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Sporadic Cases versus Outbreak Associated Cases of Legionella Pneumonia
Zbl. Bakt. Hyg., 1. Abt, Orig. A 255, 48-51 (1983)
Sporadic Cases versus Outbreak Associated Cases of Legionella Pneumonia P. L. MEENHORST Department of Infectious Diseases, University Hospital, Rijnsburgerweg 10, 2333 AA Leiden, The Netherlands
Abstract Sporadic cases and outbreaks of Legionella pneumonia are more commonly recognized; especially among hospitalized patients. Factors predisposing to L. pneumophila pneumonia and the clinical features of this type of pneumonia are similar for epidemic and sporadic cases. It is difficult to compare overall mortality figures of various epidemics and series of sporadic community-acquired cases of Legionella pneumonia, because the factors that determine the severity and outcome of Legionella pneumonia are poorly defined in most series.
Introduction Legionellosis is defined as an acute disease caused by Legionella species. Pneumonia is the major clinical manifestation of an infection caused by these organisms. All Legionella species except L. gormanii and L. iordanis have been isolated from bronchial secretions, pleural fluid, and lungs of patients suffering from pneumonia. Infection with L. pneumophila serogroup 1 may also give rise to a non-pneumonic form of illness called Pontiac fever. Not all hospitalized patients with Legionnaires' disease in the Philadelphia epidemic in 1976 had radiographically proven pneumonia; therefore the disease caused by L. pneumophila and the other Legionella species in which pneumonia is a prominent feature, might more appropriately be called Legionella pneumonia. The term Legionnaires' disease should be reserved for an epidemic showing the clinical and epidemiological characteristics of the outbreak caused by L. pneumophila in Philadelphia in 1976 (Fraser et al., 1977). Sporadic cases and outbreaks of Legionella pneumonia have been reported from many countries around the world. Especially sporadic and epidemic cases of nosocomial Legionella pneumonia are becoming more commonly recognized.
Sporadic Cases versus Outbreak Associated Cases of Legionella Pneumonia
49
Predisposing Factors A high proportion of th e hospitalized patients from the Philadelphia epidemic in 1976 had an underlying illness (Fraser et al., 1977). In spora d ic communityacquired 1. pneumophila pneumonia an underlying illne ss appea rs to be an unimportant, and non-specific predisposing factor (Storch et al., 1979). Risk-factors for community-acquired 1. pneumophila pneumonia include adva ncing age, male sex, cigarette smoking, alcohol consumption, residence near or work at construction site, and recent tr avel (Storch et al., 1979). Factors predisposing to nosocomial 1. pneumophila pneumonia are similar for epidemic and spo radic cases: immunosuppressive treatment, renal dialysis, neoplastic diseases, diabetes and cigarette smoking (England, Fraser, 1981 ).
Clinical Features The clinical features of 1. pneumopbila infections ha ve been described extensively (Fraser et al. , 1977, 1979 ; Glick et al., 1978; Tsai et al., 1979 j Kirby et al., 1980) (see T able 1). It seems th at th e features of Legionella pneumonia in epidemic and sporad ic cases are not essent ially distinct, whether th e infection ha s been acquired in the ho spital or not. Ho wever, subclinical no socomi al infections with 1. pneumophila may occur (Haley et al., 1979). Legionella pneumonia is a mult isystem disease for wh ich bacteri al products and /or local outgrowth of Legion ellae in different organs may be respon sible. The role of va rious products formed by Legionellae in disea se in man is no t clear; 1. pneumophila has been demonstr at ed in the bone marrow, brain, kidn eys, liver, lymph nod es, myocardium and spleen (Dorman, Hardin, Winn, 1980 ; Weisenburger et al., 1980, 1981 j Whit e, Felton, Still, 1980 ; Evans, Winn, 1981; Cutz et al., 1982). Recentl y, Dournon et al. (1982) described a patient with Legionella pneumonia, wh o also suffered from peritonitis; the same serogroup of 1. pneumophila wa s cultured from the lun g, ileum wall, and from mucu s of th e sma ll bowel. These finding s illustrate a po ssible dir ect role for 1. pneumophila in the pathogenesis of the gastro-intestinal symptom s, which are frequently seen in Legion ella pneumonia. Although laboratory features, such as the number of lymphocytes, the serum
Table 1. Common Signs and Symptoms in Patients with Leglonella Pneumonia Prodromal state (1- 4 days)
During development of lung infi ltrate
During progression of the disease
Malaise Anorexia Myalgia Headache Diarrhea 'N ausea
Cold chills High fever (> 38.9 DC) Diarrhea Nausea Dry cough Chest pain
Mental confusion and other abnormal neurological findings Chest pain Cough No sputum or small amounts
4 Zb l. Bakt . Hyg., I. Ab r, Orig . A 155
50
P. L. Meenhorst
sodium, phosphate, and albumin are frequently abnormal in Legionella pneumonia, none of these seems to be specific (Kirby et al., 1978; Miller, 1979; Helms et al., 1979; Yu et al., 1982). The severity and outcome of Legionella pneumonia are determined by many factors. In most series these factors are poorly defined and therefore it is difficult to compare overall mortality figures of various epidemics and series of sporadic community-acquired cases of Legionella pneumonia.
References Evans, C. P. and W. C. Winn: Extrathoracic localization of Legionella pneumophila in Legionnaires' pneumonia. Amer. Soc. Clin. Path. 76 (1981) 813-815 Cutz, E., P.S. Thorner, C.P.Rao, S. Toma, R. Gold, and E. W. Gelfand: Dissiminated Legionella pneumophila infection in an infant with severe combined immunodeficiency. J. Pediat. 100 (1982) 760-762 Dorman, S. A., N. J. Hardin, and W. C. Winn: Pyelonephritis associated with Legionella pneumophila, serogroup 4. Ann. Intern. Med. 93 (1980) 835-837 Dournon, E., A. Bure, J. L. Kemeny, ]. L. Pourriat, and D. Valeyre: Legionella pneumophila peritonitis. Lancet i (1982) 813 England III, A. C. and D. W. Fraser: Sporadic and epidemic nosocomial Legionellosis in the United States. Epidemiologic features. Amer. J. Med. 70 (1981) 707-711 Fraser, D. W., T.R. Tsai, W. Orenstein, W.E. Parkin, H.J.Beecham, R. G.Sharrar, J. Harris, G.F.Mallison, S.M.Martin, J.E.McDade, C.C.Shepard, P.S.Brachman, and the Field Investigation Team: Legionnaires' disease. Description of an epidemic of pneumonia. New Engl. J. Med. 297 (1977) 1189-1197 Fraser, D. W., D.C.Deubner, D.L.Hill, and D.K.Gilliam: Nonpneumonic, short-incubation-period Legionellosis (Pontiac fever) in men who cleaned a steam turbine condenser. Science 205 (1979) 690-691 Glick, T. H., M. B. Gregg, B. Berman, G. Mallison, W. W. Rhodes ir., and 1. Kassanoff: Pontiac fever. An epidemic of unknown etiology in a health department. 1. Clinical and epidemiologic aspects. Amer. J. Epidem. 107 (1978) 149-160 Haley, C.E., M.L.Cohen, ].Halter, and R.D.Meyer: Nosocomial Legionnaires' disease: A continuing common-source epidemic at Wadsworth Medical Center. Ann. Intern. Med. 90 (1979) 583-586 Helms, c.P., J.P. Viner, R.H.Sturm, E.D.Renner, and W.Johnson: Comparative features of pneumococcal, mycoplasmal, and Legionnaires' disease pneumonias. Ann. Intern. Med. 90 (1979) 543-547 Kirby, B. D., K. M. Snyder, D. R. Meyer, and S. M. Finegold: Legionnaires' disease: Clinical features of 24 cases. Ann. Intern. Med. 89 (1978) 297-309 Kirby, B. D., K. M. Snyder, R. D. Meyer, and S.M. Finegold: Legionnaires' disease: Report of sixty-five nosocomiaJly acquired cases and review of the literature. Medicine 59 (1980) 188-205 Miller, A. C.: Early clinical differentiation between Legionnaires' disease and other sporadic pneumonias. Ann. Intern. Med. 90 (1979) 526-528 Storch, G., W. B. Baine, D. W. Fraser, C. V. Broome, H. W. Clegg II., M. L. Cohen, S. A. J. Goings, B.D.Politi, W.A. Terranova, T.F. Tsai, B.D.Plikaytis, C.C.Shepard, and J. V. Bennet: Sporadic community-acquired Legionnaires' disease in the United States. A casecontrol study. Ann. Intern. Med. 90 (1979) 596-600 Tsai, T.F., D.R.Finn, B.D.Plikaytis, W.McCauley, S.M.Martin, and D. W.Fraser: Legionnaires' disease: Clinical features of the epidemic in Philadelphia. Ann. Intern. Med. 90 (1979) 509-517
Sporadic Cases versus Outbreak Associated Cases of Legionella Pneumonia
51
Weisenburger, D. D., H. Rappaport, M. S.Ahluwalia, R. Melvani, and E. D. Renner: Legionnaires' Disease. Amer. ]. Med. 69 (1980) 467-482 Weisenburger, D. D., C. M. Helms, and E.D. Renner: A pathologic study of 23 fatal cases. Arch. Path. Lab. Med. 104 (1981) 287-289 White, H.]., W. W.Felton, and C.N.Sun: Extrapulmonary histopathologic manifestations of Legionnaires' disease. Evidence for myocarditis and bacteriema. Arch. Path. Lab. Med. 104 (1980) 287-289 Yu, V.L., F.]. Kroboth,]. Sbonnard, A. Brown, S.McDearman, and M. Magnussen: Legionnaires' disease: New clinical perspective from a prospective pneumonia study. Amer. ]. Med.73 (1982) 357-361
Sporadic Cases versus Outbreak Associated Cases of Legionella Pneumonia P. L. MEENHORST Department of Infectious Diseases, University Hospital, Rijnsburgerweg 10, 2333 AA Leiden, The Netherlands
Abstract Sporadic cases and outbreaks of Legionella pneumonia are more commonly recognized; especially among hospitalized patients. Factors predisposing to L. pneumophila pneumonia and the clinical features of this type of pneumonia are similar for epidemic and sporadic cases. It is difficult to compare overall mortality figures of various epidemics and series of sporadic community-acquired cases of Legionella pneumonia, because the factors that determine the severity and outcome of Legionella pneumonia are poorly defined in most series.
Introduction Legionellosis is defined as an acute disease caused by Legionella species. Pneumonia is the major clinical manifestation of an infection caused by these organisms. All Legionella species except L. gormanii and L. iordanis have been isolated from bronchial secretions, pleural fluid, and lungs of patients suffering from pneumonia. Infection with L. pneumophila serogroup 1 may also give rise to a non-pneumonic form of illness called Pontiac fever. Not all hospitalized patients with Legionnaires' disease in the Philadelphia epidemic in 1976 had radiographically proven pneumonia; therefore the disease caused by L. pneumophila and the other Legionella species in which pneumonia is a prominent feature, might more appropriately be called Legionella pneumonia. The term Legionnaires' disease should be reserved for an epidemic showing the clinical and epidemiological characteristics of the outbreak caused by L. pneumophila in Philadelphia in 1976 (Fraser et al., 1977). Sporadic cases and outbreaks of Legionella pneumonia have been reported from many countries around the world. Especially sporadic and epidemic cases of nosocomial Legionella pneumonia are becoming more commonly recognized.
Sporadic Cases versus Outbreak Associated Cases of Legionella Pneumonia
49
Predisposing Factors A high proportion of th e hospitalized patients from the Philadelphia epidemic in 1976 had an underlying illness (Fraser et al., 1977). In spora d ic communityacquired 1. pneumophila pneumonia an underlying illne ss appea rs to be an unimportant, and non-specific predisposing factor (Storch et al., 1979). Risk-factors for community-acquired 1. pneumophila pneumonia include adva ncing age, male sex, cigarette smoking, alcohol consumption, residence near or work at construction site, and recent tr avel (Storch et al., 1979). Factors predisposing to nosocomial 1. pneumophila pneumonia are similar for epidemic and spo radic cases: immunosuppressive treatment, renal dialysis, neoplastic diseases, diabetes and cigarette smoking (England, Fraser, 1981 ).
Clinical Features The clinical features of 1. pneumopbila infections ha ve been described extensively (Fraser et al. , 1977, 1979 ; Glick et al., 1978; Tsai et al., 1979 j Kirby et al., 1980) (see T able 1). It seems th at th e features of Legionella pneumonia in epidemic and sporad ic cases are not essent ially distinct, whether th e infection ha s been acquired in the ho spital or not. Ho wever, subclinical no socomi al infections with 1. pneumophila may occur (Haley et al., 1979). Legionella pneumonia is a mult isystem disease for wh ich bacteri al products and /or local outgrowth of Legion ellae in different organs may be respon sible. The role of va rious products formed by Legionellae in disea se in man is no t clear; 1. pneumophila has been demonstr at ed in the bone marrow, brain, kidn eys, liver, lymph nod es, myocardium and spleen (Dorman, Hardin, Winn, 1980 ; Weisenburger et al., 1980, 1981 j Whit e, Felton, Still, 1980 ; Evans, Winn, 1981; Cutz et al., 1982). Recentl y, Dournon et al. (1982) described a patient with Legionella pneumonia, wh o also suffered from peritonitis; the same serogroup of 1. pneumophila wa s cultured from the lun g, ileum wall, and from mucu s of th e sma ll bowel. These finding s illustrate a po ssible dir ect role for 1. pneumophila in the pathogenesis of the gastro-intestinal symptom s, which are frequently seen in Legion ella pneumonia. Although laboratory features, such as the number of lymphocytes, the serum
Table 1. Common Signs and Symptoms in Patients with Leglonella Pneumonia Prodromal state (1- 4 days)
During development of lung infi ltrate
During progression of the disease
Malaise Anorexia Myalgia Headache Diarrhea 'N ausea
Cold chills High fever (> 38.9 DC) Diarrhea Nausea Dry cough Chest pain
Mental confusion and other abnormal neurological findings Chest pain Cough No sputum or small amounts
4 Zb l. Bakt . Hyg., I. Ab r, Orig . A 155
50
P. L. Meenhorst
sodium, phosphate, and albumin are frequently abnormal in Legionella pneumonia, none of these seems to be specific (Kirby et al., 1978; Miller, 1979; Helms et al., 1979; Yu et al., 1982). The severity and outcome of Legionella pneumonia are determined by many factors. In most series these factors are poorly defined and therefore it is difficult to compare overall mortality figures of various epidemics and series of sporadic community-acquired cases of Legionella pneumonia.
References Evans, C. P. and W. C. Winn: Extrathoracic localization of Legionella pneumophila in Legionnaires' pneumonia. Amer. Soc. Clin. Path. 76 (1981) 813-815 Cutz, E., P.S. Thorner, C.P.Rao, S. Toma, R. Gold, and E. W. Gelfand: Dissiminated Legionella pneumophila infection in an infant with severe combined immunodeficiency. J. Pediat. 100 (1982) 760-762 Dorman, S. A., N. J. Hardin, and W. C. Winn: Pyelonephritis associated with Legionella pneumophila, serogroup 4. Ann. Intern. Med. 93 (1980) 835-837 Dournon, E., A. Bure, J. L. Kemeny, ]. L. Pourriat, and D. Valeyre: Legionella pneumophila peritonitis. Lancet i (1982) 813 England III, A. C. and D. W. Fraser: Sporadic and epidemic nosocomial Legionellosis in the United States. Epidemiologic features. Amer. J. Med. 70 (1981) 707-711 Fraser, D. W., T.R. Tsai, W. Orenstein, W.E. Parkin, H.J.Beecham, R. G.Sharrar, J. Harris, G.F.Mallison, S.M.Martin, J.E.McDade, C.C.Shepard, P.S.Brachman, and the Field Investigation Team: Legionnaires' disease. Description of an epidemic of pneumonia. New Engl. J. Med. 297 (1977) 1189-1197 Fraser, D. W., D.C.Deubner, D.L.Hill, and D.K.Gilliam: Nonpneumonic, short-incubation-period Legionellosis (Pontiac fever) in men who cleaned a steam turbine condenser. Science 205 (1979) 690-691 Glick, T. H., M. B. Gregg, B. Berman, G. Mallison, W. W. Rhodes ir., and 1. Kassanoff: Pontiac fever. An epidemic of unknown etiology in a health department. 1. Clinical and epidemiologic aspects. Amer. J. Epidem. 107 (1978) 149-160 Haley, C.E., M.L.Cohen, ].Halter, and R.D.Meyer: Nosocomial Legionnaires' disease: A continuing common-source epidemic at Wadsworth Medical Center. Ann. Intern. Med. 90 (1979) 583-586 Helms, c.P., J.P. Viner, R.H.Sturm, E.D.Renner, and W.Johnson: Comparative features of pneumococcal, mycoplasmal, and Legionnaires' disease pneumonias. Ann. Intern. Med. 90 (1979) 543-547 Kirby, B. D., K. M. Snyder, D. R. Meyer, and S. M. Finegold: Legionnaires' disease: Clinical features of 24 cases. Ann. Intern. Med. 89 (1978) 297-309 Kirby, B. D., K. M. Snyder, R. D. Meyer, and S.M. Finegold: Legionnaires' disease: Report of sixty-five nosocomiaJly acquired cases and review of the literature. Medicine 59 (1980) 188-205 Miller, A. C.: Early clinical differentiation between Legionnaires' disease and other sporadic pneumonias. Ann. Intern. Med. 90 (1979) 526-528 Storch, G., W. B. Baine, D. W. Fraser, C. V. Broome, H. W. Clegg II., M. L. Cohen, S. A. J. Goings, B.D.Politi, W.A. Terranova, T.F. Tsai, B.D.Plikaytis, C.C.Shepard, and J. V. Bennet: Sporadic community-acquired Legionnaires' disease in the United States. A casecontrol study. Ann. Intern. Med. 90 (1979) 596-600 Tsai, T.F., D.R.Finn, B.D.Plikaytis, W.McCauley, S.M.Martin, and D. W.Fraser: Legionnaires' disease: Clinical features of the epidemic in Philadelphia. Ann. Intern. Med. 90 (1979) 509-517
Sporadic Cases versus Outbreak Associated Cases of Legionella Pneumonia
51
Weisenburger, D. D., H. Rappaport, M. S.Ahluwalia, R. Melvani, and E. D. Renner: Legionnaires' Disease. Amer. ]. Med. 69 (1980) 467-482 Weisenburger, D. D., C. M. Helms, and E.D. Renner: A pathologic study of 23 fatal cases. Arch. Path. Lab. Med. 104 (1981) 287-289 White, H.]., W. W.Felton, and C.N.Sun: Extrapulmonary histopathologic manifestations of Legionnaires' disease. Evidence for myocarditis and bacteriema. Arch. Path. Lab. Med. 104 (1980) 287-289 Yu, V.L., F.]. Kroboth,]. Sbonnard, A. Brown, S.McDearman, and M. Magnussen: Legionnaires' disease: New clinical perspective from a prospective pneumonia study. Amer. ]. Med.73 (1982) 357-361