Legionnaires Disease in Emergency Medicine Clinical Presentation

  • Author: Frank C Smeeks lll, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Mar 31, 2011
 

History

Legionnaires disease is more common in the summer, especially in August, and is slightly more prevalent in the northern US.

  • The classical presentation begins with an incubation period of 2-10 days.
  • Patients often experience a prodrome of 1-2 days of mild headache and myalgias, followed by high fever, chills, and multiple rigors.
  • Cough is present in 90% of cases; cough usually is nonproductive at first but may become productive as the disease progresses.
  • Other pulmonary manifestations include dyspnea, pleuritic chest pain, and hemoptysis, which may be present in as many as one third of cases.
  • Gastrointestinal symptoms include nausea, vomiting, diarrhea, and anorexia.
  • Neurologic symptoms include headache, lethargy, altered mental status, and rarely, focal symptoms.
  • Musculoskeletal symptoms include arthralgias and myalgias.
  • Nonpulmonary symptoms are prominent early in the disease.
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Physical

  • The vital signs may reveal high fever and tachypnea. Relative bradycardia may occur in up to 66% of patients.
  • Absence of inflammation of the upper respiratory tract is common and is a clinically useful indicator.
  • Chest auscultation findings may be normal or may reveal rales, rhonchi, or signs of consolidation.
  • Pericarditis and endocarditis may be present.
  • Hepatomegaly may be seen in rare cases.
  • The neurologic examination findings or the patient's mental status may be abnormal.
  • The patient may have blood-streaked sputum.
  • Mild, generalized abdominal pain and bloating may be present.
  • The rest of the physical examination may be unremarkable, but signs and symptoms of risk factors for the disease should be sought.
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Causes

Investigations of outbreaks have documented aerosol transmission from contaminated water sources, including the following (Note: No person-to-person spread of Legionella is documented.):

  • Cooling systems
  • Showers
  • Decorative fountains
  • Humidifiers
  • Respiratory therapy equipment
  • Whirlpool spas

Risk factors for Legionnaires disease include the following:

  • Smoking
  • Diabetes
  • Cancer, particularly hematological or pulmonary malignancy
  • AIDS
  • End-stage renal disease
  • Chronic cardiopulmonary disease
  • Advanced age
  • Alcohol abuse
  • Surgery
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Contributor Information and Disclosures
Author

Frank C Smeeks lll, MD  Chief Medical Officer, Frye Regional Medical Center

Frank C Smeeks lll, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Medical Association, and North Carolina Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Eric M Kardon, MD, FACEP  Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, Division of Emergency Medicine, Athens Regional Medical Center

Eric M Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Jeter (Jay) Pritchard Taylor III, MD  Compliance Officer, Attending Physician, Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Health Richland, University of South Carolina School of Medicine; Medical Director, Department of Emergency Medicine, Palmetto Health Baptist

Jeter (Jay) Pritchard Taylor III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD 

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

  1. CDC. Summary of notifiable diseases, United States 2008. MMWR Morb Mortal Wkly Rep. June 25 2010;57(54):1-94.

  2. [Guideline] Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. Mar 1 2007;44 Suppl 2:S27-72. [Medline]. [Full Text].

  3. Amsden GW. Treatment of Legionnaires' disease. Drugs. 2005;65(5):605-14. [Medline].

  4. Blanquer J, Blanquer R, Borras R, et al. Aetiology of community acquired pneumonia in Valencia, Spain: a multicentre prospective study. Thorax. Jul 1991;46(7):508-11. [Medline].

  5. CDC. Legionnaires disease associated with a whirlpool spa display--Virginia, September-October, 1996. MMWR Morb Mortal Wkly Rep. Jan 31 1997;46(4):83-6. [Medline].

  6. Cunna B. Legionnaire's disease - Case studies in infectious disease. Emerg Med. 1992;24:227-234.

  7. Falco V, Fernandez de Sevilla T, Alegre J, Ferrer A, Martinez Vazquez JM. Legionella pneumophila. A cause of severe community-acquired pneumonia. Chest. Oct 1991;100(4):1007-11. [Medline].

  8. Lane G, Ferrari A, Dreher HM. Legionnaire's disease: a current update. Medsurg Nurs. Dec 2004;13(6):409-14. [Medline].

  9. Marrie TJ, Haldane EV, Noble MA, Faulkner RS, Martin RS, Lee SH. Causes of atypical pneumonia: results of a 1-year prospective study. Can Med Assoc J. Nov 15 1981;125(10):1118-23. [Medline].

  10. Marston BJ, Lipman HB, Breiman RF. Surveillance for Legionnaires' disease. Risk factors for morbidity and mortality. Arch Intern Med. Nov 14 1994;154(21):2417-22. [Medline].

  11. Palmer L. Legionella pneumonia - Cardiopulmonary problems in the office. Emerg Med. 1992;24:84-94.

  12. Reingold AL. Role of legionellae in acute infections of the lower respiratory tract. Rev Infect Dis. Sep-Oct 1988;10(5):1018-28. [Medline].

  13. Shah A, Check F, Baskin S, Reyman T, Menard R. Legionnaires' disease and acute renal failure: case report and review. Clin Infect Dis. Jan 1992;14(1):204-7. [Medline].

 
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This electron micrograph depicts an amoeba, Hartmannella vermiformis (orange), as it entraps a Legionella pneumophila bacterium (green) with an extended pseudopod. After it is ingested, the Legionella pneumophila bacterium can survive as a symbiont within what then becomes its protozoan host. The amoeba then becomes what is referred to as a "Trojan horse," for by harboring the pathogenic bacteria, the amoeba can afford them protection, and in fact, in times of adverse environmental conditions, are able to metamorphose into a cystic-stage enabling it, and its symbiotic resident pathogens to withstand such environmental stresses. Image courtesy of the Centers for Disease Control and Prevention and Dr. Barry S Fields.
 
 
 
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