(Chest. 2000;117:398-403.)
© 2000
American College of Chest Physicians
The Radiologic Manifestations of Legionnaire’s Disease*
Michael J. Tan, MD;
James S. Tan, MD, FCCP;
Robert H. Hamor, MD;
Thomas M. File, Jr., MD, FCCP;
Robert F. Breiman, MD and
and
the Ohio Community-Based Pneumonia Incidence Study Group
*
From the Departments of Internal Medicine (Drs. Tan, Tan, and File) and Radiology (Dr. Hamor), Summa Health System, Akron, OH; and the Centers for Disease Control and Prevention (Dr. Breiman), Atlanta, GA. Part of this study was supported by a grant from the Centers for Disease Control and Prevention.
Correspondence to: James S. Tan, MD, 75 Arch St, Suite 105, Akron, OH 44304; e-mail: tanj{at}summa-health.org
 |
Abstract
|
|---|
Study objectives: To study the serial radiographic
manifestations of Legionnaire’s disease from the initial presentation
on admission to recovery using strict criteria for the diagnosis of
infection.
Materials and methods: We prospectively
studied the chest radiographs of patients hospitalized with a diagnosis
of community-acquired pneumonia in Summit County, Ohio between November
1990 and November 1992. Forty-three patients fulfilled strict criteria
for legionellosis. The diagnosis of infection was based on the criteria
of "definite" diagnosis as defined by the Ohio Community-Based
Pneumonia Incidence Study Group report. The criteria included the
isolation of the microorganism, the presence of a significant antibody
rise, or the presence of Legionella antigen in the urine.
Results: Forty of 43 patients had admission radiographs
interpreted as compatible with pneumonia. In spite of appropriate
antimicrobial therapy, worsening of the infiltrates was found in more
than half of the patients within the first week. Twenty-seven patients
were observed to have pleural effusion during the course of
hospitalization: 10 effusions were found on admission, another 14
developed during the first week, and 3 new effusions were discovered
after the first week. Cavitation was found in only one patient. None of
the patients had apical involvement.
Conclusion: This
study confirms previous reports using less stringent etiologic
diagnosis criteria that chest radiographic findings in Legionnaire’s
disease are not specific. Even with appropriate therapy, more than half
of the patients will have worsening of the infiltrates during the first
week. Pleural effusion is common among our patients, and it is
frequently detected during the serial radiographic studies during the
first week of hospitalization. Chest radiography in Legionnaire’s
disease is useful only for the monitoring of disease progression and
not for diagnostic purposes. In addition, worsening of infiltrates and
pleural effusion are seen in more than half of the patients in spite of
appropriate therapy and clinical improvement.
Key Words: Legionnaire’s disease • Legionella • legionellosis • pleural effusion • pneumonia • radiography
|
Introduction
|
|---|
Legionnaire’s
disease is a febrile illness with pneumonia caused by Legionella spp.
This illness presents both in outbreaks and sporadic
situations.1
2
This microorganism is responsible for 1 to
5% of community-acquired pneumonias requiring
hospitalization.3
4
5
6
The report from the Ohio
Community-Based Pneumonia Incidence Study Group projected that the
annual cases in a noninstitutionalized population range from 10,800 to
18,000 in the United States.6
There are > 40 different Legionella spp, with Legionella
pneumophila accounting for 90% of legionellosis.7
Among the 14 serogroups of L pneumophila, L
pneumophila serogroup 1 (Lp1) is responsible for 80% of
reported cases.7
Positive confirmation of Legionella
infection has been traditionally based on the culture of sputum, paired
serologic tests based on rising antibody titers, and antigen detection
techniques such as urinary antigen or direct fluorescent antibody.
Plouffe et al8
reported that a single acute antibody
titer 
1:256 had a low positive predictive value (15%) for acute
legionellosis.
Legionnaire’s disease is often classified as an "atypical
pneumonia" based on the dogma that chest radiographic findings are
neither lobar nor consolidating, as in the classic pyogenic pneumonias.
We report our experience with serial chest radiographs in patients with
a diagnosis of Legionnaire’s disease using stringent laboratory
criteria to demonstrate the course of radiologic findings.
|
Materials and Methods
|
|---|
Patient Population:
Summit County, Ohio residents who were
18 years old, who were not residents of institutions (nursing
homes, long-term care facilities, or prisons), and who were admitted to
Summa Health System (Akron City Hospital and St. Thomas Hospital),
Akron General Medical Center, Cuyahoga Falls Medical Center, and
Barberton Citizens Hospital with a diagnosis of community-acquired
pneumonia were included as part of a prospective study of Ohio
Community-Based Pneumonia Incidence Study Group.6
Between
November 1990 and November 1992, 2,750 patients were admitted with a
confirmed diagnosis of community-acquired pneumonia. Serial chest
radiographs were obtained on patients admitted with the diagnosis.
These radiographs were read by a staff radiologist at each of the
participating hospitals in addition to being reviewed by the authors,
including a radiologist (RHH). Forty-three patients fulfilled the
criteria for definite diagnosis of Legionnaire’s disease. Two patients
did not have a follow-up chest radiograph after admission.
Criteria for Diagnosis:
The diagnosis of Legionnaire’s
disease was based on criteria defined by Marston et al6
as
a "definite" diagnosis: the isolation of Legionella from
respiratory secretions, the presence of urine Lp1 antigens at a ratio
3 of sample-to-control, or a fourfold rise in antibody attaining
1:128 in paired acute and convalescent phase sera. Sputum samples were
stored at 4°C prior to culture for Legionella and were cultured at
the microbiology laboratory of Summa Health System using a standard
technique.9
Sera from patients with pneumonia were stored
at - 20°C and were tested at the Centers for Disease Control and
Prevention for antibodies to L pneumophila antigens by
indirect immunofluorescent antibody assay.10
Urine samples
were stored at 4°C at the Ohio State University laboratory and were
tested for the Lp1 antigen at Ohio State University Medical Center
using radioimmunoassay (Binax; South Portland, ME).11
|
Results
|
|---|
Forty-three patients fulfilled the criteria for a definite
diagnosis of Legionnaire’s disease. Thirty-two patients fulfilled the
fourfold antibody rise criterion. Among these 32 patients, 13 also had
a positive urine Lp1 antigen and 9 had a positive culture for
Legionella from respiratory secretions. Among 18 patients with a
positive urine Lp1 antigen test, 13 had fourfold antibody rise and 3
had a positive culture. Two remaining patients with positive urine Lp1
antigen did not have an antibody rise or a positive culture. Legionella
was isolated from nine patients, three of whom had a concomitant
fourfold antibody rise and the presence of urine Lp1 antigen. Table 1
shows the demographic distribution. All of these patients received at
least one antimicrobial agent with activity against Legionella during
the hospitalization.
Initial Radiographic Presentation
Among the 43 patients included in the study, 40 patients had
positive findings (infiltrates) on the initial chest radiograph (Table 2 ). The infiltrates of 33 were patchy (76.7%), 7 were confluent or lobar
in character (16.3%), and 3 were interpreted as having no acute
pneumonic infiltrate (7%). One was interpreted as pleural effusion (by
day 3, the chest radiograph showed confluent infiltrates with a
cavity); the second was interpreted as "changes compatible with
chronic lung disease" (this patient later had both a positive
Legionella culture and a positive urinary Lp1 antigen); and the third
was interpreted as compatible with congestive heart failure and was
later interpreted as inflammatory infiltrate. Twenty-six infiltrates
were unilobar, 12 were multilobar, and 7 were bilateral in
distribution. Thirty-two patients had infiltrates involved the lower
lung fields. The right upper lobe infiltrates were found in 11
patients, whereas 5 patients had left upper lobe involvement (lingula
involvement excluded). One patient had perihilar infiltrate with
sparing of the periphery. He died on day 10. None of the patients had
apical involvement. Ten patients presented with pleural effusion on
admission.
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Table 2.. Admission and Serial Chest Radiographic Findings of
Patients With Confirmed Diagnosis of Legionnaire’s Disease*
|
|
Radiographic Findings From Days 1 and 2
Sixteen patients had follow-up chest radiograph studies during
days 1 and 2 of hospitalization. Eight patients had minimal or no
change, two progressed from patchy to unilateral confluent infiltrates,
three had progression of patchy infiltrates unilaterally, and none who
had unilateral disease had contralateral progression. Six patients who
had no pleural effusion on admission had an effusion on day 2: one
bilateral effusion, two left-sided effusions, and three right-sided
effusions, including one with a bulging fissure. Three patients with
new effusion did not have increasing pulmonary infiltrates.
Radiographic Findings From Days 3 to 6
Twenty-six patients had chest radiography between days 3 and 6 of
hospitalization (Fig 1
). We were not able to show any correlation between the worsening of
radiologic findings and the clinical course. Ten patients had minimal
or no change, 1 had reduction of infiltrate size, and 15 showed
worsening (1 developed confluent infiltrates and 11 had progression of
infiltrates unilaterally to other lobes, 5 of which involved the
contralateral lung). One patient who had small bilateral pleural
effusion on admission improved to undetectable on day 3; eight patients
had new pleural effusion during this time: four patients on day 3,
three patients on day 4, and one patient on day 5. Three effusions were
on the right, one was on the left, and three were bilateral. A patient
with bilateral effusion started with the right-sided bulging fissure on
day 2.
Radiographic Findings From Day 7 and Later
Twenty-seven patients had follow-up chest radiography after day 6.
Only one patient had increased infiltrates, which most likely were due
to superinfection. Four patients were observed to have new effusion.
Pleural Effusion
Twenty-seven (62.8%) had pleural effusion. Figure 2
shows the number of patients with pleural effusion detected by chest
radiography. On admission, only 10 patients had detectable pleural
effusion (7 on the left, 1 on the right, and 2 bilateral). An
additional 17 patients developed effusion during hospitalization. Six
more patients had pleural effusion detected on day 2. Eleven more
patients developed pleural effusion subsequently. Five patients had
bilateral effusion, 11 had effusion on the left side, and 11 had
effusion on the right side. Most effusions were small and were detected
based on the blunting of the costophrenic angle.
Other Findings
Cavitation and pulmonary infiltrates were found on day 3 in a
70-year-old woman who had pleural effusion but no infiltrates on
admission. This patient had no known immunosuppressive disease or
medication. By day 7, the cavitation was smaller; by day 10, it had
completely resolved. Perihilar infiltrate was observed in one patient.
Hilar and mediastinal lymphadenopathy were not observed.
Course of Illness and Correlation With Anti-Legionella Antibiotic
Treatment
Among 37 patients with serial radiographs beyond day 2, 24
patients had worsening of radiologic findings during the first week.
Radiologic improvement was observed most commonly after 6 days. Three
patients showed improvement after > 10 days. Five patients had no
significant change from the admission radiograph by day 14. The
radiographic changes lagged behind clinical improvement and were not
related to the antimicrobial agent used. All but six patients received
antimicrobial agents with anti-Legionella activity. Three patients who
were treated with ß-lactam alone had resolution of infiltrates within
the first week. The other three patients treated with ß-lactam alone
showed resolution after the first week. None of the six patients died.
One patient received anti-Legionella agent on day 3; this patient on
admission had a small left pleural effusion but had no pulmonary
infiltrate. Cavity with air fluid was detected on day 3. Follow-up on
day 7 showed that the cavity had decreased in size, and on day 10 the
cavity was not seen on radiograph.
Deaths
Two patients died during the follow-up. One patient had
progressive worsening of pulmonary infiltrates on day 4 with
involvement of the perihilar area. This patient died on day 10. Another
patient died on day 39 with the diagnosis of congestive heart failure.
The chest radiograph findings of this patient were consistent with the
diagnosis of heart failure.
|
Discussion
|
|---|
This report is a prospective study on the chest radiographic
findings of community-acquired Legionnaire’s disease proven by strict
diagnostic criteria. The initial presenting chest radiographic findings
among our patients reviewed are comparable to those reported in earlier
studies that were retrospective and based on less stringent
criteria.12
13
Eighty-six percent of our patients
presented with patchy infiltrates, and more than two thirds of these
patients had unilobar involvement. Figure 3
shows the chest radiograph of a patient with right upper lobe
consolidation. This observation is comparable to that of Kroboth et
al,14
who noted that 76% of 34 patients had initial
patchy alveolar infiltrates and more than three fourths of their
patients had a single lobe disease at presentation. Three of our
patients did not have active pulmonary infiltrate on admission;
however, the nonspecific findings may have represented an earlier
pneumonia. The lack of active pulmonary findings during the early phase
of illness is not unique. Kirby et al,15
in their report
of 35 patients, noted that 3 patients had no infiltrates on admission.
Both Kirby et al,15
in their study of Legionella infection
in California, and Pedro-Botet et al,16
in their study of
immunosuppressed hosts in Barcelona, Spain, reported that 71% of their
patients had unilobar patchy infiltrates. Dietrich et al17
noted that 68% of patients had unilateral left lung infiltrates
initially, whereas the Barcelona study16
found that 73%
of their patients presented with unilateral distribution. Pleural
effusion was noted in 62.8% of our patients, compared to 35 to 63% as
reviewed by Kroboth et al.14
Bulging fissure sign, as
described in a single case report by Lucas et al,18
was
noted in one of our patients.
In most cases, in spite of clinical improvement, chest radiographic
findings continued to worsen between days 2 and 6 in the form of
increasing consolidation of the same lobe, involvement of a contiguous
lobe or ipsilateral noncontiguous lobe, infiltration of the
contralateral lung, and development of pleural effusion. Lower lobe
involvement was more common in our study. Sixty-seven percent of our
patients had lower lobe involvement, compared to 79% reported by
Kroboth et al14
and 92% in the study of Storch et
al.19
Cavitation is found rarely in immunocompetent
hosts,2
20
21
22
23
24
25
26
and it was noted in only one of our
patients. Cavitation and air fluid level improved rapidly after
therapy. Fairbank et al22
estimated that cavitation is
found in 4.3% of patients with the disease. Storch et
al19
reported a patient with cavity formation that on
biopsy showed signs of a necrotizing pneumonia. Perihilar involvement
or mediastinal node involvement was not reported in many of the large
studies.14
15
17
27
28
As a rule, perihilar involvement is
not commonly reported. Perihilar involvement was observed in one of our
patients on day 4 of hospitalization. He died on day 10 due to the
infection. Storch et al19
reported 1 of their 17 patients
with hilar lymphadenopathy. The diagnosis was based on a fourfold
antibody rise using indirect fluorescent antibody titer. Cavitation is
uncommon among immunocompetent hosts. However, among the
immunocompromised host, cavitation is fairly common.29
30
31
32
33
34
Perihilar infiltrates have been reported but are rarely encountered.
Our only patient with hilar infiltrate died of progressive pneumonia.
Apical involvement was not observed among our patients and was rarely
observed in other reports. Pleural effusion may be found on admission.
Many patients developed effusion during the first week of
hospitalization. Figure 4
shows an example of the delayed progression of pleural effusion. The
development of new effusion after the first week is uncommon.
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|
Figure 4.. Chest radiographs of a patient showing the delay
in progression of pleural effusion in relationship to lung infiltrates.
Top: The admission radiograph showing left upper lobe
infiltrates and pleural effusion. Bottom: A week later,
the infiltrates resolved but pleural effusion increased.
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Conclusion
|
|---|
We report our prospective study of chest radiographic findings in
patients with laboratory-proven Legionnaire’s disease. Our study
showed that three fourths of our patients with Legionnaire’s disease
had patchy pneumonic infiltrates. Lobar distribution was observed in
the minority of the patients. Only 16% of patients had lobar
distribution of infiltrate on admission, and this increased to 28%
after hospitalization. Pleural effusion, usually small, was found in
about 23% of the patients on admission and increased to 63% of the
patients during the hospitalization. Despite radiographic
deterioration, most patients improved clinically. Although it has been
suggested that radiographic findings may be helpful in differentiating
Legionnaire’s disease from other forms of pneumonia,35
reports from many investigators, including the present study, did not
support this contention.14
15
17
27
28
When pneumonia is
suspected, we recommend that chest radiography be obtained to confirm
the presence of pneumonia and effusion but not to guide antimicrobial
therapy. Consequently, in immunocompetent hosts, antimicrobial therapy
should be directed to treat the common etiologic agents, namely,
Streptococcus pneumoniae, Haemophilus influenzae,
Moraxella catarrhalis, L pneumophila,
Mycoplasma pneumoniae, and Chlamydia pneumoniae.
Among immunocompromised hosts, every effort should be made to identify
the infecting agent. Chest radiographs are clinically useful to confirm
the diagnosis of pneumonia and to monitor the disease progression.
|
Footnotes
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|---|
Abbreviations:
Lp1 = Legionella pneumophila serogroup 1
Received for publication April 15, 1999.
Accepted for publication August 9, 1999.
|
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TOP
Abstract
Introduction
