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Risk factors for aspiration
11%
4/35
Recent travel to Arizona
9%
3/35
Exposure to incarcerated population
3%
1/35
Recent cruise travel
63%
22/35
Exposure to bird droppings
14%
5/35
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This patient presents with respiratory symptoms, gastrointestinal distress, and hyponatremia, which suggests a diagnosis of Legionella pneumonia. Legionella pneumonia is commonly caused by exposure to contaminated water supplies on cruise ships. Among the many causes of pneumonia, Legionella is notable for its particularly high fever (usually > 38.5°C) and associated symptoms of gastrointestinal distress and altered mental status. On laboratory testing, the most common electrolyte disturbance is hyponatremia, as is seen in this patient’s case and should be a clue to the diagnosis. Testing may also reveal transaminitis on liver function testing as well as hematuria and proteinuria on urine analysis. The appearance of Legionella pneumonia on chest radiograph can be variable, showing either lobar consolidation or interstitial infiltrates. The diagnosis is confirmed by urine antigen testing, and it is usually treated with a fluoroquinolone or macrolide antibiotic. Figure A demonstrates bilateral patchy consolidations with a lower lung zone predominance, which would be consistent with Legionella pneumonia. Incorrect Answers: Answer 1: Risk factors for aspiration include alcoholism or dysphagia and predispose patients to pulmonary infection with Klebsiella or mixed anaerobes. Aspiration pneumonia usually appears on chest radiograph as a unilateral lobar consolidation with a lower lung zone predominance due to the effects of gravity. It would not cause the associated symptoms and laboratory disturbances seen in this patient. Answer 2: Recent travel to Arizona would put a patient at risk of inhaling Coccidioides, an endemic mold of the southwestern United States. Coccidioides can cause a community-acquired pneumonia that may be accompanied by arthralgias or skin findings, but it usually does not cause the gastrointestinal distress or neurological findings present in this patient. Answer 3: Exposure to an incarcerated population is a risk factor for tuberculosis. Primary tuberculosis may present with night sweats but would not cause the hyponatremia seen in this patient. Answer 5: Exposure to bird droppings can cause Chlamydia psittaci (“parrot fever”), which presents with fever and dry cough. It would not cause the gastrointestinal complaints, neurologic disturbances, or laboratory findings found in this patient. Bullet Summary: Risk factors for Legionella pneumonia include recent travel on a cruise or in a hotel where the water has been contaminated by the bacteria.
4.7
(9)
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