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Defeating the Legionella of Doom: A Case of Severe ARDS Requiring ECMO Support
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A5255 - Defeating the Legionella of Doom: A Case of Severe ARDS Requiring ECMO Support
Author Block: M. Rahbe1, M. Megally2, E. Awerbuch3; 1Internal Medicine, Elmhurst Hospital Center, queens, NY, United States, 2Department of Medicine, Brooklyn, NY, United States, 3Elmhurst Hospital Center, Elmhurst, NY, United States.
Introduction:
Legionairre’s disease is a rare but often fatal etiology of pneumonia. Early diagnoses and treatment with antibiotics is imperative. We present a case without initial findings of pneumonia rapidly progressing to severe Acute Respiratory Distress Syndrome (ARDS) requiring Extracorporeal Membrane Oxygenation (ECMO) can serve as a lifesaving treatment alternative for patients with legionnaire’s disease that progress to ARDS leading to hypoxia refractory to vent management.
Case:
A 41-year-old female with unknown past medical history presented to emergency department with altered mental status. Temperature was 102.8F, heart rate of 131, and saturating 99% on room air. Initial physical exam was significant for an obese female that was disoriented with normal lung sounds, and a non-tender abdomen. Labs were significant for white blood cell count of 11.6k and a sodium level of 130. Additional workup included a negative urinalysis, clear chest X-ray (CXR), and negative cerebrospinal fluid analysis. Blood was cultured and sepsis workup in progress. Patient was empirically covered for meningitis and admitted to telemetry. Day two, legionella urine antigen returned positive and levofloxacin was started. Repeat CXR showed a new left lower consolidation. Progressive hypoxia and acidosis was followed by intubation and upgrade to the MICU. Despite aggressive care, CXR showed extensive diffuse infiltrates consistent with acute respiratory distress syndrome. Efforts to correct the patient’s hypoxia progressed despite increasing to 100% FiO2 and 20 cmH2O of PEEP. Given the patient’s rapid decline they were placed on Venovenous ECMO and transported to Montefiore Hospital for continued care. Patient was maintained on ECMO for five days and was discharged home after a relatively short course in the hospital.
Discussion: Legionnaires disease accounts for 1-9% of all community acquired pneumonias. Legionella is an aerobic, gram- negative bacilli that is transmitted from inhalation of aerosolized mist from water sources including cooling systems, showers, fountains, and respiratory therapy equipment. Factors increasing the risk of infection include advanced age, smoking, chronic heart or lung disease, immunocompromised host, diabetes, end stage renal disease, and alcohol abuse. Patients commonly present with pneumonia-like symptoms with or without nausea, vomiting, and diarrhea. Treatment typically involves a fluoroquinolone or macrolide. A retrospective multicenter published in 2016 showed no significant difference in outcome in patients treated with levofloxacin vs azithromycin.
References:
1. Vidal, Garcia C., et al. “Levofloxacin versus azithromycin for treating legionella pneumonia: a propensity score analysis.” Clinical Microbiology and Infection , 6 Mar. 2016. Pub Med, doi:2/30/2017.
Author Block: M. Rahbe1, M. Megally2, E. Awerbuch3; 1Internal Medicine, Elmhurst Hospital Center, queens, NY, United States, 2Department of Medicine, Brooklyn, NY, United States, 3Elmhurst Hospital Center, Elmhurst, NY, United States.
Introduction:
Legionairre’s disease is a rare but often fatal etiology of pneumonia. Early diagnoses and treatment with antibiotics is imperative. We present a case without initial findings of pneumonia rapidly progressing to severe Acute Respiratory Distress Syndrome (ARDS) requiring Extracorporeal Membrane Oxygenation (ECMO) can serve as a lifesaving treatment alternative for patients with legionnaire’s disease that progress to ARDS leading to hypoxia refractory to vent management.
Case:
A 41-year-old female with unknown past medical history presented to emergency department with altered mental status. Temperature was 102.8F, heart rate of 131, and saturating 99% on room air. Initial physical exam was significant for an obese female that was disoriented with normal lung sounds, and a non-tender abdomen. Labs were significant for white blood cell count of 11.6k and a sodium level of 130. Additional workup included a negative urinalysis, clear chest X-ray (CXR), and negative cerebrospinal fluid analysis. Blood was cultured and sepsis workup in progress. Patient was empirically covered for meningitis and admitted to telemetry. Day two, legionella urine antigen returned positive and levofloxacin was started. Repeat CXR showed a new left lower consolidation. Progressive hypoxia and acidosis was followed by intubation and upgrade to the MICU. Despite aggressive care, CXR showed extensive diffuse infiltrates consistent with acute respiratory distress syndrome. Efforts to correct the patient’s hypoxia progressed despite increasing to 100% FiO2 and 20 cmH2O of PEEP. Given the patient’s rapid decline they were placed on Venovenous ECMO and transported to Montefiore Hospital for continued care. Patient was maintained on ECMO for five days and was discharged home after a relatively short course in the hospital.
Discussion: Legionnaires disease accounts for 1-9% of all community acquired pneumonias. Legionella is an aerobic, gram- negative bacilli that is transmitted from inhalation of aerosolized mist from water sources including cooling systems, showers, fountains, and respiratory therapy equipment. Factors increasing the risk of infection include advanced age, smoking, chronic heart or lung disease, immunocompromised host, diabetes, end stage renal disease, and alcohol abuse. Patients commonly present with pneumonia-like symptoms with or without nausea, vomiting, and diarrhea. Treatment typically involves a fluoroquinolone or macrolide. A retrospective multicenter published in 2016 showed no significant difference in outcome in patients treated with levofloxacin vs azithromycin.
References:
1. Vidal, Garcia C., et al. “Levofloxacin versus azithromycin for treating legionella pneumonia: a propensity score analysis.” Clinical Microbiology and Infection , 6 Mar. 2016. Pub Med, doi:2/30/2017.
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