Disseminated extrapulmonary Legionella pneumophila infection presenting with panniculitis: case report and literature review - PubMed


Maria N Chitasombat 1 ,

Article Images

Review

Disseminated extrapulmonary Legionella pneumophila infection presenting with panniculitis: case report and literature review

Maria N Chitasombat et al. BMC Infect Dis. .

Abstract

Background: Legionellosis is a well-known cause of pneumonia. Primary cutaneous and subcutaneous infection caused by Legionella pneumophila is rare and the diagnosis is challenging.

Case presentation: A 38-year-old Thai woman with systemic lupus erythematosus and myasthenia gravis treated with prednisolone and azathioprine presented to our hospital with low-grade fever, diarrhea, and indurated skin lesions on both thighs. Initial examination showed plaques on both inner thighs. Magnetic resonance imaging showed myositis and swelling of the skin and subcutaneous tissue. Diagnosis of panniculitis due to L. pneumophila was carried out by histopathology, Gram stain, and 16S rRNA gene sequencing method of tissue biopsy from multiple sites on both thighs. Myocarditis was diagnosed by echocardiography. The final diagnosis was disseminated extrapulmonary legionellosis. Treatment comprised intravenous azithromycin for 3 weeks and the skin lesions, myositis and myocarditis resolved. Oral azithromycin and ciprofloxacin were continued for 3 months to ensure eradication of the organism. The patient's overall condition improved.

Conclusions: To our knowledge, we report the first case of L. pneumophila infection manifesting with panniculitis, possible myositis, and myocarditis in the absence of pneumonia. The diagnosis of extrapulmonary Legionella infection is difficult, especially in the absence of pneumonia. A high index of suspicion and appropriate culture with special media or molecular testing are required. Initiation of appropriate treatment is critical because delaying therapy was associated with progressive infection in our patient.

Keywords: Legionella pneumophila; Lupus; Myocarditis; Myositis; Panniculitis.

PubMed Disclaimer

Conflict of interest statement

Ethics approval and consent to participate

This study was approved by the Committee on Human Rights Related to Research Involving Human Subjects, Faculty of Medicine Ramathibodi Hospital, Mahidol University.

Consent for publication

The patient gave written consent for publication of her potentially identifying information (including individual details and images).

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1

Multiple erythematous indurated plaques on the proximal right thigh, multiple healed crusted papules on the right lower extremity, and whitish striae (before treatment)

Fig. 2
Fig. 2

a. Coronal T2-weighted MRI of the thighs. b. Axial T2-weighted MRI of the thighs demonstrating enhancement of subcutaneous tissue and muscle. MRI, magnetic resonance imaging

Fig. 3
Fig. 3

Histopathology of subcutaneous tissue of right thigh. Photomicrograph revealed neutrophil infiltration in the deep dermis to subcutaneous tissue and fat necrosis (200×, hematoxylin and eosin)

Fig. 4
Fig. 4

Proximal right thigh showed resolution of indurated plaque after 8 days of treatment for Legionella, biopsy stiches, healed scar of varicella lesions, and whitish striae

Similar articles

Cited by

References

    1. Burke PT, Thabolingam R, Saba S. Suspected Legionella-induced Perimyocarditis in an adult in the absence of pneumonia: a rare clinical entity. Tex Heart Inst J. 2009;36(6):601–3. - PMC - PubMed
    1. Ishimaru Naoto, Suzuki Hiromichi, Tokuda Yasuharu, Takano Tomoko. Severe Legionnaires' Disease with Pneumonia and Biopsy-Confirmed Myocarditis Most Likely Caused by Legionella pneumophila Serogroup 6. Internal Medicine. 2012;51(22):3207–3212. doi: 10.2169/internalmedicine.51.7952. - DOI - PubMed
    1. Bodur H., Savran Y., Koca U., Kilinç O., Albayrak S., Itil O., Akoğlu S. Legionella pneumonia with acute respiratory distress syndrome, myocarditis and septic shock successfully treated with Drotrecogin Alpha (activated) European Journal of Anaesthesiology. 2006;23(9):808–810. doi: 10.1017/S0265021506221252. - DOI - PubMed
    1. Sommer JB, Erbguth FJ, Neundorfer B. Acute disseminated encephalomyelitis following Legionella pneumophila infection. Eur Neurol. 2000;44(3):182–4. - PubMed
    1. Padrnos LJ, Kusne S, DiCaudo DJ, Mikhael JR. Cutaneous legionellosis: case report and review of the medical literature. Transpl Infect Dis. 2014;16:307–14. doi: 10.1111/tid.12201. - DOI - PubMed

Publication types

MeSH terms