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A5192 - Legionella: Pneumonia and Rhabdomyolysis
Author Block: K. Ahmad1, A. Nikamal1, A. Fatima2, U. Nazir3, D. Saha4; 1UIC/ Advocate Christ Medical Center, Chicago, IL, United States, 2UIC/ Advocate Christ Medical Center, CHICAGO, IL, United States, 3Rhode Island Hospital, Providence, RI, United States, 4Critical Care Medicine, UIC/Advocate Christ Medical Center, Oak Lawn, IL, United States.
Introduction
Legionella is a gram-negative bacterium, found in freshwater bodies
that can be transmitted via water droplets. It generally causes
atypical pneumonia. Rhabdomyolysis is rapid destruction of skeletal
muscles, which can lead to acute renal failure either by acute
interstitial nephritis or acute tubular necrosis. We present a case of
legionella pneumonia associated with rhabdomyolysis and acute renal
failure.
Case presentation
54-year-old African American gentleman with no past medical history
presented for worsening cough, dyspnea, diarrhea, and severe nausea
with non-bloody, non-bilious vomiting over the previous 7 days. Review
of systems was remarkable for somnolence and generalized muscle pain.
On presentation, he was febrile, tachycardic, hypotensive, tachypneic
and appeared in distress, with physical exam remarkable for
generalized tenderness, lethargy and mild bibasilar crackles. His labs
were remarkable for hyponatremia (123 mmol/L), acute renal failure
(BUN 84 mg/dl, Creatinine 11.53 mg/dl), hyperphosphatemia (8.7 mg/dl),
transaminitis (AST 1276 unit/L, ALT 361 unit/L), leukocytosis (WBC;
13.7 thousand/mcl) and procalcitonin elevated to 21.64 ng/ml. He was
also found to have an elevated Creatinine Kinase level of 54,000
unit/l. Chest X-Ray revealed left patchy infiltrate. Patient had
emergent hemodialysis with transient improvement in the metabolic
panel, as well as creatinine kinase levels. Blood cultures, HIV,
hepatitis panel and viral respiratory pathogen panel were sent.
Considering the hyponatremia, diarrhea, and pneumonia legionella urine
antigen was also tested which came back positive. He also developed
atrial fibrillation with RVR, unable to be rate controlled with
Diltiazem and was started on Amiodarone. He was initially treated with
5 days of azithromycin with some improvement, however considering his
diagnosis of complicated Legionella Pneumonia, patient was switched to
levofloxacin for 14 days. He was discharged to acute inpatient rehab
with resolution of pneumonia and rhabdomyolysis, still requiring
dialysis for renal failure.
Discussion
Legionella pneumonia complicated by rhabdomyolysis subsequently
leading to acute renal failure is a rare presentation. Rhabdomyolysis
is postulated to result from endotoxin mediated tissue injury and
direct bacterial invasion of the muscles, subsequently leading to
acute renal failure. There is significant morbidity and mortality
associated with Legionella pneumonia complicated by rhabdomyolysis. It
is imperative to be aware of the association between bacterial
infections and rhabdomyolysis and subsequent renal failure as
demonstrated by our case. Uncomplicated cases warrant treatment with
Macrolide or Fluroquinolone for 7-10 days. Dual antibiotic therapy may
be required in complicated cases for 14 days.