SESSION TYPE: Critical Care Student/Resident Case Report Posters II
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Legionella pneumophilia can be a cause of severe community-acquired pneumonia. Due to their anti-inflammatory effects, the use of corticosteroids has been studied for severe pneumonia. Although clinical trials have not shown reduction in mortality, the data remains limited. Here we describe a case of Legionella pneumonia that chronologically improved with the initiation of corticosteroids.
CASE PRESENTATION: A 53 year-old woman was admitted with acute hypoxemic respiratory failure due to Legionella pneumophilia pneumonia. Despite appropriate initial antibiotic therapy with levofloxacin, and subsequent broadening of antibiotic coverage to include piperacillin/tazobactam and rifampin, the patient’s chest x-ray showed worsening bilateral pulmonary opacities. In addition, her lung compliance worsened, and her oxygen requirements increased despite the antibiotics and subsequent trial of diuresis. For four days prior to extubation the patient’s ratio of arterial oxygen concentration to the fraction of inspired oxygen (P/F) remained between 100 and 192, consistent with acute respiratory distress syndrome. The patient’s C-reactive protein (CRP) was 206 mg/L (normal range 0-8 mg/L). In an effort to suppress ongoing inflammation, high dose intravenous corticosteroids were started. Within 24 hours, the patient’s P/F ratio improved to 227, and her chest x-ray showed improvement in the bilateral opacities. She was extubated within thirty-six hours of steroid initiation to four liters/minute of oxygen via nasal cannula and was discharged from the hospital on room air.
DISCUSSION: Although corticosteroids are not routinely used in patients with severe Legionella pneumonia, there are several reports in the Japanese medical literature of their successful use in combination with antibiotics and sometimes other immunomodulators. In this case the patient’s condition declined despite antibiotics. The worsening clinical condition and elevated CRP prompted concerns for ongoing inflammation, and corticosteroids were initiated in an effort to improve her deteriorating pulmonary status.
CONCLUSIONS: While a cause and effect relationship between the initiation of high dose corticosteroids and the patient’s dramatic clinical and radiographic improvement cannot be established, this is the first report in the United States in which corticosteroids have been chronologically associated with improvement in a patient with respiratory failure secondary to Legionella pneumonia.
1) Póvoa P, Salluh JI. What is the role of steroids in pneumonia therapy? Curr Opin Infect Dis. 2012 Apr;25(2):199-204.
2) Kakeya H, Ehara N, Fukushima K, Seki M, Izumikawa K, et al. Severe Legionnaires’ Disease successfully treated using a combination of fluoroquinolone, erythromycin, corticosteroid, and sivelestat. Intern Med. 2008;47(8):773-7.
DISCLOSURE: The following authors have nothing to disclose: Katherine Duello, Jeffrey Garland
No Product/Research Disclosure InformationMayo Clinic Florida, Jacksonville, FL