Key words: atypical pneumonia; bronchoalveolar Case ... recipients have an increased risk of severe pneumonia haemodialysis, the dose of prednisolone had ...
Nephrol Dial Transplant (1999) 14: 455–457
Nephrology Dialysis Transplantation
Case Report
The haemodialysis patient who developed acute respiratory distress syndrome after a trip to a hot spring spa Yoshio Shimizu1,2, Keisuke Nagase1, Ken-Nosuke Kadono2, Yasunori Funayama2, Yohko Tsurushima2, Toshiko Hibino2, Hiroshi Kikuchi2, Sohji Nagase1 and Akio Koyama1 1Department of Internal Medicine, Institute of Clinical Medicine, University of Tsukuba, and 2Department of Internal Medicine, Tsukuba Gakuen Hospital, Tsukuba, Ibaraki, Japan
Key words: atypical pneumonia; bronchoalveolar lavage fluid; haemodialysis patients; hot spring spa; immunocompromised hosts; Legionella pneumophila
Introduction Legionnaire’s disease was first identified in 1976 as an epidemic pneumonia in people attending an American Legion Convention in Philadelphia [1,2]. Legionella pneumophila is the pathogen in Legionnaire’s pneumonia and Pontiac fever [2,3]. Patients who are receiving chronic haemodialysis or who are renal transplant recipients have an increased risk of severe pneumonia after infection with this organism, and there already has been a report of an outbreak of Legionnaire’s disease in a haemodialysis unit [4–6 ]. Outbreaks of Legionnaire’s disease have been caused by contamination of cooling tower water, shower units, and whirlpool spas [7–9]. Legionella organisms have been shown to be present in spring water at concentrations of 103–105 colony forming units per litre [10]. Pneumonia developed in a woman who had almost drowned in a tub at a hot spring spa, and L.pneumophila serogroup 3 was isolated from the patient’s intratracheal exudate [11]. Recently, there has been an increase in the number of elderly people who attend spa resorts. We report a case of severe Legionnaire’s pneumonia in a chronic haemodialysis patient which developed after a trip to a hot spring spa. The patient’s medical condition had been stable, and he had not swallowed any hot spring water. His family and neighbours who travelled with him remained asymptomatic. We suggest that immunocompromised hosts, such as haemodialysis patients, are at higher risk for sporadic infections with legionella in hot spring spas. Correspondence and offprint requests to: Yoshio Shimizu MD, Department of Internal Medicine, Institute of Clinical Medicine, University of Tsukuba, 1–1–1 Ten-nodai, Tsukuba, Ibaraki 305–8575 Japan.
Case A 62-year-old male undergoing chronic haemodialysis complained of general fatigue and a low grade fever (37.6°C ) on November 21, 1997. The patient was a smoker, but did not drink alcohol. He managed a pet shop and handled dogs, cats and birds. The patient and his wife occasionally visited spas. He travelled to a spa in the Niigata prefecture at the beginning of November 1997. The cause of his chronic renal failure was chronic glomerulonephritis (IgA nephropathy) requiring prednisolone, 30 mg daily as an initial dose, with a gradual taper to a lower dose over a 3-year period. By the time of the induction of maintenance haemodialysis, the dose of prednisolone had been tapered to 5 mg daily. He was treated with oral cephem for a week, although it was not effective. The chest radiograph on November 24 did not show pulmonary infiltrates, however, he experienced palpitations and increasing fatigue. He developed a moderate cough and large amounts of mucoid sputum. Other haemodialysis patients in the same clinic did not have similar symptoms. The patient was referred to our hospital and was hospitalized on November 29, 1997. The physical examination showed only right pulmonary rales. Clinical laboratory tests showed an elevation of the leukocyte count with a shift to the left, a markedly elevated C-reactive protein, moderate abnormalities of liver function, azotemia, severe hypoxia, hypocapnia ( Table 1). The chest radiograph showed nodular infiltrative shadows in the right middle and lower lobes (Figure 1). The chest computed tomography showed lobar consolidation with air bronchograms in the right lower lobes and interstitial changes bilaterally (Figure 2). We diagnosed the adult respiratory distress syndrome (ARDS) caused by fulminant pneumonia. Panipenem (0.5 g daily), fluconazole (100 mg daily), and sulfamethoxazole/trimetoprim (800/160 mg daily) were started as well as steroid pulse therapy (1 g daily for 3 days). In spite of this treatment, the disease progressively worsened during the initial 3 days of
© 1999 European Renal Association–European Dialysis and Transplant Association
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Table 1. Laboratory values on the day of hospitalization
Peripheral blood Erythrocyte (104/mm3) Haemoglobin (g/dl ) Haematocrit (%) Leukocyte (mm3) Basophil (%) Eosinophil (%) Neutrophil (%) Lymphocyte (%) Monocyte (%) Platelet (103/mm3) Blood gas PH pO (Torr) 2 pCO ( Torr) 2 Base excess Biochemical data Total protein (g/dl ) Albumin (g/dl ) Aspartate aminotransferase (IU/l ) Alanine aminotransferase (IU/l ) Lactate dehydrogenase (IU/l ) Gamma-glutamyl transpeptidase (IU/l ) Alkaline phosphatase (IU/l ) Blood urea nitrogen (mg/dl ) Creatinine (mg/dl ) C-reactive protein (mg/dl ) Sodium (mEq/l ) Potassium (mEq/l ) Calcium (mg/l )
Patient
Normal range
298 9.3 29 25 800 0 0 96.5 2 1 312
420–550 13.6–16.7 40–50 3000–10 000
7.39 35 30.8 −5.5
7.38–7.48 85–105 32–45 0±2
6.3 3.3 47 34 400 78
5.6–8.1 3.5–5.1 15–40 5–33 180–460 6–56
1093 96.5 8.9 37.2 133 5.3 9.6
108–386 6.0–20.0 0.4–1.2 0–0.3 138–145 3.8–5.0 8.3–10.2
140–350 Fig. 2. Chest computed tomography. Consolidation with air bronchograms and some interstitial shadows are demonstrated.
tive by culture. The bronchoalveolar lavage fluid specimen showed no specific bacterial or protozoal species although there were a large number of neutrophils. Chlamydial pneumonia was suspected because of the patient’s occupation, but the antibody titre against Chlamydia pneumoniae was 154. A presumptive diagnosis of atypical pneumonia was made and erythromycin (400 mg daily) and rifampicin (600 mg daily) were administered through the gastric tube. During the next 3 days, the patient’s lung consolidation decreased. As the clinical symptom improved, the antiL.pneumophila serogroup 1 antibody titre was reported to be 15512. Thus, we diagnosed this patient with Legionnaire’s disease in accordance with the criteria of the Japanese Ministry of Health and Welfare, whose criterion for a diagnosis of Legionnaire’s disease in patients with a clinically compatible illness is antibody titre greater than or equal to 15256 [12]. Urinary antigen assey could not be performed because the patient was anuric. Although this patient responded to the treatment with erythromycin and rifampicin, he remained in respiratory failure and required mechanical ventilation. Although there was initial improvement, new consolidations appeared in the right upper lobe. Methicillinresistant Staphylococcus aureus (MRSA) was cultured from the transtracheal aspirate 21 days after admission, and vancomycin (0.5 g daily) was added to the regimen. Eventually, he recovered from his pneumonia, and was discharged 3 months later after rehabilitation. During his 91 days of hospitalization, haemodialysis was performed 59 times.
Discussion Fig. 1. Chest radiograph of the chronic haemodialysis patient with fulminant pneumonia. A film on the day of hospitalization.
hospitalization. The chest radiograph showed bilateral nodular consolidations. The patient required mechanical ventilation and vasoactive amines 2 days after admission. Repeated sputum examinations were nega-
Outbreaks of Legionnaire’s disease have been reported in chronic haemodialysis patients [6,13]. However, these reports have emphasized the nosocomial and epidemic aspects of L.pneumophila Travel-related Legionnaire’s disease occurs mostly in healthy people, whereas the disease is a known complication of adult immunodeficiency syndrome (AIDS) [14]. An out-
Legionnaire’s disease in a haemodialysis patient
break of both Legionnaire’s disease and Pontiac fever occured in six students in 1993 after a point exposure to L.pneumophila in a ski resort [15]. One student had well-controlled insulin-dependent diabetes mellitus and the others were in good heath. Our patient travelled to a hot spring spa with his family and neighbours, and was the only individual among spa visitors who developed this disease. The similarity of the reported case with diabetes and our subject emphasizes the importance of host factors in the development of infection. The source of L.pneumophila in outbreaks of travelrelated Legionnaire’s disease is likely to be hot spring and whirlpool spas [9,16,17]. Whirlpool spas can produce water droplets of respirable size that can carry legionella [18]. Legionella is present in both soil and spring water [10]. Legionella was isolated from 42.5% of hot spring spas in Japan [19]. In Niigata prefecture, it was isolated from 66.7% of hot spring spas [19]. Common Japanese bathtubs do not aerosolize water, but there are an increasing number of resorts where whirlpool baths and Finnish saunas generate mist and water droplets [19]. In summary, we diagnosed a case of Legionnaire’s disease in a chronic haemodialysis patient. He had visited a hot spring spa approximately 3 weeks prior to admission. Haemodialysis patients in the same clinic as well as his family and neighbours who travelled with him were asymptomatic. Although we could not obtain the blood samples of family members and neighbours unfortunately, we suggest that haemodialyis patients are at increased risk for infectious diseases such as legionella because they are relatively immunosuppressed. Regular bacteriologic sampling and sterilization of water and equipment are necessary to maintain adequate hygienic conditions in hot spring spas because infection with legionella is dependent on the size of the inoculum [17].
Acknowledgements. The authors are grateful to the nursing and haemodialysis staff of the Tsukuba Gakuen Hospital for their devoted assistance.
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