Abstract Legionella pneumophila causes 1-10% of community-acquired pneumonias requiring hospitalization and is associated with a mortality rate of up to 10% in hospitalized patients, and as high as 30% in ICU patients with respiratory failure. The disease typically presents with fever, dyspnea, diarrhea, hyponatremia, and pulmonary infiltrates. While most patients respond to appropriate antibiotics within 3-7 days, persistent fever despite treatment is rare and can complicate the clinical course. This is a case of severe Legionella pneumonia complicated by prolonged fever and ARDS in an immunocompetent patient. A 41-year-old woman with obesity presented with a one-week history of fever, dyspnea, productive cough, and diarrhea after exposure to a jacuzzi. Her sister developed a similar but milder illness. On presentation, she was febrile, hypoxic, and hypotensive, requiring ICU admission and was admitted intubated on hospital day. Chest CT showed multilobar pneumonia with bilateral ground-glass opacities. She was empirically started on ceftriaxone, azithromycin, and methylprednisolone. Legionella pneumophila urine antigen and BAL PCR was found to be positive for which levofloxacin was initiated, and azithromycin was continued. Despite this, the patient remained febrile with cyclical spikes (Tmax 39.5 °C) for 21 days. She underwent tracheostomy on hospital day 21 and defervesced on day 22. She completed a 21-day course of levofloxacin and was discharged on day 28 to a long-term acute care facility. A persistent fever despite appropriate antibiotic therapy is uncommon in Legionella pneumonia. Multiple diagnostic and management strategies were used to exclude other causes of persistent fever. Blood cultures and repeat bronchoscopies with bacterial, fungal, and mycobacterial testing (days 10 and 16) for ventilator-associated pneumonia, were negative. Repeated chest imaging and a separate transthoracic echocardiography were performed to rule out complications of Legionella infection such as- empyema, lung abscess, or endocarditis. Daily physical examination was negative for suppurative arthritis. Testing for HIV, hepatitis B/C, immunoglobulins to detect any common underlying immunodeficiency was unremarkable. Drug-induced-fever was considered; azithromycin was discontinued on hospital day 4 and propofol on day 18 without resolution. Prolonged fever in Legionella infection has been described, albeit rarely, particularly in patients with ARDS, high organism load, and systemic inflammation. Obesity was the only identifiable risk factor. Fever resolution shortly after tracheostomy may have reflected reduced ventilator-associated inflammation and improved secretion clearance. Given the thorough exclusion of alternative infectious, inflammatory, and pharmacologic causes, the fever was ultimately attributed to the severe inflammatory response and high bacterial burden associated with Legionella pneumonia. This abstract is funded by: None
Guliani et al. (Fri,) studied this question.