Legionella Infection Clinical Presentation

  • Author: Mobeen H Rathore, MD, CPE, FAAP, FIDSA; Chief Editor: Russell W Steele, MD   more...
 
Updated: Oct 25, 2011
 

History

Pneumonia is the predominant clinical manifestation of Legionnaires disease (LD). After an incubation period of 2-10 days, patients typically develop the following nonspecific symptoms:

  • Fever
  • Weakness
  • Fatigue
  • Malaise
  • Myalgia
  • Chills

Respiratory symptoms may not be present initially but develop as the disease progresses. Almost all patients develop a cough, which is initially dry and nonproductive, but may become productive, with purulent sputum and, (in rare cases) hemoptysis. Patients may experience chest pain.

Neurologic and GI symptoms are usually prominent. Neurologic complaints may include the following:

  • Headache
  • Lethargy
  • Confusion
  • Cerebellar ataxia
  • Agitation
  • Stupor

Common GI symptoms include diarrhea (watery and nonbloody), nausea, vomiting, and abdominal pain.[18]

In neonates, Legionnaires disease can manifest as septicemia and/or pneumonia with a fulminant course, often diagnosed at autopsy.

Extrapulmonary legionellosis is rare; the most common site of extrapulmonary infection in adults is the heart. In children, extrapulmonary sites may include the liver, spleen, brain, and lymph nodes.[19] Manifestations of extrapulmonary legionellosis may include the following:

Pontiac fever is an influenzalike illness, typically with an abrupt onset. The incubation period is 24-48 hours. Prominent symptoms include fever, malaise, myalgia, cough, and headache. Pontiac fever tends to occur in outbreaks, and the infection rate is greater than 90%. The disease is self-limiting, persisting for approximately 1 week.

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Physical

The severity of illness at presentation varies from mild nonspecific findings to profound respiratory and/or multiorgan failure.

  • Fever is typically present (98%). Temperatures exceeding 40°C occur in 20-60% of patients. The occurrence of bradycardia relative to fever has been overemphasized, but it may occur in patients with advanced pneumonia.[18]
  • Hypotension has been reported in 17% of patients with community-acquired pneumonia(CAP).
  • Lung examination reveals rales and signs of consolidation late in the disease course.
  • In patients with extrapulmonary legionellosis, physical findings relate to the involved organs.
  • Manifestations in children who are immunocompromised appear similar to manifestations in adults. However, in neonates, signs of sepsis with multisystemic involvement appear to be more prominent. Progression to respiratory failure is very rapid, and the disease is likely to be fatal.[20]
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Causes

In adults, recognized risk factors for legionellosis include the following:

  • Cigarette smoking
  • Chronic lung disease
  • Immunosuppression (eg, malignancies, immunosuppressive therapy such as corticosteroids, human immunodeficiency virus [HIV], acquired immunodeficiency syndrome [AIDS])
  • End-stage renal disease
  • Diabetes mellitus
  • Advanced age

Surgery, especially for head and neck malignancies and for solid organ transplantations, predisposes patients to nosocomial infections.

Risk factors for children are less well defined than they are in adults. Apparent predisposing factors, from reported cases, include the following:[3]

Rare cases of legionellosis are reported in children who are immunocompetent and who lack predisposing conditions.

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Contributor Information and Disclosures
Author

Mobeen H Rathore, MD, CPE, FAAP, FIDSA  Chief of Division of Pediatric Infectious Diseases/Immunology, Associate Chairman of Department of Pediatrics, University of Florida College of Medicine at Jacksonville; Hospital Epidemiologist and Section Chief of Infectious Disease and Immunology, Wolfson Children's Hospital; Director of University of Florida Center for HIV/AIDS Research, Education and Service (UF CARES)

Mobeen H Rathore, MD, CPE, FAAP, FIDSA is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, European Society for Paediatric Infectious Diseases, Florida Medical Association, Florida Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Society for Healthcare Epidemiology of America, Society for Pediatric Research, Southern Medical Association, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Coauthor(s)

Ana Alvarez, MD  Associate Professor of Pediatrics, Pediatric Infectious Diseases Fellowship Director, University of Florida College of Medicine, Jacksonville

Ana Alvarez, MD is a member of the following medical societies: American Academy of Pediatrics, Florida Medical Association, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Glenn Fennelly, MD, MPH  Director, Division of Infectious Diseases, Lewis M Fraad Department of Pediatrics, Jacobi Medical Center; Clinical Associate Professor of Pediatrics, Albert Einstein College of Medicine

Glenn Fennelly, MD, MPH is a member of the following medical societies: Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Larry I Lutwick, MD  Professor of Medicine, State University of New York Downstate Medical School; Director, Infectious Diseases, Veterans Affairs New York Harbor Health Care System, Brooklyn Campus

Larry I Lutwick, MD is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: Novartis Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

References

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