Volume 3, Number 14;  October 03, 2004

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 Resident Report 10/03/04—Simpson, Rubin, Steinberg

Case: 

Yet one more peril of modern travel

Simpson L, MD; Rubin Z, MD; and Steinberg J, MD

Case Report: 30 year female with no significant past medical history presents to her primary care physician (PCP) with right lower extremity pain. She had just returned from recent travel to Washington, D.C. She did a lot of walking in sandals on the trip and stayed at a well known local hotel. The day after she returned to GA, she began having R calf pain. An initial ultrasound (USG) of the lower extremity showed no DVT and patient returned home. At night her pain worsened and she spiked a fever to 104. She returned to her PCP who again repeated an USG that was negative and referred her to hospital. She has no previous history of blood clots and is known to use oral contraceptives.

Physical exam revealed a blood pressure (BP) of 120/66 mm Hg, pulse rate(PR) of 127/min, respiratory rate (RR) of 18/min , temperature(temp) of 39°celsius and an O2sat (Sat)of 98% on room air(RA). Rest of physical exam was only significant for tachycardia and tenderness overlying right calf from popliteal area extending to ankle. There was some dry skin on right heel with excoriations on Achilles area but otherwise pulses were intact with no redness, erythema or discoloration.

On admission to hospital, magnetic resonance imaging (MRI) of lower extremity was performed which showed fluid in fascial plane consistent with necrotizing fasciitis. She was started on Unasyn and Clindamycin. She was taken to operating room (OR) by plastic surgery where a linear incision was made over the medial head of the gastrocnemius muscle. A small quantity of slightly turbid fluid was found in the subfascial plane, but the muscle itself looked extremely healthy, soft with excellent color. There was no necrosis and no evidence of necrotizing fasciitis. Post surgery she was extubated and taken from the OR to the intensive care unit in good condition. Few hours later, patient began complaining of shortness of breath. Vital signs revealed BP of 123/71 mmHg , PR of 123 per minute, RR of 18 per minute ,temperature of 37° celsius and oxygen saturation of 92% on room air. Arterial blood gases showed pH 7.54 pCO2 27 and pO2 of 65 on RA with an A-a gradient of 43. Chest radiography air space densities on bilateral lower lobes and a computed tomography scan showed bibasilar air space opacities and small underlying effusions. Urine for legionella was sent and returned positive and patient was started on levoquine with improvement in her symptoms and discharged on day 4. Public health authorities were notified and, so far there were no other cases from hotel.

Discussion : In 1977 pathologic studies demonstrated dissemination of Legionella beyond the lung in post-mortem series. Primary extrapulmonary presentations of Legionella very rare and there are less than 20 papers describing extrapulmonary manifestations mostly in immunocompromised, dialysis and post surgical patients. Extrapulmonary manifestations of legionella include myocarditis, pericarditis, pyelonephritis, perirectal abcess and diarrhea. Legionella and skin/soft tissue has been described a 60 year old male with follicular lymphoma admitted with pneumonia post thoracentesis.. We present here the third case in literature of legionella involving fascia/muscle and the second case of skin/soft tissue involvement in an immunocompetent patient.

Clinical Question(s): 

 Are there reports of legionella involving fascia/muscle or legionella involving skin/soft tissue involvement in immunocompetent patitents?

Readings:

<1>

Unique Identifier:12394886

Authors: Losanoff JE. Metzler MH. Richman BW. Cotton BA. Jones JW.

Institution: Department of Surgery, University of Missouri-Columbia, 65212, USA.

Title: Necrotizing chest wall infection after blunt trauma: case report and review of the literature. [Review] [24 refs]

Source: Journal of Trauma-Injury Infection & Critical Care. 53(4):787-9, 2002 Oct.

<2>

Unique Identifier:11724886

Authors: Gubler JG. Schorr M. Gaia V. Zbinden R. Altwegg M.

Institution: Department of Medicine, Stadtspital Triemli, CH-8063 Zurich, Switzerland. jacques.gubler@triemli.stzh.ch

Title: Recurrent soft tissue abscesses caused by Legionella cincinnatiensis.

Source: Journal of Clinical Microbiology. 39(12):4568-70, 2001 Dec.

Abstract: Recurrent soft tissue abscesses of the jaw, wrist, and arm developed in a 73-year-old housewife with nephrotic syndrome and immunoglobulin A(kappa) gammopathy of unknown etiology. Conventional cultures remained negative, despite visible gram-negative rods on microscopy. Broad-spectrum PCR revealed Legionella cincinnatiensis, which was confirmed by isolation of the organism on special Legionella medium. Infections due to Legionella species outside the lungs are rare. L. cincinnatiensis has been implicated in only four cases of clinical infection; these involved the lungs in three patients and the central nervous system in one patient. We conclude that broad-spectrum PCR can be a valuable tool for the evaluation of culture-negative infections with a high probability of bacterial origin and that Legionella might be an underdiagnosed cause of pyogenic soft tissue infection.

<3>

Unique Identifier:10435897

Authors: Kumar A. Will EJ.

Institution: Renal Unit, St. James's University Hospital, Leeds, UK.

Title: Necrotizing fasciitis and Legionnaires' disease after combined renal and pancreatic transplantation: a penalty of overseas travel.

Source: Nephrology Dialysis Transplantation. 14(7):1781-3, 1999 Jul.

<4>

Unique Identifier:8448318

Authors: Waldor MK. Wilson B. Swartz M.

Institution: Department of Medicine, Massachusetts General Hospital, Boston.

Title: Cellulitis caused by Legionella pneumophila.

Source: Clinical Infectious Diseases. 16(1):51-3, 1993 Jan.

Abstract: A patient with lymphoma presented with pneumonia. While receiving antibiotics, he developed a rapidly spreading cellulitis. The soft tissues were debrided in the operating room, and pathological examination showed fat necrosis and a fibrinopurulent exudate in the fibroadipose tissue; direct immunofluorescence of the debrided tissue revealed the presence of Legionella pneumophila. Culture of the specimen obtained during the operation yielded L. pneumophila. To our knowledge, this represents the first case report of cellulitis due to L. pneumophila.

<5>

Unique Identifier:1731498

Authors: Kilborn JA. Manz LA. O'Brien M. Douglass MC. Horst HM. Kupin W. Fisher EJ.

Institution: Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan.

Title: Necrotizing cellulitis caused by Legionella micdadei.

Source: American Journal of Medicine. 92(1):104-6, 1992 Jan.

Abstract: Legionella micdadei is primarily considered a pathogen of the pulmonary tract of immunocompromised patients, the majority of whom have been renal transplant recipients. We report the case of a necrotizing soft tissue infection in a cadaveric renal transplant recipient resulting in amputation of the left arm. Only one other extrathoracic bacteriologically documented L. micdadei infection has been reported in the literature.

<6>

Unique Identifier:4001648

Authors: Riou B. Richard C. Teboul JL. Rimailho A. Auzepy P.

Title: [Muscular involvement in Legionnaires' disease. Review of the literature apropos of 2 cases]. [French]

Original Title: Atteinte musculaire au cours de la maladie des legionnaires. Revue de la litterature a propos de 2 observations.

Source: Revue de Medecine Interne. 6(2):105-10, 1985 Mar.

Abstract: Two cases of Legionnaires' disease proven by seroconversion in indirect immunofluorescence are reported. Creatine phosphokinase (CPK) was increased in both patients, and one had rhabdomyolysis with acute renal failure and acute respiratory distress. A review of the literature brought out 9 other cases of rhabdomyolysis associated with Legionnaires' disease. Myalgias are an inconstant warning symptom; renal impairment is present in more than one half of the cases, and although pulmonary lesions are moderate, respiratory muscle involvement may require mechanical ventilation. In view of the severe complications of rhabdomyolysis, CPK should be systematically assayed in patients with Legionnaires' disease; 57 p. 100 of whom, according to published reports, have high CPK levels. In a retrospective study of bacterial pneumonia caused by common pathogens, we found that CPK was elevated in 31 p. 100 of the cases. The mechanism of muscular involvement is discussed.

<7>

Unique Identifier:3885816

Authors: Ampel NM. Ruben FL. Norden CW.

Title: Cutaneous abscess caused by Legionella micdadei in an immunosuppressed patient.

Source: Annals of Internal Medicine. 102(5):630-2, 1985 May.

<8>

Unique Identifier:7012392

Authors: Helms CM. Johnson W. Donaldson MF. Corry RJ.

Title: Pretibial rash in Legionella pneumophila pneumonia.

Source: JAMA. 245(17):1758-9, 1981 May 1.

Abstract: Legionella pneumophila pneumonia developed in a 46-year-old man, 23 days after receiving a cadaveric renal homograft. A painful, nonpruritic, macular, erythematous rash limited to the pretibial surfaces of both legs appeared on the fifth day of illness. Fever, pneumonia, and rash resolved in association with erythromycin lactobionate therapy.

Resident Report / Department of Medicine & Grady Branch Library

Emory University School of Medicine

2004 Edition

Participating Faculty:  Carlos Del Rio MD  / Joyce Doyle MD / Lorenzo Difrancesco MD /  Monica Adams MD  / Josh Larned MD

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