Clinical manifestations and diagnosis of Legionella infection
- Victor L Yu, MD
Victor L Yu, MD
- Professor of Medicine
- University of Pittsburgh Medical Center
- Janet E Stout, PhD
Janet E Stout, PhD
- Director, Special Pathogens Laboratory
- Research Associate Professor, University of Pittsburgh
- Nieves Sopena Galindo, MD
Nieves Sopena Galindo, MD
- Assistant Professor of Medicine
- Universitat Autònoma de Barcelona
Since the organism was first recognized in 1976 during an outbreak at an American Legion Convention in Philadelphia, Legionella has been identified as a relatively common cause of both community-acquired and hospital-acquired pneumonia.
Legionellosis refers to the two clinical syndromes caused by bacteria of the genus Legionella:
●Legionnaires' disease is the more common syndrome of pneumonia caused by Legionella species
●Pontiac fever is an acute, febrile, self-limited illness that has been linked to Legionella species
The clinical manifestations and diagnosis of Legionella infection will be reviewed here. The epidemiology, pathogenesis, treatment, and prevention of this entity are discussed separately. (See "Epidemiology and pathogenesis of Legionella infection" and "Treatment and prevention of Legionella infection".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Fraser DW, Tsai TR, Orenstein W, et al. Legionnaires' disease: description of an epidemic of pneumonia. N Engl J Med 1977; 297:1189.
- Kirby BD, Snyder KM, Meyer RD, Finegold SM. Legionnaires' disease: report of sixty-five nosocomially acquired cases of review of the literature. Medicine (Baltimore) 1980; 59:188.
- Mulazimoglu L, Yu VL. Can Legionnaires disease be diagnosed by clinical criteria? A critical review. Chest 2001; 120:1049.
- Fang GD, Fine M, Orloff J, et al. New and emerging etiologies for community-acquired pneumonia with implications for therapy. A prospective multicenter study of 359 cases. Medicine (Baltimore) 1990; 69:307.
- Roig J, Aguilar X, Ruiz J, et al. Comparative study of Legionella pneumophila and other nosocomial-acquired pneumonias. Chest 1991; 99:344.
- Yu VL, Kroboth FJ, Shonnard J, et al. Legionnaires' disease: new clinical perspective from a prospective pneumonia study. Am J Med 1982; 73:357.
- Cunha BA. Highly elevated serum ferritin levels as a diagnostic marker for Legionella pneumonia. Clin Infect Dis 2008; 46:1789.
- Haeuptle J, Zaborsky R, Fiumefreddo R, et al. Prognostic value of procalcitonin in Legionella pneumonia. Eur J Clin Microbiol Infect Dis 2009; 28:55.
- de Jager CP, de Wit NC, Weers-Pothoff G, et al. Procalcitonin kinetics in Legionella pneumophila pneumonia. Clin Microbiol Infect 2009; 15:1020.
- Tan MJ, Tan JS, Hamor RH, et al. The radiologic manifestations of Legionnaire's disease. The Ohio Community-Based Pneumonia Incidence Study Group. Chest 2000; 117:398.
- Singh N, Muder RR, Yu VL, Gayowski T. Legionella infection in liver transplant recipients: implications for management. Transplantation 1993; 56:1549.
- Yu VL, Greenberg RN, Zadeikis N, et al. Levofloxacin efficacy in the treatment of community-acquired legionellosis. Chest 2004; 125:2135.
- Glick TH, Gregg MB, Berman B, et al. Pontiac fever. An epidemic of unknown etiology in a health department: I. Clinical and epidemiologic aspects. Am J Epidemiol 1978; 107:149.
- Kaufmann AF, McDade JE, Patton CM, et al. Pontiac fever: isolation of the etiologic agent (Legionella pneumophilia) and demonstration of its mode of transmission. Am J Epidemiol 1981; 114:337.
- Edelstein PH. Urine antigen tests positive for Pontiac fever: implications for diagnosis and pathogenesis. Clin Infect Dis 2007; 44:229.
- Lowry PW, Tompkins LS. Nosocomial legionellosis: a review of pulmonary and extrapulmonary syndromes. Am J Infect Control 1993; 21:21.
- Bemer P, Leautez S, Ninin E, et al. Legionella pneumophila Arthritis: use of medium specific for Mycobacteria for isolation of L. pneumophila in culture of articular fluid specimens. Clin Infect Dis 2002; 35:E6.
- Tompkins LS, Roessler BJ, Redd SC, et al. Legionella prosthetic-valve endocarditis. N Engl J Med 1988; 318:530.
- Antonarakis ES, Wung PK, Durand DJ, et al. An atypical complication of atypical pneumonia. Am J Med 2006; 119:824.
- Lowry PW, Blankenship RJ, Gridley W, et al. A cluster of legionella sternal-wound infections due to postoperative topical exposure to contaminated tap water. N Engl J Med 1991; 324:109.
- Tan MJ, Tan JS, File TM Jr. Legionnaires disease with bacteremic coinfection. Clin Infect Dis 2002; 35:533.
- Lepine LA, Jernigan DB, Butler JC, et al. A recurrent outbreak of nosocomial legionnaires' disease detected by urinary antigen testing: evidence for long-term colonization of a hospital plumbing system. Infect Control Hosp Epidemiol 1998; 19:905.
- Heath CH, Grove DI, Looke DF. Delay in appropriate therapy of Legionella pneumonia associated with increased mortality. Eur J Clin Microbiol Infect Dis 1996; 15:286.
- Fiore AE, Butler JC, Emori TG, Gaynes RP. A survey of methods used to detect nosocomial legionellosis among participants in the National Nosocomial Infections Surveillance System. Infect Control Hosp Epidemiol 1999; 20:412.
- Fields BS, Benson RF, Besser RE. Legionella and Legionnaires' disease: 25 years of investigation. Clin Microbiol Rev 2002; 15:506.
- Muder RR, Yu VL. Infection due to Legionella species other than L. pneumophila. Clin Infect Dis 2002; 35:990.
- Marrie TJ. Diagnosis of legionellaceae as a cause of community-acquired pneumonia- "... continue to treat first and not bother to ask questions later"--not a good idea. Am J Med 2001; 110:73.
- Stout JE, Rihs JD, Yu VL. Legionella. In: Manual of Clinical Microbiology, Murray PR, Baron EJ, Jorgensen JH, et al (Eds), ASM Press, Washington, DC 2003. Vol 52, p.809.
- Benin AL, Benson RF, Besser RE. Trends in legionnaires disease, 1980-1998: declining mortality and new patterns of diagnosis. Clin Infect Dis 2002; 35:1039.
- Kool JL, Fiore AE, Kioski CM, et al. More than 10 years of unrecognized nosocomial transmission of legionnaires' disease among transplant patients. Infect Control Hosp Epidemiol 1998; 19:898.
- Kazandjian D, Chiew R, Gilbert GL. Rapid diagnosis of Legionella pneumophila serogroup 1 infection with the Binax enzyme immunoassay urinary antigen test. J Clin Microbiol 1997; 35:954.
- Yu VL, Plouffe JF, Pastoris MC, et al. Distribution of Legionella species and serogroups isolated by culture in patients with sporadic community-acquired legionellosis: an international collaborative survey. J Infect Dis 2002; 186:127.
- Helbig JH, Uldum SA, Bernander S, et al. Clinical utility of urinary antigen detection for diagnosis of community-acquired, travel-associated, and nosocomial legionnaires' disease. J Clin Microbiol 2003; 41:838.
- von Baum H, Ewig S, Marre R, et al. Community-acquired Legionella pneumonia: new insights from the German competence network for community acquired pneumonia. Clin Infect Dis 2008; 46:1356.
- Mercante JW, Winchell JM. Current and emerging Legionella diagnostics for laboratory and outbreak investigations. Clin Microbiol Rev 2015; 28:95.
- Domínguez J, Galí N, Matas L, et al. Evaluation of a rapid immunochromatographic assay for the detection of Legionella antigen in urine samples. Eur J Clin Microbiol Infect Dis 1999; 18:896.
- Stout JE. Laboratory diagnosis of Legionnaires' disease: the expanding role of the Legionella urinary antigen test. Clin Microbiol Newsletter 2000; 22:62.
- Rihs JD, Jarraud S, Luck C, et al. Lack of comparable sensitivity and specificity among seven Legionella urinary antigen test kits: An international collaborative study (abstract no. 2473). 50th Interscience Conference on Antimicrobial Agents and Chemotherapy, Boston, MA 2010.
- Blázquez RM, Espinosa FJ, Martínez-Toldos CM, et al. Sensitivity of urinary antigen test in relation to clinical severity in a large outbreak of Legionella pneumonia in Spain. Eur J Clin Microbiol Infect Dis 2005; 24:488.
- Burnsed LJ, Hicks LA, Smithee LM, et al. A large, travel-associated outbreak of legionellosis among hotel guests: utility of the urine antigen assay in confirming Pontiac fever. Clin Infect Dis 2007; 44:222.
- Benson RF, Tang PW, Fields BS. Evaluation of the Binax and Biotest urinary antigen kits for detection of Legionnaires' disease due to multiple serogroups and species of Legionella. J Clin Microbiol 2000; 38:2763.
- Guidelines for prevention of nosocomial pneumonia. Centers for Disease Control and Prevention. MMWR Recomm Rep 1997; 46:1.
- McWhinney PH, Ragunathan PL, Rowbottham TJ. Failure to produce detectable antibodies to Legionella pneumophila by an immunocompetent adult. J Infect 2000; 41:91.
- Plouffe JF, File TM Jr, Breiman RF, et al. Reevaluation of the definition of Legionnaires' disease: use of the urinary antigen assay. Community Based Pneumonia Incidence Study Group. Clin Infect Dis 1995; 20:1286.
- Ramirez JA, Ahkee S, Tolentino A, et al. Diagnosis of Legionella pneumophila, Mycoplasma pneumoniae, or Chlamydia pneumoniae lower respiratory infection using the polymerase chain reaction on a single throat swab specimen. Diagn Microbiol Infect Dis 1996; 24:7.
- Jonas D, Rosenbaum A, Weyrich S, Bhakdi S. Enzyme-linked immunoassay for detection of PCR-amplified DNA of legionellae in bronchoalveolar fluid. J Clin Microbiol 1995; 33:1247.
- Bencini MA, van den Brule AJ, Claas EC, et al. Multicenter comparison of molecular methods for detection of Legionella spp. in sputum samples. J Clin Microbiol 2007; 45:3390.
- Murdoch DR, Podmore RG, Anderson TP, et al. Impact of routine systematic polymerase chain reaction testing on case finding for Legionnaires' disease: a pre-post comparison study. Clin Infect Dis 2013; 57:1275.
- CLINICAL MANIFESTATIONS
- Legionnaires' disease
- - Symptoms
- - Physical examination
- - Laboratory findings
- - Chest radiograph
- - Clinical clues for the diagnosis
- Pontiac fever
- Extrapulmonary disease
- SPECIFIC LABORATORY DIAGNOSIS
- Culture on selective media
- Urinary antigen testing
- DFA staining
- Polymerase chain reaction
- Approach to diagnosis
- SUMMARY AND RECOMMENDATIONS