Case ReportLegionnaires Disease Complicated with Rhabdomyolysis andAcute Kidney Injury in an AIDS Patient
Karan Seegobin, Satish Maharaj, Cherisse Baldeo, Julio Perez Downes, and Pramod Reddy
Department of Internal Medicine, University of Florida College of Medicine, Jacksonville, FL 32209, USA
Correspondence should be addressed to Karan Seegobin; firstname.lastname@example.org
Received 8 May 2017; Revised 22 August 2017; Accepted 5 September 2017; Published 4 October 2017
Academic Editor: Alexandre R. Marra
Copyright 2017 Karan Seegobin et al.This is an open access article distributed under the Creative CommonsAttribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objective. To present a case of an uncommon triad of Legionella pneumonia, rhabdomyolysis, and renal failure, with review of therelevant literature. Case. A 51-year-old with a history of human immunodeficiency virus (HIV), chronic obstructive pulmonarydisease (COPD), and hypertension presented with fever, cough, and shortness of breath over four days. Chest X-ray showedconsolidation in left lower lung field; urine was positive for Legionella antigen and myoglobin; creatine kinase was 51092U/L;creatinewas 6.9mg/dL, and hisCD4 countwas 41 cells/ul.Hewasmanagedwith azithromycin and levofloxacin and further requireddialysis and ventilatory support in the intensive care unit due to renal failure and respiratory failure. He responded well to thetreatment and made a complete recovery. Legionella pneumophila infection is a recognized but rare cause of rhabdomyolysis withhigh morbidity and mortality when there is extrapulmonary involvement. Early diagnosis and appropriate treatment is essential toimprove outcomes. Conclusion. Physicians should consider Legionella pneumonia in patients with rhabdomyolysis, renal failure,and respiratory symptoms. Early diagnosis and treatment have been shown to have good clinical response. Timely intensive caremanagement, together with early and judicious use of dialysis in patients complicated with rhabdomyolysis and renal failure, maylead to good outcomes.
Legionella pneumophila (LP) infection is a recognized butrare cause of rhabdomyolysis [1, 2]. It can be further com-plicated with renal impairment which can be due to acutetubular necrosis (ATN) or acute tubulointerstitial nephritis(ATIN) . This triad of pneumonia, renal failure, and rhab-domyolysis is associated with high morbidity and mortality. We report a case of an immunocompromised patientwith Legionella pneumonia complicated with acute kidneyinjury and rhabdomyolysis. He required dual antibiotics withlevofloxacin and azithromycin, in addition to dialysis, andintensive care treatment.Hemade a full recoverywith normalrenal function. After review of the relevant literature onreported cases of this uncommon triad of Legionella pneu-monia, renal failure, and rhabdomyolysis, early diagnosis hasbeen shown to have good clinical response. We advocate fortimely transfer to the intensive care unit (ICU) and judicioususe of dialysis in patients with complicated Legionella pneu-mophilia as the outcomes are good.
A 51-year-old male with a past medical history of HIV,COPD, and hypertension presented with a four-day historyof fever, shortness of breath, and nonproductive coughassociated with headache and reduced appetite. He had a 30-pack-year history of smoking cigarettes and had not beencompliant with hisHIVmedications as well as trimethoprim-sulfamethoxazole. He had no history of nonsteroidal anti-inflammatory drug (NSAID), herbal drug, or cocaine use.He denied recent ill contacts, recent travel, or camping. Onexamination, he was in respiratory distress with blood pres-sure 143/95mmHg, pulse 135 beats per minute, respiratoryrate 24 breaths per minute, temperature 39.5 degrees Celsius,and sPO2 92% on room air and 98% on 2 litres nasal cannula.He had bronchial breath sounds in the left mid and lowerlung fields with crackles, but no wheezing. His heart soundswere normal. Abdomen was soft and nontender, with normalbowel sounds. Other aspects of his examination were unre-markable.
HindawiCase Reports in Infectious DiseasesVolume 2017, Article ID 8051096, 5 pageshttps://doi.org/10.1155/2017/8051096
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Figure 1: Chest X-ray with homogenous consolidation in the leftlower lung field.
His white cell count was 4.6 (4.511 103/uL); haemo-globin was 10.7 (1216 g/dL); platelet was 246 (140440 thou/cumm); mean corpuscular volume was 94 (82101 fl); Pro-thrombin Time (PT) was 12.9 (1113.5 seconds); inter-national normalised ratio (INR) was 1.0 (0.81.2); par-tial thromboplastin time (PTT) was 34 (2535 seconds);HbA1c was 5.7% (45.6%); procalcitonin was 31.2 ng/mL(
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Reference Age (years) DialysisrequiredICU treatment
Antimicrobial class (quinolone,macrolide, or both quinolone
Koufakis et al.  45 Yes Yes Quinolone and macrolide RecoveryShimura et al.  54 Yes Yes Quinolone and macrolide RecoveryMcConkey et al.  56 No Yes Quinolone RecoveryShah et al.  26 Yes Undetermined Macrolide RecoveryErdogan et al.  67 Yes Undetermined Quinolone and macrolide RecoveryAbe et al.  56 Yes Yes Quinolone and macrolide DiedWiegele and Krenn 44 Yes Yes Undetermined Recovery
Linga and Deo  40 Undetermined Yes Undetermined RecoveryAgu et al.  45 No Undetermined Quinolone RecoveryNakatani et al.  50 Yes Undetermined Quinolone RecoveryLi et al.  55 Yes Undetermined Quinolone and macrolide RecoveryDaumas et al.  55 Yes Undetermined Quinolone and macrolide RecoveryNarita et al.  48 Yes Yes Quinolone RecoverySposato et al.  61 Yes Yes Macrolide DiedMatsumoto et al.  67 Yes Yes Macrolide RecoveryTokuda et al.  57 Undetermined Yes Macrolide Died
Figure 4: CXR after three-week follow-up, without consolidation.
total bilirubin 0.2mg/dL. After three-weeks follow-up in theoutpatient setting, his creatine was back to normal at 1.06(0.61.17mg/dL), with resolution of the chest X-ray consol-idation (Figure 4). Renal biopsy was not pursued in lightof recovery of normal renal function.
In adults, Legionella causes 215% of community acquiredpneumonia (CAP) cases that require hospitalization . Itis the second most common cause of serious pneumoniathat needs admission in an intensive care unit (ICU) .Thefirst report that associated Legionella and rhabdomyolysiswas published in 1980 by Posner et al.  It is a recognized
but rare cause of rhabdomyolysis [1, 2]; a clinical syndromecharacterized by elevated serum concentrations of creatinephosphokinase (CPK) and myoglobinuria leading to renaldysfunction .
Renal impairment in Legionella pneumophila infectionaccompanied by rhabdomyolysis can be due to ATN or ATIN. Legionellosis-associated ATIN could be either indirectlyassociatedwith L pneumophila via rhabdomyolysis or directlyaffected by L pneumophila . Interestingly, renal anomaliescan develop days before the imaging demonstration of pneu-monia .
Many of the laboratory findings are nonspecific andinclude renal and hepatic dysfunction, hyponatremia, hypo-phosphatemia, thrombocytopenia, leukocytosis, hematuria,and proteinuria . The gold standard is culture and sensi-tivity on specialized charcoal media, which has a sensitivityof 7080% . However, this is not a rapid test and usuallytakes 35 days . Urine antigen test is a rapid, practical,and inexpensive method for the diagnosis of the disease,characterized by sensitivities of 7090% and specificitiesapproaching 100% [4, 5]. In our case the use of urine antigentesting confirmed the etiology of the pneumonia.
From a search on PubMed and Google with the termsLegionella, rhabdomyolysis, and renal failure we anal-ysed case reports (Table 1) of 16 patients with the triad of renalfailure, rhabdomyolysis, and Legionella pneumonia withfocus on CK levels, need for dialysis, intensive care admis-sion, outcomes after treatment, and the use of quinolones,macrolides, or both.
Thirteen patients made full recovery, five of which weretreated with a quinolone and macrolide, with the othershaving either a quinolone or macrolide as part of theirtreatment. Observational studies suggest that quinolones are
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more likely to achieve a favourable outcome in terms ofpatient survival and length of hospitalization . Combinedtreatment is believed to be superior to monotherapy incases of severe clinical disease or in immunosuppressedsubjects . In our case early treatment with a quinolone andmacrolide led to good outcome.
Of the 16 patients analysed, 8 patients had CK levelsgreater than 5,000U/L at presentation, with four out ofthose 8 having levels >20,000U/L. Our patient also had asignificantly high CK level at 51092U/L. Considering thatpatients present to the hospital days after the onset ofdisease, this may give the bacteria sufficient time to causemuscle injury. The exact mechanism of muscle injury causedby Legionella is still unclear . However, release of anendotoxin or exotoxin that causes rhabdomyolysis and directbacterial invasion seem to be the most probable mechanisms. In another report published in 1992 that studied renalfailure in patients with Legionella disease, 8 patients hadrhabdomyolysis out of 45 cases, three of which died; 2of which did not undergo dialysis . Physicians shouldalways anticipate rhabdomyolysis and check for its presencein patients with Legionella disease, as early anticipation ofthis event and initiation of early aggressive fluid resus