Physicians | Legionella.org

Can you treat a patient before they have symptoms to prevent
Legionnaires’ disease if you know that they may have been exposed
(water supply where they stayed tested positive)?

Many buildings have Legionella in the drinking water,
and you have undoubtedly been exposed to Legionella in the
past. Most patients who contract Legionnaires’ disease have a risk
factor. Cigarette smoking is the most common. Disease in which
the immune system is compromised is another. If you develop high
fever and symptoms of pneumonia (cough), see a physician.

I am about to see a young patient who has had a three months of
upper respiratory symptoms without a fever. He was found to have
the following L. pneumophila serological results: IgG-1:
128 (ref </=64), IgM-1: 512 (ref </= 256)

 

Others at his building have had similar symptoms. I only have
info from a phone call and I have little additional information.
The MD didn’t know if there was a fountain in the building lobby. I
am suspicious regarding the diagnosis of Legionnaires’ in the
“index case.” Any thoughts?

Surprisingly, this is not an uncommon problem, and we get this
question occasionally. The missing info is whether he has ever
had pneumonia in the past, especially within a year. It
would also help to know the past medical history and the history of
cigarette smoking.

 

Assuming that he has no overt history of pneumonia, this
serology suggests that he has contracted Legionnaires’ disease and
has either subclinical pneumonia or Legionella infection without
pneumonia.  Assuming no other striking info comes from his PMH
(including no antibiotic history); I would order a chest x-ray. It
might be justifiable anyway given his prolonged duration of
URI.

 

If it was negative, you have 2 pragmatic choices:

1) Give him empiric azithromycin 500 mg for 7 days

2) Have an ENT evaluate him for chronic sinusitis

(I had similar symptoms to this patient and didn’t use antibiotics
for a likely viral URI. My cough exacerbated in the third month and
I was moved to another room due to spastic coughing fits lying
supine with copious rhinorrhea. I had a nasal endoscopy and
laryngoscopy with the ENT rhinologist. [See CID article, Jan 2012]
The endoscopic cultures revealed H influenza-beta-lactamase
positive. I took Augmentin with clinical response in 3 days; I took
my last dose of Augmentin last night and cough has
disappeared.)

 

Based on the limited history, I would give empiric azithro. One
reason is relief of anxiety for both referring physician and
patient. (For the other employees with similar symptoms/anxiety
about Legionnaires’ disease, I don’t believe that decorative
fountains cause Legionnaires’ disease.)

 

When you get the remaining history, email me again. We have
devised an inexpensive solution for buildings which are colonized
with Legionella and are not healthcare facilities with
high-risk patients. Example: hotels, dormitories, office buildings.
 

 

My husband is 31 and has a fever ranging from 38 °-40 ° C,
severe pain, sore throat, chills, sweats, muscle aches, headaches,
cramps, diarrhea, and nausea. It has been a hard two days at home.
We gave him pills for his fever which were effective for 3 hours.
He was hospitalized after 3 days and the symptoms persist for 3
more days. After 5 days the fever wasn’t controlled by pills or
neo-melubrine. He was given an antibiotic for strep throat
(clindamycin).

 

On the fifth day, we consulted infectious diseases, and he
suggested it was Legionnaires’ disease. We performed blood studies
and the lymphocytes were 8 with the reference range of 20 – 40. The
doctor changed to oral antibiotics (Klaricid OD klaritromicin 500
mg) taken every 12 hrs for 10 days and Avelox – Moxifloxacin 400 mg
tablets for 5 days. These antibiotics cured all the symptoms. The
doctor said the tests to determine if it was Legionnaires’ are done
in the U.S. and the results will take 15 days. For this reason,
these antibiotics were prescribed because we couldn’t wait on
results. No tests were done to determine if it was
Legionnaires’.

 

 My question is: How to know if my husband has the
Legionella bacteria after receiving this treatment? He was
released and began to work, but he went to the doctor and there are
still spots in the lungs. I am very upset because I hope he does
not have a relapse. 

Klaritromicin and Moxifloxacin are effective against
legionnaires’ disease and many other types of pneumonia. If
his fever has resolved and he is well, his pneumonia may have been
cured. If he contracted Legionnaires’ disease, he may have gained
some immunity since recurrent cases of Legionnaires’ disease is
unusual. The chest x-ray may still show spots in the lung, but
they will resolve over time. The important prognostic sign is
resolution of fever and return of appetite. Your husband is likely
cured with the antibiotics.

Can the Legionella bacterium survive in the lung even
after a three week course of Clarithromycin (500mg) taken twice
daily, and can it then re-infect the patient about two months
later?

It is unlikely that Legionella could survive 3 weeks of
clarithromycin if you responded within the first 5 days. Was
the Legionnaires’ disease confirmed by a Legionella test
ordered by a physician? If so, what is the name of the
test?

 

Re-infection by Legionella is theoretically possible,
but we have only seen one convincing case. 

 

Follow-Up:

Here’s the timeline of my Legionella infection and my
patient history. I’m a 60 yr old male recently retired carpenter,
so I am fairly fit. There was an outbreak of Legionnaires’ here in
Edinburgh Scotland, UK, in May 2012 which took three lives and
hospitalized ~50.

 

I first had symptoms on May 5th which I thought was the flu. It
rapidly progressed into high fever with vomiting and diarrhea.
After three days, I was too wiped out and confused to seek medical
help so I tried to battle through it.

 

On June 7, I was well enough to visit my doctor who sent me to
the hospital where a blood sample was tested. I also had a chest
x-ray. The blood sample was positive for Legionella, and I
was given Clarithromycin (500mg).

 

About two weeks of being off my antibiotics, I began having
symptoms of Legionnaires’. I had lower leg pain, headaches, a bit
of diarrhea, and was coughing up phlegm. This only lasted a couple
of days and I got back to normal.

 

A week later I gave a blood sample for my Legionella
follow-up survey. My doctor called to say the sample was positive
for Legionella and put me on a seven day course of
Clarithromycin (500mg) again. I went for a chest x-ray where it was
confirmed I had an infection of the lower lung. This is why I asked
if it was possible to carry the Legionella bacteria after
antibiotic treatment. I’m due to give another blood sample and I
will await the results with interest.

 

Reply:

The more important test is comparison of your next chest X-ray
with the chest X-ray of 20/07/12. Your next chest X-ray may be
abnormal for the next 2 – 3 months, but it should not be
worse. If your fever has subsided, you are probably
recovering.

 

Your Legionella blood test may remain abnormal for many more
months, but that is not of concern – this test shows you contracted
Legionnaires’ disease, but it is not that useful for measuring
outcome.

 

Although the NHS maintains that cooling towers are a
primary source, the actual source is the drinking water, and for
reasons unclear, UK health officials rarely will admit to this
likely possibility and therefore classify the source as
unknown.

 

The following articles may be of interest to your physicians and
can be downloaded from the Publications section.

Cooling towers and Legionellosis: A conundrum with proposed
solutions

Legionnaires’ disease Contracted from Patient Homes: The Coming of
the Third Plague?

 

If a patient had been diagnosed with pneumonia in May can there
be a test now (September) to see if they had had Legionnaires’?

The blood serology test for antibodies to Legionella
may be positive for many years after contracting Legionnaire’s
disease. A positive test at a high antibody titer is circumstantial
evidence for Legionnaires’ disease. Unfortunately, a negative test
is not helpful, i.e. if the test shows a low titer, this result
does not rule out Legionnaires’ disease. You may need a medical
authority to assist you with interpretation of this test.

Where exactly does Legionella travel in the body? Can
it travel to the brain and through the blood after infection the
lungs?

Legionella infects the lungs (pneumonia). It can travel
by blood to other parts of the body including heart and kidney.
Brain infection is extremely rare, but is theoretically
possible.

 

Neurologic and central nervous system (brain, CNS) problems
may also be due to immune-reactions to Legionella. See Lin COID
2011, page 351, top right.

A hospitalized patient who was admitted with lung cancer (not on
chemo) developed new wheezing and a shortness of breath, but does
not have a fever. It has been seven days since their admission. The
chest x-ray showed new small pleural effusions but no infiltrates.
The urine antigen was positive, and there was no sputum produced.
Another urine antigen was done five days later, but it showed up
negative.

Could this still be possible hospital acquired
Legionella despite the absence of fever (but new clinical
respiratory findings) and a repeated urine antibody which was
negative? I know the urine antigen can remain positive for weeks,
but I did not know about a positive that can become a negative so
soon.

The scenario you describe is somewhat unusual, as you indicate.
The urine antigen will usually remain positive, even after
receiving antibiotic therapy. But, on occasion the second one may
be negative for a variety of reasons. One of them is that the
pathogen may not be L. pneumophila serogroup 1, but
another species or serogroup, and weak cross-reactivity with
urinary antigen has occurred.

 

If you have pleural fluid available, the urinary antigen test
may be positive in the pleural fluid. I would also obtain a third
urinary antigen for confirmation.

 

At this point, obtain sera immediately and repeat it as an
outpatient. Order antibody titers for Legionella
pneumophila serogroups 1-6. The maximal time for
seroconversion is three months. So, obtain sera acutely (best time
is admission), about 4-6 weeks later, and again 3 months later.
This may give you the answer if seroconversion is seen.

There is a patient in the ICU that has been diagnosed with
Legionnaires’ disease. She was diagnosed with a positive
Legionella serology test.

 

She has had a masectomy on one breast. She has a pacemaker. She
also has had chronic spinal issues and walks with the aid of a
walker.

 

What is the correct treatment for a patient who requires such
intensive care? She is in the ICU and has been on a ventilator for
about five days now. Her vital signs are looking pretty good and
her heart is strong, but she is not getting better.

The drugs of choice for Legionnaires’ disease are:

Quiniolones: levofloxacin, moxifloxican

Macrolides: azithromycin, clarithromycin

 

Most patients who receive correct treatment early respond within
five days (fever will disappear).  If she is receiving one of
these antibiotics, she is being treated correctly. If an infection
disease specialist is a consultant, I would guess that everything
is being done for her and her care is appropriate.

 

Regardless, ICU physicians are well trained and knowledgeable
about Legionnaires’ disease. The biggest problems in patients with
Legionnaires’ disease is that disease is often overlooked by
physicians. Your physicians have already made a correct
diagnosis.

 

If she is deteriorating, we may recommend the addition of
rifampin (600 mg/day) for only 3-5 days. This does not need to be
done if an improvement is seen. Good luck.

Legionella pneumonia is increasingly diagnosed only
with urinary antigen rather than cultures, which are often no
longer obtained in most hospitals. If UA is positive, how does one
then link to enviroinmental samples?

As you know, the urinary antigen detects only L.
pneumophila, serogroup 1.

 

If the Legionella in the environmental water sample is
also L. pneumophila, serogroup 1, it is weak
circumstantial evidence that the water may be the source. In
essence, a positive match might be less useful than a negative
match; a negative match might rule out the water as the source.
This assumes that the water sample is performed as rigorously as
our Special Pathogens
Lab which uses multiple selective media and heat/acid treament
to exclude contaminating flora.