03 June 2022: Articles
The Triad of Legionnaires’ Disease, Rhabdomyolysis, and Acute Kidney Injury: A Case Report
Unusual clinical course, Rare coexistence of disease or pathology
Andrew S. Kao1EF*, Chandima J. Herath2E, Rana Ismail2EF, Malitha E. Hettiarachchi2EDOI: 10.12659/AJCR.936264
Am J Case Rep 2022; 23:e936264
Abstract
BACKGROUND: Legionella infection is a common cause of atypical pneumonia, known as Legionnaires’ disease when infection extends to extrapulmonary involvement, which often leads to hospitalization. The triad of Legionella pneumonia, rhabdomyolysis, and renal failure displays a rare yet fatal complication without prompt management.
CASE REPORT: Our patient was a 62-year-old man with no significant medical history who developed Legionnaires’ disease with severely elevated creatinine phosphokinase (CPK) of 9614 mcg/L, consistent with rhabdomyolysis. He experienced severe headache, anorexia, and hematuria, which prompted him to seek medical care. Pertinent social history included recent flooding in his neighborhood, which surrounded the outer perimeter of his home. His clinical manifestations and laboratory findings were consistent with Legionella infection, with concomitant acute kidney injury. A chest X-ray revealed hazy left perihilar opacities concerning for atypical pneumonia. Immediate interventions of hydration and antigen-directed azithromycin were initiated to prevent rapid decompensation. His clinical symptoms resolved without further complications, and he was not transferred to the Intensive Care Unit (ICU).
CONCLUSIONS: Legionella-induced rhabdomyolysis is an uncommon association that can lead to acute kidney failure and rapid clinical deterioration. Early and aggressive management with fluid repletion and appropriate antibiotics can improve clinical manifestations and hospital length of stay. Our patient’s reduction in CPK levels and clinical improvement confirmed that extrapulmonary involvement in Legionella infection can lead to rhabdomyolysis. It is important for healthcare providers to recognize the clinical triad of Legionella pneumonia, rhabdomyolysis, and renal failure as prompt and timely management to reduce associated morbidity.
Keywords: Acute Kidney Injury, Legionnaires' Disease, rhabdomyolysis, Azithromycin, Humans, Influenza, Human, Male, Middle Aged, Pneumonia, Mycoplasma
Background
Case Report
A 62-year-old previously healthy man presented to the hospital with a 4-day history of worsening fever and fatigue, not alleviated by ibuprofen. The patient experienced headache, anorexia, knee pain, and hematuria but denied cough, dyspnea, sputum production, chest pain, abdominal pain, nausea, vomiting, constipation, or diarrhea. He had no recent travel or exposure to sick contacts. The patient had received his primary series vaccines for COVID-19. He described himself as a social drinker, non-smoker, and nonuser of illicit or recreational substances. He noted a recent flood on his street due to heavy rain, with the flooding confined to the household surroundings.
On admission, the patient was febrile at 39.5°C and tachycardic at 120 beats per minute, fulfilling 2 of the Systemic Inflammatory Response Syndrome (SIRS) criteria. On physical examination, he was shivering and lung crackles were detected in the left middle and lower lobe on auscultation. His basic metabolic panel showed CPK at 9614 mcg/L (reference: 30–223 mcg/L), ALT at 83 U/L (reference: 7–52 U/L), AST at 255 U/L (reference: 13–39 U/L), creatinine at 1.41 mg/dL (reference: 0.7–1.3 mg/dL), hyponatremia at 129 mEq/L (reference: 136–145 mEq/L), and hypophosphatemia 1.8 mg/dL (reference 2.5–4.5 mg/dL). Potassium was 3.6 mEq/L (3.5–5.1 mEq/L) and BUN was 22 mg/dL (reference: 7–25 mg/dL). His WBC count was within normal limits at 6.2 K/mm3 (reference: 3.5–10.6 K/mm3). Urinalysis detected hematuria, proteinuria, and nitrites. A chest X-ray showed hazy left perihilar opacities, suggestive of pneumonia (Figure 1). He was started on i.v. 0.9% NaCl iso-tonic fluid, azithromycin, and cephalexin.
Differential diagnoses at the time were sepsis secondary to
Discussion
The case report highlights the need to recognize possible environmental exposures to pathogens implicated in disease causation, as this patient’s exposure to sewage-contaminated pluvial floods near his house predisposed him to infection by
local ischemic damage to myocytes [7,8].
Rhabdomyolysis caused by bacteria is associated with high mortality and morbidity, with 57% of cases leading to acute renal failure and 38% of cases leading to death [11].
Legionnaires’ disease is a severe manifestation of
Management of the rhabdomyolysis with acute kidney injury is aggressive isotonic fluid administration, which resolved our patient’s electrolyte and metabolic abnormalities. The first-line treatment of Legionnaires’ disease is empiric therapy with fluoroquinolones or macrolide monotherapy, or in combination with beta-lactam after ruling out
Conclusions
The literature on
Figures
Figure 1.. Chest X-ray on initial presentation. Hazy left perihilar opacities indicated a likely diagnosis of atypical baterial pneumonia. Figure 2.. Creatinine trend during hospital stay. Creatinine level was elevated at 1.41 mg/dL on admission and gradually stabilized to a baseline of 0.75 mg/dL by discharge. Figure 3.. Creatinine phosphokinase (CPK) trend during the hospital stay. CPK level was elevated at 9614 mcg/L on admission, peaked at 9710 mcg/L on repeat blood draw, and trended down to 4976 mcg/L by discharge.References:
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