Legionellosis in Children

LegionellosisRecently we discussed Urinary Retention in Kids and highlighted how this is not a condition that only affects adults and the elderly. Obviously, there are numerous examples of conditions typically segregated in our medical school texts as affecting only adults that, in fact, are important for us to consider in children as well (ex, PID, PancreatitisCholelithiasis – interesting aside, one of my PEM fellows, Dr. Mary Grady, actually diagnosed Choledocholithasis in kid 2 weeks ago). When someone says “Legionella,” I’ll be honest, I typically imagine an elderly person developing pneumonia after swimming at the local American Legion… but, I am now adjusting my perception. Let’s review Legionellosis in Children:

 

Legionellosis

  • Legionellosis incidence has been increasing steadily since 2000. [cdc.gov]
    • Likely underestimated in children. [Yu, 2010]
  • Legionellosis = multi-system illness caused by Legionella pneumophila
    • Legionella pneumophila – named after outbreak in 1976 at an American Legion convention.
    • Infection occurs after inhalation of aerosolized water or from aspiration of water.
    • Outbreaks associated with contaminated water often found in:
      • Natural water sources
      • Cooling towers
      • Hot tubs and other human-made water systems
      • Medical equipment (yup… nosocomial transmission is important) [Campins, 2000]
  • Legionellosis can present as two distinct illnesses:
    • Pontiac Fever (www.cdc.gov)
      • Mild febrile, influenza-like illness
      • No pneumonia.
    • Legionnaires’ Disease (www.cdc.gov)
      • More severe than Pontiac Fever
      • Fever, cough, respiratory distress
      • Gastrointestinal symptoms
      • Neurologic symptoms
      • Respiratory failure occurs in ~10% of all cases.

 

Legionellosis in Children

  • Legionellosis in children is rare, but likely under-reported. [Yu, 2010]
  • Features typically are of non-specific respiratory illness
    • Fever, cough, tachypnea [Greenberg, 2006]
    • There is no exam finding that clearly distinguishes Legionella infection from other causes of pneumonia [Greenberg, 2006]
  • 46% of cases were community-acquired…
    • Which means most were hospital acquired. [Yu, 2010; Greenberg, 2006]
    • Legionella pneumophila can survive in plumbing for a long time.
  • Immunocompromised children were the most commonly affected. [Greenberg, 2006; Campins, 2000]
    • Mortality was 33% higher in immunocompromised patients.
    • Children < 1 year of age were also at high risk of mortality.
    • Neonates who have been exposed are at high risk. [Shachor-Meyouhas, 2010]

 

Legionellosis: Management

  • Should maintain a high clinical suspicion in:[Yu, 2010; cdc.gov]
    • Patients with history of exposure or travel
      • Some electronic medical records have “pop-up” alerts to indicate whether a patient may have previously been exposed to hazardous water sources.
    • Patients who develop pneumonia after admission to the hospital (>47 hrs from admission) are at risk for possible nosocomial legionellosis.
    • Immunocompromised patients (and neonates) with pneumonia.
    • Not improving when on 1st line therapies for pneumonia.
    • Patients with severe pneumonia requiring intensive care.
      • Patients with lung abscesses [Leruste, 2017]
  • Make the diagnosis by: [cdc.gov]
    • Sending sputum sample (lower respiratory tract sample) on buffered charcoal yeast extract media for culture AND
    • Sending urine for Legionella antigen.
    • Serology is not helpful.
  • Treat with: [cdc.gov]
    • Macrolides or respiratory fluoroquinolones
    • Azithromycin is 1st line therapy in children.
    • Levofloxacin may be required for immunosuppressed patients.
    • Doxycylcine, and Trimethoprom-Sulfamethoxazole are alternatives.
  • Report it:
    • Legionellosis is a reportable disease.
    • Reporting to the local or state health departments can help with identification of source and prevention of large outbreaks.
    • Click HERE for the CDC’s Case Report Form

 

Moral of the Morsel:

  • Bacteria don’t ask to see your ID. It might be more common for adults to encounter the legionella bacterium, but it can affect kids too.
  • Being rare makes it more dangerous! Stay Vigilant!
  • Don’t ignore the Pop-up! (even though you want to) If the patient has pneumonia and the electronic medical record has an alert that the patient may have encountered a potential infected source, pay attention and cover that base.
  • Don’t give everyone Azithromycin! Ok, let’s be reasonable, Legionellosis is rare in children, so don’t start using Azithromycin on every child with pneumonia. Penicillin is still the correct answer for the vast majority of them.

 

References

Leruste A1, Rambaud J2, Picard C3, Jarraud S4, Ferroni A5, Lawrence C6, Renolleau S1. Successful pediatric ECMO in a rare case of septic shock due to a community-acquired Legionella infection. Med Mal Infect. 2017 Feb;47(1):68-70. PMID: 27810124. [PubMed] [Read by QxMD]
Shachor-Meyouhas Y1, Kassis I, Bamberger E, Nativ T, Sprecher H, Levy I, Srugo I. Fatal hospital-acquired Legionella pneumonia in a neonate. Pediatr Infect Dis J. 2010 Mar;29(3):280-1. PMID: 19934790. [PubMed] [Read by QxMD]

Greenberg D1, Chiou CC, Famigilleti R, Lee TC, Yu VL. Problem pathogens: paediatric legionellosis–implications for improved diagnosis. Lancet Infect Dis. 2006 Aug;6(8):529-35. PMID: 16870531. [PubMed] [Read by QxMD]

Campins M1, Ferrer A, Callís L, Pelaz C, Cortés PJ, Pinart N, Vaqué J. Nosocomial Legionnaire’s disease in a children’s hospital. Pediatr Infect Dis J. 2000 Mar;19(3):228-34. PMID: 10749465. [PubMed] [Read by QxMD]

Nigro G, Pastoris MC, Fantasia MM, Midulla M. Acute cerebellar ataxia in pediatric legionellosis. Pediatrics. 1983 Dec;72(6):847-9. PMID: 6646929. [PubMed] [Read by QxMD]

Sturm R, Staneck JL, Myers JP, Wilkinson HW, Cottrill CM, Towbin RB. Pediatric Legionnaires’ disease: diagnosis by direct immunofluorescent staining of sputum. Pediatrics. 1981 Oct;68(4):539-43. PMID: 6459562. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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2 Responses

  1. Lisa Patterson says:

    I live in Florida and there was recently an outbreak linked to the hot tub in one of our communities!

  2. Health_Kenya says:

    Avoiding smoking is the single most important thing you can do to lower your risk of infection. Smoking increases the chances that you’ll develop legionnaires’ disease if you’re exposed to legionella bacteria.

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