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Legionella pneumophila Pneumonia Presenting With Severe Rhabdomyolysis and Acute Kidney Failure FREE TO VIEW

Eduardo Andre*, MD; Craig Thurm, MD; Javeria Bhawal, MD; Kelly Cervellione, MPH; Kunal Patel, MD
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Jamaica Hospital Medical Center, Jamaica, NY

Chest. 2012;142(4_MeetingAbstracts):174A. doi:10.1378/chest.1389344
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SESSION TYPE: Infectious Disease Case Report Posters II

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Legionella pneumophila is a recognized cause of rhabdomyolysis. There are reports of severe rhabdomyolysis and subsequent kidney failure related to Legionella with significant mortality. We present a case of Legionella pneumonia in an alcoholic man who presented with severe rhabdomyolysis and acute renal failure who recovered successfully.

CASE PRESENTATION: A 42-year-old alcoholic male presented with three days of fever, chills, productive cough with yellowish sputum and shortness of breath. He also complained of myalgia and watery non-bloody diarrhea. A few days prior to admission the patient had cleaned an air conditioning system in a restaurant. He had a 20-pack/year smoking history. On admission he was normotensive but tachycardic and febrile (102.1F); his oxygen saturation was 90% on two liters nasal cannula. He was diaphoretic with normal mental status. Scattered rales were auscultated in the right lower lobe. Laboratory studies revealed a leukocytosis with bandemia and thrombocytopenia. He was hyponatremic. His BUN was 24 and creatinine of 1.9. Lactic acid was normal. CPK was 19,086. The ABG revealed a metabolic acidosis. A chest X-ray show right upper lobe infiltrate. CT scan showed extensive consolidation of the right upper lobe and the superior segment of the right lower lobe. Legionella urine antigen was positive and levofloxacin and rifampin were started. The following day the patient developed respiratory distress and was intubated. A lorazepam drip was started for possible delirium tremens (DTs). His CPK initially decreased to a nadir of 7,450 on day 4, but subsequently increased to a maximum of 110,355 on day 8. He developed worsening renal failure that required hemodialysis on day 4. Daily fevers continued for more than 15 days despite antibiotic therapy. Chest x-ray showed significant improvement by day 12. Kidney function recovered completely and hemodialysis was discontinued. Patient was extubated on day 21. Muscle weakness persisted.

DISCUSSION: Legionella is a known cause of pneumonia requiring ICU admission. Severe rhabdomyolysis leading to renal failure has been reported with Legionella Pneumonia. Mortality is high. We report a case of Legionella pneumonia associated with severe rhabdomyolysis (CPK level>100 000), renal failure, and protracted fevers despite appropriate antibiotic treatment. A possible confounding factor was our patient’s history of alcohol abuse and possible DTs, which can be associated with rhabdomyolysis. However our patient’s CPK level continued to rise despite the absence of clinical evidence of DTs. The patient survived after a prolonged ICU course.

CONCLUSIONS: The current case illustrates the potential for severe rhabdomyolysis in patients with Legionella pneumonia as well as other confounding comorbidities.

1) McConkey J, Obeis M, Valentini J, & Beeson MS. Legionella pneumonia presenting with rhabdomyolysis and acute renal failure: a case report. J Emerg Med 2006;30(4):389-392.

DISCLOSURE: The following authors have nothing to disclose: Eduardo Andre, Craig Thurm, Javeria Bhawal, Kelly Cervellione, Kunal Patel

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Jamaica Hospital Medical Center, Jamaica, NY




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