[Pathogenesis, diagnosis and therapy of Legionella infections]. / Pathogenese, Diagnostik und Therapie der Legionella-Infektion.

Legionella species are ubiquitous in aquatic environments. About 50 years ago they entered the engineered (technical) environment, i.e. warm water systems with zones of stagnation. Since that time they represent a hygienic problem. After transmission to humans via aerosols legionellae might cause Legionella pneumonia (legionnaires' disease) or influenza-like respiratory infections (Pontiac fever). Epidemiological data suggest that Legionella strains might differ substantially in their virulence properties. Although the molecular basis is not understood L. pneumophila serogroup 1 especially MAb 3/1-positive strains cause the majority of infections. The main virulence feature is the ability to multiply intracellularly. After uptake into macrophages legionellae multiply in a specialized vacuole and finally lyse their host cells. Several bacterial factors like surface components, secretion systems and iron uptake systems are involved in this process. Since the clinical picture of Legionella pneumonia does not allow differentiation from pneumoniae caused by other pathogens, microbiological diagnostic methods are needed to establish the diagnosis. Cultivation of legionellae from clinical specimens, detection of antigens and DNA in patients' samples and detection of antibodies in serum samples are suitable methods. However, none of the diagnostic tests presently available offers the desired quality with respect to sensitivity and specificity. Therefore, the standard technique is to use several diagnostic tests in parallel. Advantages and disadvantages of the diagnostic procedures are discussed. Therapeutic options for Legionella infections are newer macrolides like azithromycin and chinolones (ciprofloxacin, levofloxacin and moxifloxacin).

Outbreak of Legionnaires' disease on a cruise ship linked to spa-bath filter stones contaminated with Legionella pneumophila serogroup 5.

In January 2003, two cases of Legionnaires' disease associated with a ship's cruise were registered in the database of National Epidemiological Surveillance of Infectious Diseases. A 70-year-old male heavy smoker with mild emphysema contracted the disease during a cruise. Legionella pneumophila serogroup (sg) 5 was isolated from the patient's sputum and the ship's indoor spa. The isolate from the spa matched the patient's isolate by genotyping performed by pulsed-field gel electrophoresis (PFGE). The second case was in a 73-year-old female. During epidemiological investigation, a third case of Legionnaire's disease in a 71-year-old male was subsequently diagnosed among passengers on the same ship on the following cruise. Environmental investigation revealed that porous natural stones (Maifanshi) in the filters of the spas had harboured L. pneumophila, a phenomenon which has not been reported except in Japan. This is the first documented evidence of L. pneumophila sg 5 infection on a ship and of porous stones as a source of Legionella infection.

[Legionella pneumonia which occurred in a private whirlpool bath user].

A 88 year old female with active rheumatoid arthritis treated by low dose of prednisolone and methotrexate was admitted to our hospital because of severe bilateral pulmonary infiltration and acute respiratory distress syndrome. On admission, she had consciousness disturbance and was intubated because of severe respiratory failure. We heard from her family of her habit she had taking a private whirlpool bath 2 or 3 times everyday. So, we suspected a Legionella pneumophila infection. We started intravenous erythromycin (EM) (1,500mg/day) and methylprednisolone pulse therapy (1,000mg x 3days) and full controlled mechanical ventilation supported with PEEP. Her respiratory failure was gradually improved and she was discharged on the 44 the hospital day. Legionella pneumophila (serogroup 6) was isolated in her sputum by B-CYE alpha culture. Legionella pneumophila (serogroup 6) was isolated in her private whirlpool bath too. Both samples revealed the same by genetic analysis with pulse field gel electrophoresis (PFGE). This is the first adult case of Legionella pneumophila pneumonia infected from a private whirlpool bath confirmed by genetic analysis. We should always suspect Legionella pneumonia as one of the severe community-acquired pneumonia, because Legionella pneumophila were frequently detected among various water sources including the private whirlpool bath.

A nosocomial outbreak of Legionella pneumophila caused by contaminated transesophageal echocardiography probes.

A case-control study of three cases of Legionella pneumophila pneumonia identified transesophageal echocardiography (TEE) as a risk factor. Patient isolates and environmental strains from water used for rinsing TEE probes were identical by pulsed-field gel electrophoresis. This is the first report of endoscopy as a potential source of legionellosis.

Neonatal sudden death due to Legionella pneumonia associated with water birth in a domestic spa bath.

We report the first case of neonatal Legionnaires' disease associated with water birth in a spa bath at home. Legionella pneumophila serogroup 6 was detected from postmortem lung tissue.

Legionella pneumophila feoAB promotes ferrous iron uptake and intracellular infection.

In order to determine the role of ferrous iron transport in Legionella pathogenesis, we identified and mutated the feoB gene in virulent Legionella pneumophila strain 130b. As it is in Escherichia coli, the L. pneumophila feoB gene was contained within a putative feoAB operon. L. pneumophila feoB insertion mutants exhibited decreased ferrous but not ferric iron uptake compared to the wild type. Growth on standard buffered charcoal yeast extract agar or buffered yeast extract broth was unaffected by the loss of L. pneumophila FeoB. However, the L. pneumophila feoB mutant had a reduced ability to grow on buffered charcoal yeast extract agar with a reduced amount of its usual iron supplementation, a phenotype that could be complemented by the addition of feoB in trans. In unsupplemented buffered yeast extract broth, the feoB mutant also had a growth defect, which was further exacerbated by the addition of the ferrous iron chelator, 2,2'-dipyridyl. The feoB mutant was also 2.5 logs more resistant to streptonigrin than wild-type 130b, confirming its decreased ability to acquire iron during extracellular growth. Decreased replication of the feoB mutant was noted within iron-depleted Hartmannella vermiformis amoebae and human U937 cell macrophages. The reduced intracellular infectivity of the feoB mutant was complemented by the introduction of a plasmid containing feoAB. The L. pneumophila feoB gene conferred a modest growth advantage for the wild type over the mutant in a competition assay within the lungs of A/J mice. Taken together, these results indicate that L. pneumophila FeoB is a ferrous iron transporter that is important for extracellular and intracellular growth, especially in iron-limited environments. These data represent the first evidence for the importance of ferrous iron transport for intracellular replication by a human pathogen.

Nosocomial outbreak of Legionella pneumophila serogroup 3 pneumonia in a new bone marrow transplant unit: evaluation, treatment and control.

A nosocomial outbreak of pneumonia caused by Legionella pneumophila serogroup 3 occurred in four patients following hematopoietic stem cell transplantation (HSCT) in a new bone marrow transplantation (BMT) unit during a 2 week period. The causative organism was recovered from the water supply system to the same unit just before the outbreak. Nineteen other BMT patients were hospitalized in the same unit at the same time, giving a frequency of proven infection of 4/23 = 17%. Immediately after recognition of the outbreak, use of tap water was forbidden, humidifiers were disconnected, and ciprofloxacin prophylaxis was started for all patients in the unit, until decontamination of the water was achieved. No other cases were detected. In conclusion, contamination of the hospital water supply system with legionella carries a high risk for legionella pneumonia among BMT patients. Early recognition of the outbreak, immediate restrictions of water use, antibiotic prophylaxis for all non-infected patients, and water decontamination, successfully terminated the outbreak.

[Legionella pneumophila in thermal pools of hot springs in the central Anatolian district]. / Iç anadolu bölgesinde bulunan kaplicalarin termal havuz sularinda Legionella pneumophila arastirmasi.

Microbiological contamination of hot spring waters is a public health problem, and hot spring waters have been thought to be a potential source of Legionella infections. In this study, 209 water samples collected from 69 thermal pools of 36 hot springs in the Central Anatolia Region were examined for the presence of Legionella spp. between September and November 2001. The water samples were concentrated via filtration, and the filtrates were decontaminated by low-pH method. Then the samples were cultured on non-selective (Buffered Charcoal Yeast Extract Agar, BCYE) and selective (GVPC; BCYE supplemented with glycine, vancomycin, polymyxin B, cycloheximide, and MWY; BCYE supplemented with glycine, anisomycin, polymyxin B, vancomycin, bromthymol blue, bromcresole purple) media, and suspected colonies were confirmed by Legionella Latex Kit (Oxoid) and direct fluorescent antibody test. As a result, 24 out of 209 (11.5%) water samples were found positive for Legionella pneumophila, and a total 26 L. pneumophila strains were isolated from these 24 samples. Two of these isolates were found reactive with serogroup 1, 20 were reactive with serogroup 2-14 antisera in agglutination test, while 2 samples collected from the same thermal pool, have yielded 2 strains, of which one was serogroup 1 and the other was serogroup 2-14. L. pneumophila was detected in 22.2% of hot springs (8 of 36) and 14.5% of thermal pools (10 of 69). L. pneumophila concentrations which were detected in water samples ranged from 10 to 430 CFU/100 ml. This is the first data for the prevalence of Legionnaires' disease agent in hot spring spas in the Central Anatolia Region of Turkey. Colonization of bacterium in some spas indicates that the certain hot springs might be endemic focuses for Legionnaires' disease in our country.

[Legionella pneumonia caused by aspiration of hot spring water after sarin exposure].

A 72-year-old man was exposed to the sarin gas attack in a Tokyo subway on March 20 th, 1995. After exposure, he noticed eye discomfort, chest tightness, headache and weakness of the lower limbs and oropharyngeal muscles. Despite these symptoms, he visited a hot spring on the same day with his family. On March 25 th, his muscle weakness progressed, and a low grade fever appeared. His muscle weakness disappeared 8 days after exposure to sarin, but respiratory failure rapidly developed, necessitating artificial ventilation within four day after hospitalization on March 28th. Chemotherapy with erythromycin, imipenem/cilastatin, and steroid pulse therapy was begu. PCR and culture of sputum collected by bronchofiberscopy were positive for Legionella pneumophila, serogroup I. His respiratory state improved, but subsequent infection with Pseudomonous aeruginosa. Enterobacter cloacae, and Candida tropicalis/glabrata caused his death 71 days after admission. Oropharyngeal muscle weakness caused by sarin-mediated cholinesterase inhibition was strongly suspected as the cause of hot spring water aspiration. Transbronchial lung biopsy revealed organizing pneumonia with fibrosis. Bronchoscopic findings included redness, edema and fragility of all visible areas of the airway, which was thought to be due to bronchitis caused by Legionellosis.

An outbreak of Pontiac fever among children following use of a whirlpool.

We investigated an outbreak of fever, most likely due to a contaminated whirlpool, among nine adults and six children residing in a summerhouse. The outbreak was characterized by a high attack rate, short incubation periods, influenza-like symptoms, and rapid recoveries, all features typical of Pontiac fever. However, the children had less-characteristic symptoms than the adults, and they did not have any sequelae. Findings on the children's chest radiographs were unremarkable, and none of the children had leukocytosis. Evidence of Legionella pneumophila infection was found in six cases: in one case by isolation of L. pneumophila serogroup 1 and detection of legionellae by PCR, and in five cases by seroconversion to the clinical isolate. Six additional cases had presumptive evidence of legionella infection, with seroconversion to Legionella micdadei antigen; a PCR assay was also positive for legionellae for one of these cases. In contrast, two adult nonusers of the whirlpool had no symptoms and no serological evidence of infection. Serological testing and cultures for other pathogens, as well as cultures of all environmental samples, were negative. This investigation demonstrates the differences between adults and children with respect to the clinical picture of Pontiac fever; furthermore, it shows that culture and PCR assay of tracheal aspirates for legionellae can be performed in a hospital setting for rapid diagnosis, although the sensitivities of these methods are low.

Legionnaires disease associated with a whirlpool spa display--Virginia, September-October, 1996.

Contaminated whirlpool spas have been reported as a source of legionellosis. This report describes the preliminary findings of an ongoing investigation by the Virginia Department of Health (VDH) and CDC of a recent outbreak of Legionnaires disease in Virginia, which implicated a whirlpool spa display at a retail store as the source of infection.

[Legionella pneumophila serogroup 3 isolated from a patient of pneumonia developed after drowning in bathtub of a hot spring spa].

A 71-year-old Japanese female, was found unconscious by drawing, in a hot spring spa, at around noon of 20 October 1994. She recovered by emergency cardiopulmonary resuscitation, and admitted to the Takinomiya General Hospital, with adult respiratory distress syndrome (ARDS). Although she recovered from ARDS within 4 days after her admission, she developed severe pneumonia accompanied with the second attack of ARDS. Ordinary bacteriological culture of her respiratory specimens failed to yield any significant pathogen for her pneumonia, and neither cefazolin nor imipenem/cilastatin was effective. Thus minocyclin was given on the 7th hospital-day and this was effective for blood gas and C-reactive protein (CRP) levels. Intratracheal exsudate inoculated on BCYE alpha agar plate yielded grayish white colonies. Cells of the colonies were clearly agglutinated by anti-Legionella pneumophila serogroup (SG) 3 serum. Antibody titers of patient's paired sera against the strain L. pneumophila SG3 Bloomington-2 and the patient's strain (Y-1) were determined by microplate agglutination test, and a significant rise from 1:20 to 1:320 was demonstrated. Patient recovered by erythromycin treatment and was discharged on the 59th hospital day. L. pneumophila SG3 organisms were again isolated from the spa water where the patient drawn. From these findings described above, we diagnosed the patient as pneumonia due to L. pneumophila SG3, and the spa water was the most probable source of infection.

Treatment of Legionnaires' disease. Current recommendations.

Legionnaires' disease is a relatively common cause of community-acquired pneumonia and of some outbreaks of hospital-acquired pneumonia. Moreover, Legionella pneumophila is frequently involved in the aetiology of the subset of pneumonias that is characterised by severe clinical course and high mortality. No sure clinical, radiographical or analytical features are useful in differentiating Legionella infection from other aetiologies of pneumonia. On the basis of these data, a rational initial therapeutic approach to community-acquired pneumonia, as well as to nosocomial pneumonia in certain circumstances, has to include an antimicrobial agent that is clinically effective against Legionella spp. Clinical studies have provided evidence that erythromycin is the first-line treatment. An intravenous dosage of 1g every 6 hours as initial therapy will be effective in most cases. Parenteral treatment may be switched to oral administration only after clinical response is observed. In vitro susceptibilities and preliminary experimental and clinical results suggest that clarithromycin will most likely become the preferred treatment once an intravenous preparation is available worldwide. However, orally administered clarithromycin at the dosage of 500 mg every 12 hours may be recommended in those developing countries in which health systems cannot afford the costs of intravenous therapy. In the case of clinically severe illness or in seriously immunosuppressed hosts with confirmed legionellosis, a combined therapeutic approach is warranted. Rifampicin 600 mg every 12 hours intravenously or orally has to be added to the usual dosage of erythromycin. Other alternative therapies, but with less distinct clinical efficacy, that can be combined with erythromycin are doxycycline 100 mg every 12 hours intravenously or orally, and intravenous ciprofloxacin 200 mg every 6 hours.

Pathogenesis and chemotherapy of experimental Legionella pneumophila infection in the chick embryo.

The pathogenicity of Legionella pneumophila, serogroup 1, strain Nottingham N7, was assessed in terms of LD50 data and the ability of the organism to induce pathological lesions in the fertile hen's egg. Histopathological examination of embryo organs after inoculation with 1, 10, 100 and 1000 times the yolk sac LD50 revealed a disseminated infection. Systemic spread of the organism resulted in widespread necrosis and evidence of consolidation together with generation of copious amounts of oedema fluid. These were particularly severe in the liver, heart, spleen and kidney. The infection elicited a massive inflammatory response typified by infiltration with polymorphonuclear leucocytes and lymphocytes. Selected antimicrobial chemotherapeutic agents were investigated in protection studies for their capacity to ameliorate or control disease processes in this test system. Of those examined ciprofloxacin was most effective in reducing the incidence of lesions in these tissues and for prolonging embryo viability. Rifampicin, and to a lesser degree, erythromycin and doxycycline, also showed antimicrobial activity in these in vivo trials. These results indicate that the fertile hen's egg may be a useful alternative to other animal systems for the in vivo testing of clinically putative antimicrobial agents in the treatment of Legionnaires' disease.

[Recent developments in the field of infectious diseases]. / Développements récents dans le domaine des maladies infectieuses.

A résumé is presented of recent developments in the field of infectious diseases of particular interest of practising physicians. Examples are given to illustrate recent discoveries concerning the frequent misuse of antibiotics, the problem of infections developing in hospitalized patients, the biology of microbial infection, the etiology of well-known illnesses, new infectious diseases, and the development of vaccines. It is evident that the rate at which new and important information is evident that the rate at which new and important information is being reported demands particular effort in medical school teaching to ensure that students learn how to acquire and evaluate new information as well as how to discard ideas which are no longer valid.