A 36-year-old healthy women presented with high fever, headache, and “not feeling well” two weeks after she had termination of pregnancy by dilatation and curettage procedure. She had minimal vaginal bleeding and denied vaginal discharge. She also vomited several times and had two bouts of diarrhea. She denied any significant coughing, sputum, or shortness of breath. On physical examination, she had a fever of 103.9° Fahrenheit with tachycardia and tachypnea. Her chest exam was normal, but she had mild tenderness in the right lower quadrant of her abdomen. No uterine cervical tenderness was noted. Laboratory tests revealed normal white cell count, mild hyponatremia, and mild elevation of liver enzymes. Urine analysis showed hematuria but no nitrites or leukocyte esterase. Empiric broad spectrum intravenous antibiotics were started and the patient was admitted to the gynecological service with a presumptive diagnosis of pelvic inflammatory disease (PID). Abdominal obstructive series and computed tomography (CT) scan of the abdomen and pelvis revealed no intra-abdominal or pelvic pathology but patchy left and right lower lobe densities and infiltrates were demonstrated in the lower lung fields that were included in the images. Chest CT scan was then ordered and showed small pleural effusions and almost complete consolidation of the left upper lobe. The left lower and right middle lobes were also involved but to a lesser extent. On the second day of hospitalization, the patient developed coughing and shortness of breath. Sputum for acid-fast bacilli, HIV test, urine for streptococcal antigen, and vaginal swab for Chlamydia and Neisseria were all negative. However, urine for Legionella antigen was positive. The patient was treated with levofloxacin, and four days later became afebrile with much clinical improvement.
Discussion:
Work up of fever is a common reason for hospital admission. In this case, the finding of multi-lobar lung involvement in an otherwise young healthy adult without remarkable pulmonary symptoms was unusual, as most patients with legionella pneumonia have a non-productive cough upon presentation with the high fever. This led to the initial diagnosis and work-up for PID, especially given the fact that she recently had dilatation and curettage procedure. Infection with Legionella can occur in immunocompetent individuals, even in the absence of known risk factors (e.g., smoking, diabetes, alcohol, or chronic illness). It should always be suspected in patients presenting with a fever and hyponatremia, elevated transaminases or hematuria. Urine for Legionella antigen will aid in this setting to make the diagnosis early and start targeted therapy.
Conclusions:
In adults, Legionnaires’ disease remains an important cause of fever and community-acquired pneumonia, with frequent extrapulmonary manifestations that might create confusion with other diagnoses and thus delaying appropriate management. A chest radiograph should always be considered in the initial work-up of fever in young, otherwise healthy adults, even in the absence of significant pulmonary symptoms. Delay in diagnosis and management of pneumonia in general can lead to well-known complications (e.g. respiratory failure) or untoward consequences, like prolonged hospital stay or ordering unnecessary tests.