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{{Legionellosis}}
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==Overview==
Laboratory abnormalities in Legionnaires' disease include leukocytosis with relative [[lymphopenia]], [[hyponatremia]], [[hypophosphatemia]], and elevated levels of [[AST]]/[[ALT]], [[CPK]], [[ESR]], [[CRP]], [[LDH]], and [[ferritin]].  Urine antigen testing in the first-line diagnostic method.  Culture of the lower respiratory secretion is the gold standard for the detection of ''Legionella'' and diagnosis of Legionnaires' disease.
==Indications to Test for Legionnaires' Disease==
According to the [[Centers for Disease Control and Prevention]] ([[CDC]]), the following are indications to test for Legionnaires' disease:
*Patients who have failed outpatient [[antibiotic]] therapy
*Patients with severe [[pneumonia]], in particular those requiring intensive care
*Immunocompromised host with [[pneumonia]]
*Patients with [[pneumonia]] in the setting of a legionellosis outbreak
*Patients with a travel history (Patients that have traveled away from their home within two weeks before the onset of illness).
*Patients suspected of healthcare-associated pneumonia


==Laboratory Findings==
==Laboratory Findings==
Laboratory findings of Legionnaires' disease include:<ref>{{Cite journal| doi = 10.1016/j.idc.2009.10.014| issn = 1557-9824| volume = 24| issue = 1| pages = 73–105| last = Cunha| first = Burke A.| title = Legionnaires' disease: clinical differentiation from typical and other atypical pneumonias| journal = Infectious Disease Clinics of North America| date = 2010-03| pmid = 20171547}}</ref>
* [[Leukocytosis]]
* [[Lymphopenia]]
* [[Hyponatremia]]
* [[Hypophosphatemia]]
* Elevated [[AST]] and [[ALT]]
* Elevated [[CPK]]
* Elevated [[ESR]] and [[CRP]]
* Elevated [[LDH]]
* Elevated [[ferritin]]
==Diagnostic Studies==
{| {{table}} cellpadding="4" cellspacing="0" style="border:#c9c9c9 1px solid; margin: 1em 1em 1em 0; border-collapse: collapse;"
| align="center" style="background:#f0f0f0;" |'''Test'''
| align="center" style="background:#f0f0f0;" |'''Sensitivity (%)'''
| align="center" style="background:#f0f0f0;" |'''Specificity (%)'''
|-
| Culture||20-80||100
|-
| Urine antigen||70-100||100
|-
| Paired serology||80-90||>99
|-
| Direct fluorescent antibody stain||25-75||≥95
|-
| [[PCR]]||unknown||unknown
|}
===Microscopy===
[[Legionella pneumophila]] are small, Gram-negative [[coccobacilli]] which may be difficult to detect in specimens by Gram staining.<ref>{{cite book | last = Versalovic | first = James | title = Manual of clinical microbiology | publisher = ASM Press | location = Washington, DC | year = 2011 | isbn = 978-1555814632 }}</ref>  The organism can also be detected by immunofluorescent microscopy with the use of direct fluorescent antibody.
===Urine Antigen Test===
The detection of soluble antigens (a component of the cell wall lipopolysaccharide) in the urine is the first-line diagnostic technique.  The method is most accurate for detecting Lp1 MAb 3/1 subtypes. Sensitivity ranges from 56–99% and is lower in [[nosocomial]] infection and immunocompromised hosts.<ref>{{Cite journal| issn = 0095-1137| volume = 41| issue = 2| pages = 838–840| last1 = Helbig| first1 = Jürgen H.| last2 = Uldum| first2 = Søren A.| last3 = Bernander| first3 = Sverker| last4 = Lück| first4 = Paul Christian| last5 = Wewalka| first5 = Günther| last6 = Abraham| first6 = Bill| last7 = Gaia| first7 = Valeria| last8 = Harrison| first8 = Timothy G.| title = Clinical utility of urinary antigen detection for diagnosis of community-acquired, travel-associated, and nosocomial legionnaires' disease| journal = Journal of Clinical Microbiology| date = 2003-02| pmid = 12574296| pmc = PMC149701}}</ref> Urine antigen test may also be positive for Pontiac fever.  IDSA/ATS guidelines recommend urinary antigen test for the following patients:<ref>{{Cite journal| doi = 10.1086/511159| issn = 1537-6591| volume = 44 Suppl 2| pages = –27-72| last1 = Mandell| first1 = Lionel A.| last2 = Wunderink| first2 = Richard G.| last3 = Anzueto| first3 = Antonio| last4 = Bartlett| first4 = John G.| last5 = Campbell| first5 = G. Douglas| last6 = Dean| first6 = Nathan C.| last7 = Dowell| first7 = Scott F.| last8 = File| first8 = Thomas M.| last9 = Musher| first9 = Daniel M.| last10 = Niederman| first10 = Michael S.| last11 = Torres| first11 = Antonio| last12 = Whitney| first12 = Cynthia G.| last13 = Infectious Diseases Society of America| last14 = American Thoracic Society| title = Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults| journal = Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America| date = 2007-03-01| pmid = 17278083}}</ref>
* Unresponsive to outpatient [[antibiotic]] therapy
* Severe [[pneumonia]] especially requiring intensive care
* Immunocompromised hosts
* [[Alcoholism]]
* Travelled within the past 2 week
* Age > 50 years
* In areas of an outbreak
* Suspected healthcare-associated [[pneumonia]]
===Polymerase Chain Reaction===
[[Nucleic acid amplification technique|Nucleic acid amplification]]-based methods can be used to identify mip gene of Legionella in [[sputum]], [[serum]], and [[urine]].  Sensitivities range from 80–100% for lower [[respiratory]] tract secretion, 30–80% for serum, and 0–90% for urine samples.<ref>{{Cite journal| doi = 10.1007/s10096-011-1535-0| issn = 1435-4373| volume = 31| issue = 8| pages = 2017–2028| last1 = Mentasti| first1 = M.| last2 = Fry| first2 = N. K.| last3 = Afshar| first3 = B.| last4 = Palepou-Foxley| first4 = C.| last5 = Naik| first5 = F. C.| last6 = Harrison| first6 = T. G.| title = Application of Legionella pneumophila-specific quantitative real-time PCR combined with direct amplification and sequence-based typing in the diagnosis and epidemiological investigation of Legionnaires' disease| journal = European Journal of Clinical Microbiology & Infectious Diseases: Official Publication of the European Society of Clinical Microbiology| date = 2012-08| pmid = 22278293}}</ref><ref>{{cite book | last = Versalovic | first = James | title = Manual of clinical microbiology | publisher = ASM Press | location = Washington, DC | year = 2011 | isbn = 978-1555814632 }}</ref>
===Serology test===
A 4-fold or greater rise in antibody titer between acute and convalescent sera may be diagnostic.  However, seroconversion is not detectable until at least 3 weeks after infection and does not occur in up to a quarter of patients with culture-proven disease.<ref>{{Cite journal| doi = 10.1016/S0140-6736(15)60078-2| issn = 1474-547X| last1 = Cunha| first1 = Burke A.| last2 = Burillo| first2 = Almudena| last3 = Bouza| first3 = Emilio| title = Legionnaires' disease| journal = Lancet (London, England)| date = 2015-07-28| pmid = 26231463}}</ref>
===Culture===
Isolation of [[Legionella]] from [[respiratory]] secretions, lung tissue, [[pleural fluid]], or a normally sterile site is still an important method for diagnosis, despite the convenience and specificity of urinary antigen testing. Investigations of outbreaks of Legionnaires' disease rely on both clinical and environmental isolates. Clinical and environmental isolates can be compared using monoclonal antibody and molecular techniques. Because [[Legionella]] are commonly found in the environment, clinical isolates are necessary to interpret the findings of an environmental investigation.
Culture of samples (e.g., expectorated sputum, endotracheal aspirates, [[pleural]] fluid, [[blood]], or [[tissue]]) remains the gold standard for detecting Legionnaires' disease.  Unlike serology and urine antigen testing, the yield of cultures is independent of serotype and may be positive in cases of non-''Legionella pneumophila'' species.  The culture of non-respiratory samples is warranted when suspecting extrapulmonary infection.  Buffered charcoal-yeast extract (BCYE) medium supplemented with 0.1% α-ketoglutaric acid is required for isolation and growth of Legionella.<ref>{{Cite journal| doi = 10.1016/S0140-6736(15)60078-2| issn = 1474-547X| last1 = Cunha| first1 = Burke A.| last2 = Burillo| first2 = Almudena| last3 = Bouza| first3 = Emilio| title = Legionnaires' disease| journal = Lancet (London, England)| date = 2015-07-28| pmid = 26231463}}</ref>


* [[Complete blood count]] and differential count - [[lymphopenia]] and rarely [[pancytopenia]]
==CDC Recommendations for Specimen Collection==
* Serum electrolytes - [[hyponatremia]]
===Environmental Specimen Collection===
* [[Liver function test]]s - elevated [[bilirubin]] levels
#Collect water (1-liter samples, if possible) in sterile, screw-top bottles.
* [[Urinalysis]] - [[proteinuria]]
#Collect culture swabs of internal surfaces of faucets, aerators, and shower heads in a sterile, screw-top container (e.g., 50 mL plastic centrifuge tube). Submerge each swab in approximately 5 mL of sample water taken from the same device from which the sample was obtained
* [[Sputum]] Gram staining - Gram negative rods
#Transport samples and process in a laboratory proficient at culturing water specimens for Legionella spp., as soon as possible after collection.
#Test samples for the presence of Legionella spp. by using semiselective culture media using procedures specific to the cultivation and detection of ''Legionella spp.''


==Diagnostic Studies==
===Healthcare-associated Sites of Specimen Collection===
====Potable water system====
*Incoming water main
*Water softener
*Holding tanks, cisterns
*Water heater tanks (at the inflows and outflows)
 
====Potable water outlets, especially those in or near patient rooms====
*Faucets or taps
*Showers
 
====Cooling tower, evaporative condenser====
*Makeup water (e.g., added to replace water lost because of evaporation, drift, leakage)
*Basin (i.e., area under the tower for collection of cooled water)
*Sump (i.e., section of basin from which cooled water returns to heat source)
*Heat sources (e.g., chillers)


* [[Urine]] [[antigen]] test - the urine antigen test is simple, quick, and very reliable; however it will only detect ''[[Legionella pneumophila]]'' serogroup #1. If the patient has [[pneumonia]] and the test is positive then the patient is considered to have Legionnaires’ disease. Also the urine antigen test will not identify the specific subtyping so it cannot be used to match the patient with the environmental source of infection. (sensitivity 70%, specificity 100%)
====Humidifiers ( e.g ., nebulizers)====
* Cultures - Expectorated sputum, endotracheal aspirates, pleural fluid, blood, or tissue samples may be sent for culture.  Unlike serology and urine antigen testing, the yield of cultures is independent of serotype and may be positive in cases of non-''Legionella pneumophila'' species. (sensitivity 80%, specificity 100%)
*Bubblers for oxygen
* [[Antibody]] test (paired sera) - compare [[antibody]] levels to ''[[Legionella]]'' in two blood samples obtained 3 to 6 weeks apart.  A 4-fold or greater rise in titer between acute and convalescent sera is diagnostic. (sensitivity 70-80%, specificity > 90%)
*Water used for respiratory therapy equipment


* Immunofluorescent microscopy with direct fluorescent antibody - detects Legionella in respiratory tract tissues or fluids (sensitivity 25-75%, specificity 95%)
====Other sources====
* [[Polymerase chain reaction|Polymerase chain reaction (PCR)]] - detects Legionella DNA in sputum, pleural fluid, [[bronchoalveolar lavage]] samples, pulmonary tissues, urine, or environmental water.
*Decorative fountains
*Irrigation equipment
*Fire sprinkler system (if recently used)
*Hot tubs


==References==
==References==
{{reflist|2}}
{{reflist|2}}


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Latest revision as of 18:09, 18 September 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Laboratory abnormalities in Legionnaires' disease include leukocytosis with relative lymphopenia, hyponatremia, hypophosphatemia, and elevated levels of AST/ALT, CPK, ESR, CRP, LDH, and ferritin. Urine antigen testing in the first-line diagnostic method. Culture of the lower respiratory secretion is the gold standard for the detection of Legionella and diagnosis of Legionnaires' disease.

Indications to Test for Legionnaires' Disease

According to the Centers for Disease Control and Prevention (CDC), the following are indications to test for Legionnaires' disease:

  • Patients who have failed outpatient antibiotic therapy
  • Patients with severe pneumonia, in particular those requiring intensive care
  • Immunocompromised host with pneumonia
  • Patients with pneumonia in the setting of a legionellosis outbreak
  • Patients with a travel history (Patients that have traveled away from their home within two weeks before the onset of illness).
  • Patients suspected of healthcare-associated pneumonia

Laboratory Findings

Laboratory findings of Legionnaires' disease include:[1]

Diagnostic Studies

Test Sensitivity (%) Specificity (%)
Culture 20-80 100
Urine antigen 70-100 100
Paired serology 80-90 >99
Direct fluorescent antibody stain 25-75 ≥95
PCR unknown unknown

Microscopy

Legionella pneumophila are small, Gram-negative coccobacilli which may be difficult to detect in specimens by Gram staining.[2] The organism can also be detected by immunofluorescent microscopy with the use of direct fluorescent antibody.

Urine Antigen Test

The detection of soluble antigens (a component of the cell wall lipopolysaccharide) in the urine is the first-line diagnostic technique. The method is most accurate for detecting Lp1 MAb 3/1 subtypes. Sensitivity ranges from 56–99% and is lower in nosocomial infection and immunocompromised hosts.[3] Urine antigen test may also be positive for Pontiac fever. IDSA/ATS guidelines recommend urinary antigen test for the following patients:[4]

  • Unresponsive to outpatient antibiotic therapy
  • Severe pneumonia especially requiring intensive care
  • Immunocompromised hosts
  • Alcoholism
  • Travelled within the past 2 week
  • Age > 50 years
  • In areas of an outbreak
  • Suspected healthcare-associated pneumonia

Polymerase Chain Reaction

Nucleic acid amplification-based methods can be used to identify mip gene of Legionella in sputum, serum, and urine. Sensitivities range from 80–100% for lower respiratory tract secretion, 30–80% for serum, and 0–90% for urine samples.[5][6]

Serology test

A 4-fold or greater rise in antibody titer between acute and convalescent sera may be diagnostic. However, seroconversion is not detectable until at least 3 weeks after infection and does not occur in up to a quarter of patients with culture-proven disease.[7]

Culture

Isolation of Legionella from respiratory secretions, lung tissue, pleural fluid, or a normally sterile site is still an important method for diagnosis, despite the convenience and specificity of urinary antigen testing. Investigations of outbreaks of Legionnaires' disease rely on both clinical and environmental isolates. Clinical and environmental isolates can be compared using monoclonal antibody and molecular techniques. Because Legionella are commonly found in the environment, clinical isolates are necessary to interpret the findings of an environmental investigation.

Culture of samples (e.g., expectorated sputum, endotracheal aspirates, pleural fluid, blood, or tissue) remains the gold standard for detecting Legionnaires' disease. Unlike serology and urine antigen testing, the yield of cultures is independent of serotype and may be positive in cases of non-Legionella pneumophila species. The culture of non-respiratory samples is warranted when suspecting extrapulmonary infection. Buffered charcoal-yeast extract (BCYE) medium supplemented with 0.1% α-ketoglutaric acid is required for isolation and growth of Legionella.[8]

CDC Recommendations for Specimen Collection

Environmental Specimen Collection

  1. Collect water (1-liter samples, if possible) in sterile, screw-top bottles.
  2. Collect culture swabs of internal surfaces of faucets, aerators, and shower heads in a sterile, screw-top container (e.g., 50 mL plastic centrifuge tube). Submerge each swab in approximately 5 mL of sample water taken from the same device from which the sample was obtained
  3. Transport samples and process in a laboratory proficient at culturing water specimens for Legionella spp., as soon as possible after collection.
  4. Test samples for the presence of Legionella spp. by using semiselective culture media using procedures specific to the cultivation and detection of Legionella spp.

Healthcare-associated Sites of Specimen Collection

Potable water system

  • Incoming water main
  • Water softener
  • Holding tanks, cisterns
  • Water heater tanks (at the inflows and outflows)

Potable water outlets, especially those in or near patient rooms

  • Faucets or taps
  • Showers

Cooling tower, evaporative condenser

  • Makeup water (e.g., added to replace water lost because of evaporation, drift, leakage)
  • Basin (i.e., area under the tower for collection of cooled water)
  • Sump (i.e., section of basin from which cooled water returns to heat source)
  • Heat sources (e.g., chillers)

Humidifiers ( e.g ., nebulizers)

  • Bubblers for oxygen
  • Water used for respiratory therapy equipment

Other sources

  • Decorative fountains
  • Irrigation equipment
  • Fire sprinkler system (if recently used)
  • Hot tubs

References

  1. ↑ Cunha, Burke A. (2010-03). "Legionnaires' disease: clinical differentiation from typical and other atypical pneumonias". Infectious Disease Clinics of North America. 24 (1): 73–105. doi:10.1016/j.idc.2009.10.014. ISSN 1557-9824. PMID 20171547. Check date values in: |date= (help)
  2. ↑ Versalovic, James (2011). Manual of clinical microbiology. Washington, DC: ASM Press. ISBN 978-1555814632.
  3. ↑ Helbig, Jürgen H.; Uldum, Søren A.; Bernander, Sverker; Lück, Paul Christian; Wewalka, Günther; Abraham, Bill; Gaia, Valeria; Harrison, Timothy G. (2003-02). "Clinical utility of urinary antigen detection for diagnosis of community-acquired, travel-associated, and nosocomial legionnaires' disease". Journal of Clinical Microbiology. 41 (2): 838–840. ISSN 0095-1137. PMC 149701. PMID 12574296. Check date values in: |date= (help)
  4. ↑ Mandell, Lionel A.; Wunderink, Richard G.; Anzueto, Antonio; Bartlett, John G.; Campbell, G. Douglas; Dean, Nathan C.; Dowell, Scott F.; File, Thomas M.; Musher, Daniel M.; Niederman, Michael S.; Torres, Antonio; Whitney, Cynthia G.; Infectious Diseases Society of America; American Thoracic Society (2007-03-01). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 44 Suppl 2: –27-72. doi:10.1086/511159. ISSN 1537-6591. PMID 17278083.
  5. ↑ Mentasti, M.; Fry, N. K.; Afshar, B.; Palepou-Foxley, C.; Naik, F. C.; Harrison, T. G. (2012-08). "Application of Legionella pneumophila-specific quantitative real-time PCR combined with direct amplification and sequence-based typing in the diagnosis and epidemiological investigation of Legionnaires' disease". European Journal of Clinical Microbiology & Infectious Diseases: Official Publication of the European Society of Clinical Microbiology. 31 (8): 2017–2028. doi:10.1007/s10096-011-1535-0. ISSN 1435-4373. PMID 22278293. Check date values in: |date= (help)
  6. ↑ Versalovic, James (2011). Manual of clinical microbiology. Washington, DC: ASM Press. ISBN 978-1555814632.
  7. ↑ Cunha, Burke A.; Burillo, Almudena; Bouza, Emilio (2015-07-28). "Legionnaires' disease". Lancet (London, England). doi:10.1016/S0140-6736(15)60078-2. ISSN 1474-547X. PMID 26231463.
  8. ↑ Cunha, Burke A.; Burillo, Almudena; Bouza, Emilio (2015-07-28). "Legionnaires' disease". Lancet (London, England). doi:10.1016/S0140-6736(15)60078-2. ISSN 1474-547X. PMID 26231463.
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