (1977) refer to an outbreak in Nottingham, England, and Lawson et al (1977), Lawson (1978), and Reid, Grist and Natjera (1978) record the disease in Scottish tourists returning to Glasgow after holidays in Spain. The pathology of the deaths among these last cases has been reported (Boyd et al, 1978), and the pathology of the original Legionnaires' disease episode is also on record (Chandler et al, 1977;Blackmon et al, 1978). The infection has also been recorded recently in renal transplant patients (Bock et al, 1978).…”

“…4). The problems of the interpretation of Dieterle-stained sections have been referred to (Chandler et al, 1977;Blackmon, Hicklin and Chandler, 1978;Boyd et al, 1978).…”

Legionella infections in Scotland

“…Three tourists died and the diagnosis was established in retrospect by examination of sera or tissues at the Center for Disease Control (CDC), Atlanta, as was the diagnosis in three subsequent cases, one occurring in 1976 (Lees, Tyrrell & Boyd, 1977) and two in 1977. Details of the pathological findings in the cases occurring in 1973 and 1977 have been published by Boyd et al (1978). Following the isolation of L. pneumophila (McDade et al 1977) a culture was kindly provided by CDC and an ether-treated antigen was made from this as described by Fallon & Abraham (1979).…”