Case Presentation: A 56 year-old man with schizoaffective and antisocial personality disorders was admitted from the county jail witha 4-day history of fever, hemoptysis, severe headaches, hematuria, diffuse myalgias,and bloody diarrhea. Officers reported the patient frequently flooded his cell and ingested toilet water. A CXR revealed L>R bibasilar infiltrates, and a diagnosis of Legionellapneumonia was made based on positive urinary antigen. While the patient’s pneumonia improved on IV levofloxacin, his creatinine continued to worsen. CK was not initially checked, as the patient initially presented with gross hematuria and positive red blood cells onurine microscopy. However CK returned markedly elevated at >12,000on day 3 and the diagnosis of rhabdomyolysis was made. The patient was started on IV fluids, but creatinine continued to rise, and nephrology was consulted. The patient underwent extensive workup for immune mediated disease, which returned negative. A renal biopsy was ultimately performed, which revealed diffuse necrotizing crescenteric IgA glomerulonephritis. The patient was started on pulse dose methylprednisolone followed by cyclophosphamide and was ultimately discharged to complete a 21-day course of levofloxacin along with tapering doses of steroids. Outpatient nephrology follow-up was arranged for monthly cyclophosphamide infusions. Repeat creatinine values one month after discharge show improvement to 1.72 from peak of 2.87 during his index admission.
Discussion: This case illustrates the known but rare association of Legionnaires’ disease with rhabdomyolysis. Furthermore, it highlights the established correlation of Legionnaire’s disease, renal failure, and rhabdomyolysis. Early recognition of this triad can prompt swift initiation of treatment, which may serve to reduce mortality in affected patients. IgA glomerulonephritis can be seen following upper respiratory tract infections, but the presence of crescents on biopsy is predictive of a rapidly progressive glomerulonephritis and must be treated aggressively to minimize reduction of renal function and progression to ESRD.
Conclusions: Legionnaire’s disease is an often complicated condition with associations with extrapulmonary complications including rhabdomyolysis, renal failure and rarely necrotizing necrotizing crescenteric IgA glomerulonephritis, which requires prompt recognition and treatment to preserve renal function.