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Detection of Legionella pneumophila serogroup 1 in blood cultures from a patient treated with tumor necrosis factor-alpha inhibitor

  • Case Report
  • Published:
Journal of Infection and Chemotherapy

Abstract

A 65-year-old man was admitted to our hospital with a temperature of 39.3 °C, cough, sputum, and pharyngeal discomfort that had persisted for 3 days. He had been treated with methotrexate and adalimumab (a tumor necrosis factor-alpha [TNF-α] inhibitor) for rheumatoid arthritis for 2 years, and he had also been treated with S-1 (tegafur, gimeracil, and oteracil potassium) for pancreatic metastasis of gastric cancer for 2 months. Regardless of the underlying pathologies, his general condition was good and he had worked as an electrician until 2 days before admission. However, his appetite had suddenly decreased from the day before admission, and high fever and hypoxia were also evident upon admission. A chest X-ray and computed tomography scan revealed left pleural effusion and consolidation in both lungs. The pneumonia severity index score was 165 and the risk class was V. Accordingly, we started to treat the pneumonia with a combination of levofloxacin and meropenem. Thereafter, we received positive urinary antigen test findings for Legionella pneumophila. After hospitalization, hypoxia was progressed and hypotension was emerged. Despite the application of appropriate antibiotics, vasopressors, and oxygenation, the patient died 8 h after admission. Even after his death, blood cultures were continued to consider the possibility of bacterial co-infection. Although no bacteria were detected from blood cultures, Gimenez staining revealed pink bacteria in blood culture fluids. Subsequent blood fluid culture in selective medium revealed L. pneumophila serogroup 1. Recently, TNF-α inhibitors have been described as a risk factor for Legionnaires’ disease. In consideration of the increased frequency of TNF-α inhibitors, we may need to recognize anew that L. pneumophila might be a pathogen of severe community-acquired pneumonia.

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References

  1. Fraser DW, Tsai TR, Orenstein W, Parkin WE, Beecham HJ, Sharrar RG, et al. Legionnaires’ disease: description of an epidemic of pneumonia. N Engl J Med. 1977;297:1189–97.

    Article  PubMed  CAS  Google Scholar 

  2. Fang GD, Fine M, Orloff J, Arisumi D, Yu VL, Kapoor W, et al. New and emerging etiologies for community-acquired pneumonia with implications for therapy. A prospective multicenter study of 359 cases. Medicine (Baltimore). 1990;69:307–16.

    CAS  Google Scholar 

  3. Marston BJ, Plouffe JF, File TM Jr, Hackman BA, Salstrom SJ, Lipman HB et al. Incidence of community-acquired pneumonia requiring hospitalization. Results of a population-based active surveillance study in Ohio. The Community-Based Pneumonia Incidence Study Group. Arch Intern Med. 1997;157:1709–18.

    Google Scholar 

  4. Lim WS, Macfarlane JT, Boswell TC, Harrison TG, Rose D, Leinonen M, et al. Study of community acquired pneumonia aetiology (SCAPA) in adults admitted to hospital: implications for management guidelines. Thorax. 2001;56:296–301.

    Article  PubMed  CAS  Google Scholar 

  5. von Baum HS, Ewig S, Marre R, Suttorp N, Gonschior S, Welte T, et al. Community-acquired Legionella pneumonia: new insights from the German competence network for community acquired pneumonia. Clin Infect Dis. 2008;46:1356–64.

    Article  Google Scholar 

  6. Falcó V, Fernández de Sevilla T, Alegre J, Ferrer A, Martinez Vázquez JM. Legionella pneumophila: a cause of severe community-acquired pneumonia. Chest. 1991;100:1007–11.

  7. Torres A, Serra-Batlles J, Ferrer A, Jiménez P, Celis R, Cobo E, et al. Severe community-acquired pneumonia: epidemiology and prognostic factors. Am Rev Respir Dis. 1991;144:312–8.

    Article  PubMed  CAS  Google Scholar 

  8. Rello J, Quintana E, Ausina V, Net A, Prats G. A three-year study of severe community-acquired pneumonia with emphasis on outcome. Chest. 1993;103:232–5.

    Article  PubMed  CAS  Google Scholar 

  9. Marrie TJ, MacDonald S, Clarke K, Haldane D. Nosocomial Legionnaires’ disease: lessons from a four-year prospective study. Am J Infect Control. 1991;19:63–6.

    Article  Google Scholar 

  10. Sopena N, Sabrià M, the Neunos 2000 Study Group. Multicenter study of hospital-acquired pneumonia in non-ICU patients. Chest. 2005; 127:213–9.

    Google Scholar 

  11. Maesaki S, Kohno S, Koga H, Kaku M, Yoshitomi Y, Yamada H, et al. An outbreak of Legionnaires’ pneumonia in a nursing home. Intern Med. 1992;31:508–12.

    Article  PubMed  CAS  Google Scholar 

  12. Stout JE, Brennen C, Murder RR. Legionnaires’ disease in a newly constructed long-term care facility. J Am Geriatr Soc. 2000;58:1589–92.

    Google Scholar 

  13. Phares CR, Russell E, Thigpen MC, Service W, Crist MB, Salyers M, et al. Legionnaires’ disease among residents of a long-term care facility: the sentinel event in a community outbreak. Am J Infect Control. 2007;35:319–23.

    Article  PubMed  Google Scholar 

  14. Centers for Disease Control and Prevention (CDC). Surveillance for travel-associated Legionnaires’ disease—United States, 2005–2006. Morb Mortal Wkly Rep. 2007; 56:1261–3.

  15. Joseph CA, Ricketts KD, European Working Group for Legionella Infections. Legionnaires’ disease in Europe 2007–2008. Euro Surveill. 2010;15:19693.

  16. Alvarez J, Dominguez A, Sabrià M, Ruiz L, Tormer N, Cayla J, et al. Impact of the Legionella urinary test on epidemiological trends in community outbreaks of legionellosis in Catalonia, Spain, 1990–2004. Int J Infect Dis. 2009;13:e365–70.

    Article  PubMed  Google Scholar 

  17. Fields BS, Benson RF, Besser RE. Legionella and Legionnaires’ disease: 25 years of investigation. Clin Microbiol Rev. 2002;15:506–26.

    Article  PubMed  Google Scholar 

  18. Mulazimoglu L, Yu VL. Can Legionnaires’ disease be diagnosed by clinical criteria? A critical review. Chest. 2001;120:1049–53.

    Article  PubMed  CAS  Google Scholar 

  19. Greig JE, Carnie JA, Tallis GF, Ryan NJ, Tan AG, Gordon IR, et al. An outbreak of Legionnaires’ disease at the Melbourne Aquarium, April 2000: investigation and case–control studies. Med J Aust. 2000;180:566–72.

    Google Scholar 

  20. Den Boer JW, Nijhof J, Friesema I. Risk factors for sporadic community-acquired Legionnaires’ disease. A 3-year national case-control study. Public Health. 2006;120:566–71.

    Article  Google Scholar 

  21. Nakamura S, Yanagihara K, Izumikawa K, Seki M, Kakeya H, Yamamoto Y, et al. The clinical efficacy of fluoroquinolone and macrolide combination therapy compared with single-agent therapy against community-acquired pneumonia caused by Legionella pneumophila. J Infect. 2009;59:222–4.

    Article  PubMed  Google Scholar 

  22. Tubach F, Ravaud P, Salmon-Ceron D, Petitpain N, Brocq O, Grados F, et al. Emergence of Legionella pneumophila pneumonia in patients receiving tumor necrosis factor-alpha antagonists. Clin Infect Dis. 2006;43:e95–100.

    Article  PubMed  CAS  Google Scholar 

  23. Jinno S, Pulido S, Plen BC. First reported United States case of Legionella pneumophila serogroup 1 pneumonia in a patient receiving anti-tumor necrosis factor-alpha therapy. Hawaii Med J. 2009;68:109–12.

    PubMed  Google Scholar 

  24. Beigel F, Jürgens M, Filic L, Bader L, Lück C, Göke B, et al. Severe Legionella pneumophila pneumonia following infliximab therapy in a patient with Crohn’s disease. Inflamm Bowel Dis. 2009;15:1240–4.

    Article  PubMed  Google Scholar 

  25. Mariette X, Gottenberg JE, Ravaud P, Combe B. Registries in rheumatoid arthritis and autoimmune diseases: data from the French registries. Rheumatology (Oxford). 2011;50:222–9.

    Article  Google Scholar 

  26. FDA Drug Safety Communication. Drug labels for the tumor necrosis factor-alpha (TNFα) blockers now include warnings about infection with Legionella and Listeria bacteria. http://www.fda.gov/Drugs/DrugSafety/ucm270849.htm (Accessed on April 16, 2012).

  27. Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997;336:243–50.

    Article  PubMed  CAS  Google Scholar 

  28. Centers for Disease Control and Prevention (CDC). Legionellosis—United States, 2000–2009. Morb Mortal Wkly Rep. 2011; 60:1083–6.

  29. Cirillo DM, Baron EJ, Marchiaro G. Legionella pneumophila fails to multiply in blood culture broths but can be recovered from isolator tubes. Abstr. 100th General Meeting of the American Society of Microbiology. Washington DC: American Society of Microbiology, 2000; Abstr. (C-255), p 189.

  30. Macrae AD, Greaves PW, Platts P. Isolation of Legionella pneumophila from blood culture. Br Med J. 1979;2:1189–90.

    Article  PubMed  CAS  Google Scholar 

  31. Rihs JD, Yu VL, Zuravleff JJ, Goetz A, Muder RR. Isolation of Legionella pneumophila from blood with the BACTEC system: a prospective study yielding positive results. J Clin Microbiol. 1985;22:422–4.

    PubMed  CAS  Google Scholar 

  32. Lai CC, Tan CK, Chou CH, Hsu HL, Huang YT, Liao CH, Hsueh PR. Hospital-acquired pneumonia and bacteremia caused by Legionella pneumophila in an immunocompromised patient. Infection. 2010;38:135–7.

    Article  PubMed  Google Scholar 

  33. Sandkovsky U, Sandkovsky G, Suh J, Smith B, Sharp V, Polsky B. Legionella pneumonia and HIV: case reports and review of the literature. AIDS Patient Care STDS. 2008;22:473–81.

    Article  PubMed  Google Scholar 

  34. Bongartz T, Sutton AJ, Sweeting MJ, Buchan I, Matteson EL, Montori V. Anti-TNF antibody therapy in rheumatoid arthritis and the risk of serious infections and malignancies: systematic review and meta-analysis of rare harmful effects in randomized controlled trials. JAMA. 2006;295:2275–85.

    Article  PubMed  CAS  Google Scholar 

  35. Grijalva CG, Chen L, Delzell E, Baddley JW, Beukelman T, Winthrop KL, et al. Initiation of tumor necrosis factor-α antagonists and the risk of hospitalization for infection in patients with autoimmune diseases. JAMA. 2011;306:2331–9.

    Article  PubMed  CAS  Google Scholar 

  36. Dewedar AM, Shalaby MA, Al-Homaid S, Mahfouz AM, Shams OA, Fathy A. Lack of adverse effect of anti-tumor necrosis factor-α biologics in treatment of rheumatoid arthritis: 5 years follow-up. Int J Rheum Dis. 2012;15:330–5.

    Article  PubMed  Google Scholar 

  37. Brieland JK, Remick DG, Freeman PT, Hurley MC, Fantone JC, Engleberg NC. In vivo regulation of replicative Legionella pneumophila lung infection by endogenous tumor necrosis factor-alpha and nitric oxide. Infect Immun. 1995;63:3253–8.

    PubMed  CAS  Google Scholar 

  38. Fujita M, Ikegame S, Harada E, Ouchi H, Inoshima I, Watanabe K, et al. TNF receptor 1 and 2 contribute in different ways to resistance to Legionella pneumophila-induced mortality in mice. Cytokine. 2008;44:298–303.

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Internal Medicine, Japanese Red Cross Nagasaki Genbaku Hospital, Nagasaki, Japan

    Norihito Kaku, Tsuyoshi Sato, Munetoshi Nakashima, Seiji Nagashima, Minoru Fukuda & Kohji Hashiguchi

  2. Department of Clinical Laboratory, Japanese Red Cross Nagasaki Genbaku Hospital, Nagasaki, Japan

    Takahiro Sakai, Hiroo Tominaga & Fumiko Wakigawa

  3. Second Department of Internal Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan

    Norihito Kaku, Katsunori Yanagihara & Yoshitomo Morinaga

  4. Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan

    Katsunori Yanagihara, Yoshitomo Morinaga & Shigeru Kohno

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  1. Norihito Kaku
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  2. Katsunori Yanagihara
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  3. Yoshitomo Morinaga
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Correspondence to Katsunori Yanagihara.

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Kaku, N., Yanagihara, K., Morinaga, Y. et al. Detection of Legionella pneumophila serogroup 1 in blood cultures from a patient treated with tumor necrosis factor-alpha inhibitor. J Infect Chemother 19, 166–170 (2013). https://doi.org/10.1007/s10156-012-0459-7

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  • DOI: https://doi.org/10.1007/s10156-012-0459-7

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