Clinical communication
Legionella pneumonia presenting with rhabdomyolysis and acute renal failure: A case report

https://doi.org/10.1016/j.jemermed.2005.07.016Get rights and content

Abstract

Legionella pneumophila infection is a recognized but rare cause of rhabdomyolysis (1). While the mechanism of rhabdomyolysis associated with Legionella is unknown, theories include direct invasion of Legionella into the muscle itself, or the release of its endotoxin into the circulation with subsequent muscle injury (2, 3). In this case report, we describe a case of Legionella pneumonia presenting as altered mental status, high fever, and rhabdomyolysis with acute renal failure. We review the epidemiology, clinical and laboratory findings, and treatment of the disease.

Introduction

Legionella pneumophila came to attention in 1976 when the CDC identified it as the causative agent in a massive outbreak of pneumonia among attendees of an American Legion convention in Philadelphia. Hence, it was coined Legionnaires’ disease. Legionellae are intracellular gram-negative parasites that flourish naturally in fresh water (32°–45°C) and can replicate within alveolar macrophages, and potentially can be fatal. The incubation period for Legionnaires’ disease is 2–10 days. Many outbreaks have been associated with airborne transmission of Legionella bacteria found in cooling towers, showers, faucets, aerosolizing devices, evaporating condensers, humidifiers, whirlpool baths, medication nebulizers, and even potting soil. However, many cases are sporadic and the source or mode of transmission remains unknown. Also, most cases are not diagnosed or reported (4, 5, 6). Although rare, the associated complication of rhabdomyolysis and acute renal failure has the potential to carry a high morbidity and mortality if not recognized quickly. We present a case of a patient with Legionnaire’s disease and these complications. This report was considered exempt by the Summa Health System IRB.

Section snippets

Case presentation

A 56-year-old white man presented to the Emergency Department (ED) via Emergency Medical Services (EMS). His wife found him on the bathroom floor. She reported that her husband was lethargic and had decreased responsiveness for the last two days as well as a 10-pound weight loss over the last 2–3 weeks. The patient was responsive to questioning and reported copious watery diarrhea six times per day for the last two days, as well as shortness of breath, generalized weakness, and excessive

Epidemiology

At least 46 species and 68 serogroups of Legionella have been identified. Legionellosis (infections caused by the Legionella genus) is prevalent among patients with immuno-suppression, elderly male smokers, chronic lung disease patients, malignancy, renal disease, and recent travel (4, 7). Outbreaks have been recognized throughout North America, Africa, Australia, Europe, and South America (11). Cases have been reported among lung, heart, liver, kidney, and bone marrow transplant recipients,

Conclusion

A case of Legionnaire’s disease complicated by rhabdomyolysis and renal insufficiency is presented. While associated rhabdomyolysis is uncommon, Legionnaires’ disease is a fairly common cause of CAP and nosocomial pneumonia in the US. It should be considered in any ED patient with identifiable risk factors, and symptoms or signs suggestive of Legionella infection. Risk factors include immuno-suppression, elderly male smokers, malignancy, COPD, recent travel, and other underlying illnesses.

References (12)

  • D. Kaufman et al.

    Legionella pneumoniaan unusual cause of rhabdomyolysis and acute renal failure

    South Med J

    (2002)
  • D.A. Johnson et al.

    Legionnaires’ disease with rhabdomyolysis and acute reversible myoglobinuric renal failure

    South Med J

    (1984)
  • W.E. Smeal et al.

    Legionella causing rhabdomyolysis and renal failure

    Postgrad Med

    (1985)
  • H. Chambers

    Legionnaires’ disease

  • Legionnaires’ disease associated with potting soil—California, Oregon, and Washington, May–June 2000

    MMWR Morb Mortal Wkly Rep

    (2000)
  • Vergis E, Yu V. Clinical manifestations and diagnosis of Legionella Infection. Up To Date:...
There are more references available in the full text version of this article.

Cited by (18)

  • Myositis and acute kidney injury in bacterial atypical pneumonia: Systematic literature review

    2020, Journal of Infection and Public Health
    Citation Excerpt :

    Nine cases presenting with myositis and kidney injury associated with a positive microbiology laboratory testing were not included because they did not present any respiratory disease (M. pneumoniae, N = 6; C. pneumoniae, N = 1; F. tularensis, N = 1; Legionella pneumoniae, N = 1). For the final analysis, we retained 38 reports [10–47] published between 1974 and 2019 in English (N = 34), French (N = 2) and Spanish (N = 2). They had been reported from the following countries: United States of America (N = 16), France (N = 3), Australia (N = 2), Japan (N = 2), the Netherlands (N = 2), Spain (N = 2), Turkey (N = 2), Austria (N = 1), Belgium (N = 1), China (N = 1), Croatia (N = 1), Greece (N = 1), India (N = 1), South Africa (N = 1), Tunisia (N = 1) and United Kingdom (N = 1).

  • Established association of legionella with rhabdomyolysis and renal failure: A review of the literature

    2019, Respiratory Medicine Case Reports
    Citation Excerpt :

    Since the first published case in 1980, there are a further 22 published case reports on the direct correlation between rhabdomyolysis, renal failure and Legionnaires' disease. All but two patients survived with antibiotics and dialysis; or antibiotics and intravenous rehydration if the diagnosis had been made early and before severe AKI had developed [1,2,5–7,12,19,22–34]. The association of rhabdomyolysis, renal failure and Legionella has been documented to increase the mortality of Legionnaire's disease up to 40% [12], highlighting once again the poignancy of early recognition and initiation of targeted treatment.

View all citing articles on Scopus
View full text