Legionnaires Disease Clinical Presentation

  • Author: Burke A Cunha, MD; Chief Editor: Michael Stuart Bronze, MD   more...
 
Updated: Nov 15, 2011
 

History

L pneumophila causes 2 distinct disease entities. Legionnaires disease (LD) is characterized by pneumonia. Pontiac fever is a milder illness than LD and is not characterized by pneumonia; Pontiac fever manifests as fever and myalgias that resolve without treatment.

  • Legionnaires disease
    • The incubation period ranges from 2-10 days.
    • Patients who develop legionellae infection and who have been hospitalized continuously for 10 or more days before the onset of illness are classified as having definite nosocomial LD. Patients with laboratory-confirmed infection that develops 2-9 days after hospitalization are classified as having possible nosocomial LD.
    • Nosocomial LD occurs in clusters.
  • Symptoms of legionnaires disease
    • Fever greater than 40 º C (>102 º F)
    • Chills
    • Cough - Dry or productive; hemoptysis rare
    • Pleuritic or nonpleuritic chest pain
    • Neurologic symptoms
      • Headache
      • Lethargy
      • Encephalopathy
      • Mental status changes - The most common neurologic symptom
    • GI symptoms
      • Diarrhea - Watery, not bloody
      • Nausea, vomiting, and abdominal pain
    • Mild myalgias
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Physical

  • Manifestations of LD may include the following:
  • Headache
  • Mental status changes
  • Fever greater than 40°C (range, 38.8-40.5°C)
  • Relative bradycardia (excluding patients with pacemakers or arrhythmias or those receiving beta-blockers, diltiazem, or verapamil)
  • Tachypnea
  • Localized rales
  • Extrapulmonary manifestations
    • In addition to relative bradycardia, other cardiac manifestations include myocarditis, and prosthetic valve endocarditis.
    • Pancreatitis
    • Acute renal failure

Table. Modified Winthrop-University Hospital Infection Disease Division's Point System for Diagnosing Legionnaires Disease in Adults (Open Table in a new window)

Clinical Features Qualifying Conditions Point Score
Temperature >103°F*With relative bradycardia+5
HeadacheAcute onset+2
Mental confusion/lethargy*Not drug induced+4
Ear painAcute onset-3
Nonexudative pharyngitisAcute onset-3
HoarsenessAcute, not chronic-3
Sputum (purulent)Excluding chronic bronchitis-3
Hemoptysis*Mild/moderate-3
Chest pain (pleuritic)Rapidly progressive asymmetrical



infiltrates* (excluding severe influenza/severe acute respiratory syndrome)



-3
Loose stools/watery diarrhea*Not drug induced+3
Abdominal pain*With or without diarrhea+5
Renal failure*Acute, not chronic+3
Shock/hypotension*Not 2° to acute cardiac-5
/pulmonary causes+5
SplenomegalyExcluding non-CAP causes-5
Lack of response to beta lactamsAfter 72 h (excluding viral pneumonias)+5
Laboratory Features
Chest radiographRapidly progressive asymmetrical infiltrates*



(excluding severe influenza/SARS)



+3
↓ PO2 with ↑ A-a gradient (>35)*(Excluding severe influenza/SARS)-5
↓ Na+Acute onset+1
↓ PO4 =*Acute onset+5
↑ SGOT/SGPT (early mild/transient)*Acute onset+4
↑ Total bilirubinOtherwise unexplained+1
↑ LDH (>400 U/L)*Excluding HIV/PCP-5
↑ CPK/aldolaseOtherwise unexplained+4
↑ CRP (>30 mg/L)Acute onset+5
↑ Cold agglutinins (≥ 1:64)Acute onset-5
↑ CreatinineAcute onset+2
Microscopic hematuria*Excluding trauma, BPH, Foley catheter,



bladder/renal neoplasms



+2
Likelihood of Legionella infection
Total points>15 Legionella infection very likely
5-15 Legionella infection likely
< 5 Legionella infection unlikely
*Otherwise unexplained (acute and associated with pneumonia)

Adapted from Cunha BA. Antibiotic Essentials. 5th ed. Royal Oak, Mich: Physicians Press; 2006.

  • A clinical point score may be helpful in increasing probability of LD and prompting specific/definitive LD testing.
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Causes

The risk of infection increases with the type and intensity of the exposure, as well as the health status of the exposed individual. Numerous factors increase the risk of acquiring legionellae infections.

  • Risk factors for infection
    • Advanced age
    • Smoking
    • Chronic heart or lung disease
    • Immunocompromised state or immunosuppressive medication use (especially corticosteroids)
    • Recent exposure to water or soil
  • Pediatric cases of Legionella pneumonia are less common. Most of these cases occur in children who are immunosuppressed or in immunocompetent children who have undergone surgery or who are on a ventilator.
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Contributor Information and Disclosures
Author

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

Lynn E Sullivan  MD, MD, Assistant Professor of Medicine, Yale University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Fred A Lopez, MD  Associate Professor and Vice Chair, Department of Medicine, Assistant Dean for Student Affairs, Louisiana State University School of Medicine

Fred A Lopez, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, Infectious Diseases Society of America, and Louisiana State Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Joseph F John Jr, MD, FACP, FIDSA, FSHEA  Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina College of Medicine; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center

Disclosure: Nothing to disclose.

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD  Professor, Stewart G Wolf Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, and Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

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Table. Modified Winthrop-University Hospital Infection Disease Division's Point System for Diagnosing Legionnaires Disease in Adults
Clinical Features Qualifying Conditions Point Score
Temperature >103°F*With relative bradycardia+5
HeadacheAcute onset+2
Mental confusion/lethargy*Not drug induced+4
Ear painAcute onset-3
Nonexudative pharyngitisAcute onset-3
HoarsenessAcute, not chronic-3
Sputum (purulent)Excluding chronic bronchitis-3
Hemoptysis*Mild/moderate-3
Chest pain (pleuritic)Rapidly progressive asymmetrical



infiltrates* (excluding severe influenza/severe acute respiratory syndrome)



-3
Loose stools/watery diarrhea*Not drug induced+3
Abdominal pain*With or without diarrhea+5
Renal failure*Acute, not chronic+3
Shock/hypotension*Not 2° to acute cardiac-5
/pulmonary causes+5
SplenomegalyExcluding non-CAP causes-5
Lack of response to beta lactamsAfter 72 h (excluding viral pneumonias)+5
Laboratory Features
Chest radiographRapidly progressive asymmetrical infiltrates*



(excluding severe influenza/SARS)



+3
↓ PO2 with ↑ A-a gradient (>35)*(Excluding severe influenza/SARS)-5
↓ Na+Acute onset+1
↓ PO4 =*Acute onset+5
↑ SGOT/SGPT (early mild/transient)*Acute onset+4
↑ Total bilirubinOtherwise unexplained+1
↑ LDH (>400 U/L)*Excluding HIV/PCP-5
↑ CPK/aldolaseOtherwise unexplained+4
↑ CRP (>30 mg/L)Acute onset+5
↑ Cold agglutinins (≥ 1:64)Acute onset-5
↑ CreatinineAcute onset+2
Microscopic hematuria*Excluding trauma, BPH, Foley catheter,



bladder/renal neoplasms



+2
Likelihood of Legionella infection
Total points>15 Legionella infection very likely
5-15 Legionella infection likely
< 5 Legionella infection unlikely
*Otherwise unexplained (acute and associated with pneumonia)
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