LEGIONNARES HANDOUT Legionnaries’ Disease

July,1976 outbreak of a "mystery disease“ sickened 221 persons, causing 34 deaths.

The outbreak was first noticed among people attending a convention of the American Legion

– a congressionally chartered association of U.S. military veterans The convention occurred in Philadelphia during the U.S. Bicentennial year Legonella Introduction

Legionella and Disease

Had been studied for decades before advances in technology and epidemiology allowed proper classification in disease and cause. (1,2)

Known Pneumonic epidemics of Legonella infections Are now recognized occurred 1950’s, 1960’s “Pontiac fever” 1970’s

Edelstein PH, Cianciotto NP. Legonella. Principles and Practice of Infectious Disease Mandell, Douglas and Bennett. Elsevier 2005.pg 2711-2724 Pontiac Michigan 1968 Legionella Pontiac Fever 1968

Explosive epidemic of acute febrile illness occurred at a County Health Department facility in Pontiac, Michigan Illness characterized v Fever, v Myalgia v Headache v Malaise JULY 1968 144 cases 95 of 100 persons employed in the health department building v Mean incubation period : ~ 36 hours v Illness was self-limited v Generally lasting from 2 – 5 days v Secondary cases did not occur in family contacts v Second attacks did not consistently follow re-exposure in the building

Pontiac Fever Legionnaires' disease Short Incubation YES (6 - 48hr) NO (2 -10 days) FACTOID High Attack rate YES NO Severe disease NO NO Chest X-ray Negative / Atypical Typical / Atypical Causative Known Species v Legionella pneumophila v Legionella micdadei Bacteriology* v Legionella longbeachae v Legionella anisa v Legionella feeleii

*"Epidemiology and clinical management of Legionnaires' disease". The Lancet Infectious Diseases. 14 (10): 1011–1021. doi:10.1016/S1473-3099(14)70713-3. Legionella Pontiac Fever 1968 Disease Ecology

• A leak in the building's air duct that allowed water from the evaporative condensing system to enter the circulating air was found to have resulted in the epidemic. • Temporary cessation of air conditioning removed the risk of disease, whereas turning the system back on caused disease Legionella Pontiac Fever 1968 Causative Agent Identified

Nine years after the Pontiac Fever epidemic Legionella pneumophila serogroup 1 Cultured from 40%–60% of the frozen lungs 1977 of building-exposed, and aerosol-challenged guinea pigs

Stored Human Serum specimens* 37 patients with Pontiac fever who had the most characteristic illnesses were tested for antibody to the guinea pig isolate 84% patients had elevated antibody levels to the bacterium. (Control group of 10 unexposed people: NEGATIVE Antibodies)

* Direct fluorescent antibody (DFA) staining and serology are available but are generally not used in clinical practice. DFA staining has poor sensitivity and cross reacts with other respiratory pathogens. Serology requires collection of acute and convalescent samples spaced four weeks apart, which is clinically impractical. Serology is thus primarily used for retrospective diagnosis in epidemiologic investigations.

- Paul H. Edelstein. Urine Antigen Tests Positive for Pontiac Fever: Implications for Diagnosis and Pathogenesis Clinical Infectious Diseases, Volume 44, Issue 2, 15 January 2007, Pages 229–231, https://doi.org/10.1086/510394 - Kaufmann AF, McDade JE, Patton CM, et al. Pontiac fever: isolation of the etiologic agent (Legionella pneumophila) and demonstration of its mode of transmission, Am J Epidemiol , 1981, vol. 114 (pg. 337-47) Legionella Pontiac Fever Diagnosis: Definition

There is no agreed-upon definition of Pontiac fever. Epidemiologic CONSIDERATION v Short incubation period v Short-duration Diagnosis v Non-fatal • Epidemiologic v Non-pneumonic illness • Clinical presentation • Clinical laboratory Characterized: v Malaise • Environmental v Myalgia microbiology findings v Fever Legionella Pontiac Fever Diagnosis: Conformation: Laboratory

Pontiac Fever v Fever and muscle aches v Milder infection than Legionnaires’ disease (Pneumonia) v Symptoms begin between a few hours to 3 days after being exposed to the bacteria v Symptoms usually last less than a week

Pontiac Fever Laboratory Confirm /support v Urine Antigen v Paired serum antibodies

Negative test does not rule out diagnosis in the setting of other laboratiory-confirmred Legionellosis cases Culture isolation cannot be used to diagnose Pontiac fever Legonella Pontiac Fever Vs. Legionnaires’ Disease Urinary antigen testing

Urine Legionella antigen testing Commonly used “alternative” test for Legionnaires' disease (PCR, Culture) Sensitivity 70-80% Specificity ~100% (Disease caused by L. pneumophila serotype 1) Legionella antigens can be detected in urine as early as one day after symptom onset and persist for days to weeks Disadvantage Detects L. pneumophila serotype 1 v L. pneumophila > 80% (most regions of the world) v L. longbeachae et al is common in some regions

-David Murdoch, Stephen T Chambers, Patricia Priest, et al. Clinical manifestations and diagnosis of Legionella infection. UpToDate® June 2018

-Peci A, Winter AL, Gubbay JB Evaluation and Comparison of Multiple Test Methods, Including Real-time PCR, for Legionella Detection in Clinical Specimens. Front Public Health. 2016; 4:175. Epub 2016 Aug 31.

-Diederen BM. Legionella spp. and Legionnaires' disease.J Infect. 2008;56(1):1. Epub 2007 Nov 5. -Shimada T, Noguchi Y, Jackson JL, Miyashita J, et al. Systematic review and metaanalysis: urinary antigen tests for Legionellosis. Chest. 2009;136(6):1576. Epub 2009 Mar 24 Legionella Pontiac Fever Summary

SUMMARY Pontiac Fever

An acute, non-fatal respiratory disease various species of Gram-negative bacteria in the genus Legionella. mild upper respiratory infection that resembles acute influenza.

Pontiac fever resolves spontaneously and often goes undiagnosed. Both Pontiac fever and the more severe Legionnaire's disease are caused by the same bacteria, However, Pontiac fever does not include pneumonia Legonella Pontiac Fever Vs. Legionnaires’ Disease Is Pontiac Fever an Infection?

Is Pontiac Fever an Infection? v Very short incubation period Too brief to allow high-grade bacterial multiplication in the lung or elsewhere Factoid v Absence of pneumonia:

v Short duration of illness:

v Re-challenge: v Recurrent milder illness

v Antibiotics?: v Recovery without antibiotic treatment

Environmental Bacterial Inhalation or an allergic reaction to inhaled live or dead bacteria, with the Endotoxin exposure? inciting bacteria being either Legionella species or coexisting flora

Paul H. Edelstein Urine Antigen Tests Positive for Pontiac Fever: Implications for Diagnosis and Pathogenesis Clinical Infectious Diseases, Volume 44, Issue 2, 15 January 2007, Pages 229–231, Glick TH, Gregg MB, Berman B, et al. Pontiac fever: an epidemic of unknown etiology in a health department. I. Clinical and epidemiologic aspects, Am J Epidemiol , 1978, vol. 107(pg. 149-60) Kaufmann AF, McDade JE, Patton CM, et al. Pontiac fever: isolation of the etiologic agent (Legionella pneumophila) and demonstration of its mode of transmission, Am J Epidemiol , 1981, vol. 114 (pg. 337-47 Legionnaires' disease

Algonac, Michigan

The American Legion chartered and incorporated by Congress in 1919 as a patriotic Veterans organization devoted to mutual helpfulness. v U.S. war Veterans organization headquartered in Indianapolis, Indiana. v Made up of State, U.S. territory, and overseas departments, and these are in turn made up of local posts. v The nation’s largest wartime veterans service organization, committed to mentoring youth and sponsorship of wholesome programs in our communities, v Advocating patriotism and honor, promoting strong national security, and continued

devotion to our fellow servicemembers and veterans. The American Legion https://www.legion.org/mission The 58th annual convention of the American Legion, Department of Pennsylvania, was held in Philadelphia July 21–24, 1976 July 21-24 1976,

July 21, 1976, the American Legion opened its annual three- day convention at the Bellevue-Stratford Hotel in Philadelphia

• >2,000 Legionnaires, mostly men, attended the convention

• July 27: three days after the convention ended, • Legionnaire Ray Brennan, 61-year-old retired US Air Force captain and an American Legion bookkeeper, died at his home of an apparent heart attack. • July 30: Legionnaire, Frank Aveni, 60, died of an apparent heart attack, • As did 3 other Legionnaires. All of them had been convention attendees.

• August 1: 6 more Legionnaires died. (Ages from 39 – 82)

• All had complained of tiredness, chest pains, lung congestion, and fever • Within a week, more than 130 people, mostly men, had been hospitalized, and 25 had died.

Bellevue-Stratford Hotel in Philadelphia Constructed in 1904 by 1976, had been extensively modified and renovated since. Hotel guests were housed in ~700 rooms 2nd -16th floors. The air-conditioning system consisted of two water chillers in the subbasement from which chilled water was circulated to ~ 60 air-handling units in the building. Legionella Legionnaires' Disease Philadelphia 1976 Case Definition

A case was considered Legionnaires' disease if it met clinical and Epidemiologic criteria Epidemiologic criteria v Attended the American Legion Convention held July 21–24, 1976, in Philadelphia v Had entered Philadelphia Bellevue-Stratford Hotel between July 1 and the onset of the illness Illness onset: TIME FRAME EXAMINED: Between: July 1 - August18,1976, o Clinical Illness v Characterized by cough and fever ( >38.9°C :102.2 F) v Any fever and Chest X-ray evidence of Pneumonia Serology Indirect Fluorescent –antibody: v X 4 fold rise to >164 v Presenting titer : 1:128

Fraser DW, Tsai TR, Orenstein W, et al. Legionnaires' Disease — Description of an Epidemic of Pneumonia. December 1, 1977 N Engl J Med 1977; 297:1189-1197 Legionella Legionnaires' Disease Philadelphia 1976

Legionnaire's Disease Case Investigation :Philadelphia Summer 1976

Between July 1 - August 18,1976 Cases Deaths 1st week 130 25 Thereafter 149 Legionnaires (33 others) Total 182 29

EPIDEMIOLOGICAL ANALYSIS v Exposure may have occurred in the lobby of the hotel or in the area immediately surrounding the hotel v Infectious agent Appeared to be air borne v Person-to-person spread seemed not to have occurred v Many hotel employees appeared to be immune: -Suggesting that the agent may have been present in the vicinity, perhaps intermittently, for 2 or more years.

Fraser DW, Tsai TR, Orenstein W, et al. Legionnaires' Disease — Description of an Epidemic of Pneumonia. December 1, 1977 N Engl J Med 1977; 297:1189-1197 Legionnaires' Outbreak at an Air National Guard Base

19 July 2010: Reports of illness of unknown aetiologie in eight employees were received by the occupational health staff at military base. Over the next several days additional illnesses with similar symptoms were reported in employees who worked in the same area as the original eight cases.

Selfridge Air National Guard Base* Harrison Township, Michigan v A single source caused 29 confirmed and probable Legionnares; disease cases & 38 Pontiac Fever cases and disrupted operationson a military base in the summer of 2010. v Multiple findings indicate that the cooling tower of a building (one of 5 building complex) was the source of this mixed legionellosis outbreak

*Selfridge Field was one of thirty-two Air Service training camps established after the United States entry into World War I in April 1917 1 1st Lieutenant Thomas E. Selfridge:

Detailed for aeronautical duty April 1908 after being an assistant to Professor Alexander Graham Bell : conducting aeronautical experiments in Nova Scotia Canada

He was killed on 17 September 1908 while flying as a passenger with Orville Wright at Fort Myer, Virginia

Selfridge was the first person to be killed in a crash of a powered aircraft. Legonella Out Break! Legionnaires' Outbreak at Air National Guard Base HARRISON TOWNSHIP, Mich.

July 3 – August 2, 2010 29 Confirmed & probable Legionella Disease 38 Pontiac Fever cases 5 building complex - 369 people working in buildings A and B - 267 (72%) participated the cohort study

September 3, Water-cooling tower was the source of a Legionnaires' disease outbreak • L. pneumophila: serogroup 4. Cooling tower Building A 2010 • L pneumophila serogroup: 1, type Knoxville Building C The large numbers of both Legionnaires Disease & Pontiac Fever cases was unusual. Several environmental factors were present to promote the outbreak: v First: The ability of building cooling tower to amplify large amounts of Legionella. v Second: Weather conditions promoted aerosolization of blowing of that aerosol towards the base. v Third: Large number of workers were in close proximity to building A’s cooling tower.

-Selfridge Completes Legionnaires Investigation. 127th Public Affairs. September 02, 2010. http://www.127wg.ang.af.mil/News/Article-Display/Article/443849/selfridge-completes-legionnaires-investigation/ -Ambrose J, Hampton LM, Fleming-Dutra KE, et al. Large outbreak of Legionnaires' disease and Pontiac fever at a military base. Epidemiol Infect.2014 Nov;142(11):2336-46. doi: 10.1017/S0950268813003440. L. pneumophila: Found worldwide and typically acquired from contaminated water sources in late summer and early fall. Legionella Epidemiology Pneumonia Incidence and prevalence

L. pneumophila: • An important cause of nosocomial (HCAP) & Community-Acquired Pneumonia (CAP)

• Must be considered a possible causative pathogen in any patient who presents with atypical pneumonia.

Edelstein PH, Cianciotto NP. Legonella. Principles and Practice of Infectious Disease Mandell, Douglas and Bennett. Elsevier 2005.pg 2711-2724 Legionella Epidemiology Pneumonia Incidence and prevalence

OCCURANCE: • Sporadic forms (as “CAP”) : most cases • Epidemic Forms • Rare causes of Community Acquired Pneumonia • High Morbidity and Mortality in improperly treated

Edelstein PH, Cianciotto NP. Legonella. Principles and Practice of Infectious Disease Mandell, Douglas and Bennett. Elsevier 2005.pg 2711-2724 Legionella Epidemiology Incidence an prevalence

United States Reported cases grown by 4.5 X since 2000. Unclear whether this increase represents artifact Increased awareness and testing v Increased - susceptibility of the population v increased - Environmental Legionella Or combination of factors.

Legionella (Legionnaires' Disease and Pontiac Fever) History, Burden, and Trends Centers for disease control and prevention https://www.cdc.gov/legionella/about/history.html Michigan experiencing increase in legionellosis cases July 5, 2019

LANSING, Mich. – The Michigan Department of Health and Human Services (MDHHS) is coordinating with local health departments across the state to investigate cases of legionellosis this summer. This increase corresponds with national October 2019 Michigan: increases in legionellosis. Legionellosis is most ~400 cases & 27 deaths. common in the summer and early fall when v Wayne County: 62 warming, stagnant waters present the best v Macomb County: 57 v Oakland County: 42 environment for bacterial growth in water systems. - Lynn Sutfin Legionella Epidemiology Incidence and prevalence Michigan 2015

Michigan Legionnaires’ Disease Year Cases 2008 172 2009 168 2010* 180 2011 184 2012 180 2013 270 2014** 228 2015** 244 2018 633

* 2010 Selfridge Air National Guard Airbase out break ** In 2014 and 2015, Genesee County saw the largest outbreak of Legionnaires' disease in at least a decade. The outbreak coincided with the city of Flint's switch from Detroit city water to water from the Flint River (and the subsequent lead exposure crisis).

Lafond K. Animation: A recent history of Legionnaires' disease in Michigan. Michigan Radio March 9, 2017 http://michiganradio.org/post/animation-recent-history-legionnaires-disease-michigan Legionella Epidemiology Pneumonia Incidence an prevalence

Epidemic Cases: Sporadic cases: ( 65-75%) (1,2) ~1100 cases annually -CDC (0.4 / 100,000)

Community v Hospitalization: 0.5-10% annually Acquired v Uncommon in children (Neonates relatively High risk) Pneumonia v Nosocomial Out Breaks well documented

TRAVEL About 21% of all Legionnaires' disease HISTORY reported to the CDC between 1980 - 1999 was travel-associated (3) & that number is rising as reporting improves

Disease v 1% - 80% depending upon underlying health of patient Mortality: v Promptness of Specific therapy v Part of an outbreak

1 Benin AL,Beson RF Besser RE. Trends in Legionnaires’ disease 1980-1998: Declining mortality and new patterns of diagnosis. Clin Infect Dis. 2002; 35:1039-1046 2 Joseph CA, Harrison TG et. El. Legionnaires' disease in residents of England and Wales:1998. Common Dis. Public Health 1999;2280-284 3 Travel-Associated Legionnaires' disease: Common questions & answers for health departments. Legionellosis Resource Site (Legionnaires' Disease and Pontiac Fever) Centers for Disease Control http://www.cdc.gov/legionella/faq.htm (Accesses 12/28/2010) Legionella Epidemiology TRAVEL ASSOCIATED DISEASE

Clusters of Legionnaires' disease associated with travel to hotels or aboard cruise ships

Legonella pneumonia is rarely detected by individual clinicians or health departments:

v Travelers typically disperse from the source of infection before developing symptoms. v Travel history should be actively sought from patients with community-acquired pneumonia v Legionella testing should be performed for those who have traveled in the 2 weeks before onset of symptoms

Travel-Associated Legionnaires' disease: Common questions & answers for health departments Legionellosis Resource Site (Legionnaires' Disease and Pontiac Fever), Centers for Disease Control http://www.cdc.gov/legionella/faq.htm (Accessed 12/28/2010) . Legionella Epidemiology Incidence an prevalence I

Legionnaires’ Disease United states Europe, Australia ~1.4-1.8 Cases / 100,000 Local Rates 0.4- 0.5 /100,000 New Zealand v Highest: New Zealand 5.3 / 100,000 v L. longbeachae causes the majority of cases Community-Acquired v Incidence v ~ 1-10% Pneumonia v Most often diagnosed in hospital v 44% (ICU) Require ICU admission v Associated mortality : v 1-10% Nosocomial v Linked to presence and concentration of legionellae : facility's water supply pneumonia v United States in 2015: 20% cases : acquired in hospitals or long-term care facilities. v Legionella species cause both sporadic and epidemic infections. Out Breaks v Great majority of cases are sporadic, outbreaks are common. Large Out breaks: v Contaminated industrial cooling towers or water systems that supply communities or facilities: v Hospitals, hotels, Cruise ships, or Apartment buildings Legionella Epidemiology Incidence an prevalence II Bacterial Species

Legionnaires' Disease Geographic v L. pneumophila is the most commonly reported cause: ~ 90 as CAP variation v L. pneumophila species, serogroup 1 predominates: 85% cases overall.

L. pneumophila v Possibly more common in late summer and early autumn Seasonality L. longbeachae v Peaks in spring and early summer These patterns reflect warmer, wetter weather and gardening activity, respectively Legionella Epidemiology Incidence and prevalence III

Transmission to people occurs when mist or vapor containing the bacteria is inhaled. Legionellosis does not spread person to person.

Risk factors for exposure to Legionella infection include: v Recent travel with an overnight stay v Recent stay in a healthcare facility v Exposure to hot tubs v Exposure to settings : plumbing with recent repairs or maintenance work

Most healthy individuals do not become infected after exposure to Legionella Legionella Epidemiology Incidence an prevalence IV

Aids/ immunocompromised patients Those taking immunosuppressive agents v Advanced age v Males v 2-5 x more common in men >50 years older Heavy tobacco use / long smoking history At RISK Pre-existing Medical conditions: v COPD v Cancers v Chronic renal Dx End-stage chronic Kidney disease Recent surgery Malignancy: v Lung Cancer v Hematologic Legonella Bacteriology Legonella Bacteriology • Facultative intracellular bacterium • Obligate Aerobic Organisms Domain: Bacteria • Proteins rather than Carbohydrates of energy sources Phylum: Proteobacteria Class: Gammaproteobacteria Gram-negative bacteria: Order: Legionellales v Silver stain Culture: Family: Legionellaceae v Cysteine-containing media Genus: Legonella v Buffered Charcoal Yeast Extract agar Common in many environments v Soil and aquatic systems v Not transmissible from person to person

Most people exposed to the bacteria do not become ill

Buffered charcoal yeast extract agar Legonella Bacteriology & Microbiology

The Legionellaceae family > 42 species Constituting 64 serogroups ~ 90% of the cases of Human legionellosis L pneumophila Serogroups 1, 4, & 6 15 serogroups Primary causes of human disease. Serogroup 1: -Responsible for 80% Human legionellosis

~10% of the cases of Human legionellosis v L micdadei (known as the Pittsburgh pneumonia agent) v L bozemanii v L dumoffii v L longbeachae

Kozak-Muiznieks NA, Lucas CE, Brown E et al. Prevalence of Sequence Types among Clinical and Environmental Isolates of Legionella pneumophila Serogroup 1 in the United States from 1982 to 2012. J Clin Microbiol. 2014 Jan; 52(1): 201–211. doi: 10.1128/JCM.01973-13 PMCID: PMC3911437 PMID: 24197883 Legionella pneumophila Ecology Facultative* intracellular bacterium is the causative agent of legionellosis.

In the environment this pathogenic bacterium colonizes the Biofilms and Amoebae which provide a rich environment for the replication of Legionella. When seeded on pre-formed biofilms

*Facultative intracellular parasites are capable of living & reproducing either inside or outside living cells • Aqueous Environments: - Lakes – Streams - Coastal oceans o o o o § Temperatures: 5 C (41 F) – 40 C (105.8 F) • Free living Amoeba (In the same water): supports intracellular growth of legionella Naegleria, Acanthamoeba, Harmonella

Environmental BIOFILMS: Legonella pneumonia General Ecology Biofilms

Biofilm provides shelter and nutrients, exhibits a remarkable resistance to biocide compounds and chlorination, thus representing ecological niches for legionella persistence in such environments

Biofilms v “Slimy” deposits of microorganisms and extracellular substances: in piping systems and tanks. v These deposits are the breeding ground for many pathogenic bacteria ( E. coli or Legionella) and also protect them from chemical and physical influences. v Microorganisms that occur in biofilms are extremely resistant to disinfectants Environmental Source: Bacteria CFU/liter vDisinfectant treated cold potable water 1 Bacteria / liter Distribution pipes: 102 – 108 / liter v“Older pipes”: low or no water flow: vAir conditioning cooling towers: 102 – 108 / liter

v Legionella bacteria are typically transmitted to humans via inhalation of aerosols derived from water or soil v The infectious dose for humans has not been precisely quantified but is likely high, requiring >1000 organisms to cause infection.

Edelstein PH, Cianciotto NP. Legonella. Principles and Practice of Infectious Disease Mandell, Douglas and Bennett. Elsevier 2005.pg 2712 Bio film: Contain infected amoeba and “free” living Legonella organisms Legonella Intracellular -or- extracellular Amoeba: v Facultative intracellular parasite or “free living”* organism v Can Multiply 1000 X within the Amoeba v Replication within protozoa protects the organism from temperature shifts, pH changes, and nutrient-poor environments. v Additional factors that promote growth in water include warm temperatures (25 to 42°C), stagnation, and sedimentation v Legonella infected amoeba can “encyst” guaranteeing the survival of the amoeba and bacteria

*FREE living Legonella Low metabolic state (Difficult to cultivate from environmental sources) Legionella Legionnaires' Disease Pathophysiology Parasitized Amoeba

*Transmission electron micrograph of an amoeba-filled with Legionella pneumophila.

. Amoeba such as Acanthamoeba Castellani and ciliate protozoan are able to “graze” biofilm material Legionella is a target of protozoan predation v Developed the capacity to parasitize and reside in: - 20 species of amoebae, - 3 species of ciliated protozoa - 1 species of slime mould Numerous studies show the necessity of the presence of protozoans for the survival and replication of L. pneumophila in aquatic environment

H.Y. Lau HY, Ashbolt NJ. The role of biofilms and protozoa in Legionella pathogenesis: implications for drinking water Journal of Applied Microbiology 09 July 2009 https://doi.org/10.1111/j.1365-2672.2009.04208.x * Figure from: Acanthamoeba Biology and Pathogenesis Acanthamoeba: Biology and Pathogenesis Acanthamoeba: Biology and Pathogenesis | Bookhttps://www.caister.com/hsp/supplementary/acanthamoeba/g4.html Sources of Contaminated water

Sources of Contaminated water v Cooling Systems / Water towers v Ice machines v Showers (Colonized plumbing) v Potting Soil v Decorative fountains v Recirculation water supply v Humidifiers systems v Respiratory Therapy Equipment v Water fountains v Whirlpools Spas Hot tubs v Air conditioning Units v Mist sprays in grocery story producing Departments

Natural water systems, such as rivers and streams, are less common sources of infection

Edelstein PH, Cianciotto NP. Legonella. Principles and Practice of Infectious Disease Mandell, Douglas and Bennett. Elsevier 2005.pg 2712 Environmental Legionella

Potting Soil

Hospital ICE machine

Drinking fountains

Air Conditioning Cooling towers Whirlpool & Hot Tub Sources Legonella Outbreaks

v Legionnaires' disease bacteria cannot survive without water

v Air conditioning units without humidifiers have not been identified as sources of legionella disease

v For a Legionnaires' disease outbreak to be linked directly with the Heating, Ventilating, and Air Conditioning (HVAC) Systems……..

…..Legionella contaminated water must enter the system, be aerosolized, and be delivered to building occupants

Legionnaire’s Disease. Section II:D. Heating, Ventilating, and Air Conditioning (HVAC) Systems. Occupational Safety and Health administration. United States Department of Labor. https://www.osha.gov/dts/osta/otm/legionnaires/hvac.html Legonella Pathogenesis Factors

Clinical Factoid Environmental Adaptation of L. pneumophilia to protozan “niches” in nature factors (e.g. Biomasses and Amoeba) engenders the ability to infect [1] Mammalian phagocytes

Human The ability of L. pneumophilia to grow within macrophages is Intracellular central to disease pathogenesis [2] Pathogens

1 Horwitz MA. Phagocytosis of the Legionnaires disease bacteria occurs by a novel mechanism: Engulfment within a pseudopod coil. Cell 1984;36:27-33 2 Fields BS, Benson RF Besser RF. Legonella and Legionnaires’ Disease. 25 years of investigation. Clin Microbiol Rev. 2002;1506-526 Legionella Legionnaires' Disease Human Pathophysiology

Humans: Intracellular Pathogens v Adventitiously infected through inhalation of Legionella containing aerosols. v Taken up by alveolar macrophages: Replication occurs v Host immune response to infection is “atypical” for a bacterial infection” (T cells) v Air spaces fill up with an immune infiltrate consisting primarily of macrophages, v The Exact cell type that Legionella uses to replicate and propagate infection Organisms multiply extensively until they fill up and then burst out of the host cell to continue the next round of replication Wild type Legionella in macrophage

The Kirby Laboratory https://www.kirbylab.org/legionella-pneumophila.html Legionnaires’ Disease Host Response

The immune response is how your body recognizes and defends itself against bacteria, viruses, and substances that appear foreign and harmful.

Host response Helper T cells Activates Legonella v Associated with Inflammatory cytokines v Crucial for clearance of the Legonella organism Antibody (B Cell / Plasma Cells) develop in response, v Humoral immune response does not appear to be critical for host defense Legionella Pneumonia Legionnaires'’ Disease Clinical Presentations

Patients with pneumonia should be tested for Legionnaires Disease if they have any of the following histories: v Have failed outpatient antibiotic treatment for community-acquired pneumonia v Are immunocompromised v Are admitted to an intensive care unit v Traveled within 10 days prior to symptoms onset v Were recently Hospitalized v Developed pneumonia 48 hours or more after hospital admission Legionnaires'’ Disease Clinical Presentations

LEGIONNAIRES' DISEASE (LEGIONELLA PNEUMONIA)

Clinical v Symptoms typically arise 2 -10 days after exposure Features v Fever and fatigue often precede the onset of cough. v Predominant symptoms include fever, cough, and shortness of breath v Crackles and Egophony consolidation can be present on physical examination Radiographs v Varied and nonspecific v Most common findings are patchy unilobar infiltrates v Can progress to consolidations v Radiographically similar to other forms of pneumonia.

Clinical v Gastrointestinal symptoms: Nausea, Vomiting, and Diarrhea Clues v Hyponatremia v Elevated hepatic transaminases v C-reactive protein levels >100 mg/L v Failure to respond to treatment for pneumonia with beta-lactam monotherapy Legionniares Pneumonia Clinical features

Clinical Features Pneumonia caused by Legionella is clinically & radiographically similar to other forms of pneumonia. Predominant Symptoms Symptoms typically arise 2 - 10 days after exposure to contaminated water or soil.

v Fever & fatigue often precede the onset of cough v Shortness of breath v Rales and/or other signs of consolidation can be present on physical examination.

v Multifocal and bilateral. There may be a middle and lower zone predominance Pleural effusions can be common and are occasionally seen even in the absence of lung field infiltrates. Resolution of infiltrates may be slow, and the tendency for delayed clearing should be considered before initiating any further invasive diagnostic investigation*

*Dr Rohit Sharma and Dr Yuranga Weerakkody et al. Legionella pneumonia. Radiopaedia https://radiopaedia.org/articles/legionella-pneumonia?lang=us Certain features may raise the index of suspicion: v Gastrointestinal symptoms nausea, vomiting & Legionnaires’ Disease diarrhea General Clinical Pneumonia v Hyponatremia ranges from mild to severe. v Elevated hepatic transaminases v C-reactive protein levels >100 mg/L v Failure to respond to treatment for pneumonia with beta-lactam monotherapy

The image part with relations hip ID rId2 was Lungs not - Cough with sputum / phlegm found in the file. - Shortness of Breath - Pleuritic Chest Pain - Hemoptysis Legionnaires’ Disease Pathophysiology General clinical Response

2-10 days Peak Replication

Bacterial antigens Urine Bacterial load Bacterial

6 days Infections Controlled

IMMUNE Response

Exposure INCUBATION (Asymptomatic)

Symptoms Legonella Diagnostic AND testing

v Culture (Gold Standard) v Immunofluorescent Microscopy v Molecular Amplification (PCR) v Antigenuria Legonella Diagnostic testing General Considerations

Culture

Antigen ACUTE DISEASE Days-several weeks Potential Window Antibodies Testing 2-6 weeks to develope Sensitivity

PCR: Sputum / Tissues / Urine/ Serum

Time v Culture, Antigen and PCR testing for acute infection: v Antigen drop rapidly as antibody appears with “window” below detectable antigen and before Anti-body can be detected v PCR generally detectable with acute onset and after Antibody response until complete resolution on the infection Legonella Diagnostic testing I Antigens / Cultures / PCR

Diagnostic tests for Legionella species Test Characteristic Urine Antigen Cultures** PCR Strains Detected Detects only L. All species All species pneumophila serogroup 1* & serogroup &serogroups Time to results <1 hour > 3 Days Hours Overall Sensitivity 70-80% <10-80% Exceeds cultures*** Over all Specificity >99% 100% >99%

PCR: polymerase chain reaction. * L. pneumophila accounts for about 85% of cases worldwide but rates may be lower in some regions of the world, \ such as Australia and New Zealand, where L. longbeachae is prevalent. ** Legionella species can be cultured from blood, but the yield is poor and the growth may not activate the alarm on some commercial blood culture machines *** Typically detects twice as many cases as culture when testing lower respiratory samples.

Diagnostic tests for Legionella species. Diagnostic tests for Legionella species. Clinical manifestations and diagnosis of Legionella infection UptoDate®© 2019 UpToDate, Inc. and/or its affiliates. All Rights Reserved Legonella Diagnostic testing II Antigens / Cultures / PCR Edelstein PH, Cianciotto NP. Legonella. Principles and Practice of Infectious Disease. Mandell, Douglas and Bennett. Elsevier 2005. pg 2718 Test Specimen Type Sensitivity Specificity Culture* Sputum / Pulmonary Secretions, 20% - 95% 100%* Gold Standard Tissues, Fluid Immunofluorescent Sputum / Pulmonary 20% - 50% 99% Microscopy Secretions,Tissues,Fluid Antibody (Serum)** Paired Serum (6 weeks) 20% -70% 95%-99% Molecular Sputum, Pulmonary Secretions, 20% -70% 90%-95% Amplification (PCR) Urine Antigenuria*** Urine 60% - 90% >99%

* Colonization with Legonella DOES not occur: recovery of organism from appropriate specimen is therefore 100% “specific” for an infection. Legionella species can be cultured from blood, but the yield is poor and the growth may not activate the alarm on some commercial blood culture machines ** Direct fluorescent antibody (DFA) staining & serology are available but are generally not used in clinical practice. DFA staining has poor sensitivity &cross reacts with other respiratory pathogens. Serology requires collection of acute and convalescent samples spaced four weeks apart, which is clinically impractical. Serology is thus primarily used for retrospective diagnosis in epidemiologic investigations. ***One disadvantage is that the urine antigen test only detects anti-bodies towards Legionella pneumophila; only a culture will detect infection by the other Legionella species.1

1 Trends in legionnaires disease, 1980-1998: declining mortality and new patterns of diagnosis. Benin AL; Benson RF; Besser RE. Clin Infect Dis November 1, 2002;35(9):1039-46. Epub October 14, 2002 Legonella Diagnostic Testing III Pontiac Fever Vs. Legionnaires’ Disease Urinary antigen testing

Urine Legionella antigen testing Commonly used “alternative” test for Legionnaires' disease Sensitivity 70-80% Specificity ~100% (Disease caused by L. pneumophila serotype 1) Legionella antigens can be detected in urine as early as one day after symptom onset and persist for days to weeks Disadvantage Detects ONLY L. pneumophila serotype 1. v L. pneumophila > 80% (most regions of the world), v L. longbeachae et al is common in some regions,

-David Murdoch, Stephen T Chambers, Patricia Priest, et al. Clinical manifestations and diagnosis of Legionella infection. UpToDate® June 2018

-Peci A, Winter AL, Gubbay JB Evaluation and Comparison of Multiple Test Methods, Including Real-time PCR, for Legionella Detection in Clinical Specimens. Front Public Health. 2016; 4:175. Epub 2016 Aug 31.

-Diederen BM. Legionella spp. and Legionnaires' disease.J Infect. 2008;56(1):1. Epub 2007 Nov 5. -Shimada T, Noguchi Y, Jackson JL, Miyashita J, et al. Systematic review and metaanalysis: urinary antigen tests for Legionellosis. Chest. 2009;136(6):1576. Epub 2009 Mar 24 Legionnaires’ Disease Advantages and Disadvantages for Each Diagnostic Test

TEST ADVANTAGE DISADVANTAGE v Detects all species & v Technically difficult CULTURE* serogroups v Slow (>5 days to grow) v Clinical & environmental v Sensitivity highly dependent : technical skill isolates can be compared v Affected by appropriate antibiotic treatment v Requires BCYE agar, which some laboratories may not have readily available v Can only be used to detect L. pneumophila Urinary v Possible to detect species serogroup 11 (Lp1) (which may account for up to and serogroups other than 84%of cases) Antigen Lp1 v Does not allow for molecular comparison to environmental isolates

*special media (buffered charcoal yeast extract [BCYE] agar with L-cysteine and ferric ions to support growth, antibiotics to prevent overgrowth of other organisms, and dyes to impart a distinctive color to the organisms). Legionnaires’ Disease Advantages and Disadvantages for Each Diagnostic Test

TEST ADVANTAGE DISADVANTAGE v Possible to detect species v Must have paired sera collected at acute onset to 2 weeks & serogroups other than after symptoms and 3 to 6 weeks later SEROLOGY Lp1 v ~5 -10% of the population has titer 1:≥256 (single acute phase antibody titers of 1: ≥256 v Does not discriminate between cases of Legionnaires’ disease and other causes of community-acquired pneumonia) v Can be performed on pathologic specimens DFA (Tissue) (usually lung tissue) v Technically difficult v Possible to detect species v Reagents may be difficult to obtain and serogroups other than Lp1 v Can be performed on pathologic specimens PCR (usually lung tissue) v Assays vary by laboratory and commercial v Rapid v Possible to detect species availability may be limited in the United States5 and serogroups other than Lp Legonella Diagnostic Testing Pontiac Fever Vs. Legionnaires’ Disease Urinary antigen testing Vs. PCR Vs. Culture

Urine antigen: Vs. CULTURE PCR Sensitivity: 87% 74.7% Specificity: 94.7% 98.3% Positive Predictive: 63.8% 77.7% Negative Predictive: 98.5% 98.1%

146 Patients Sputum CULTURE Positive PCR POSITIVE 66 (45.2%) Sputum BAL Sensitivity 10.3% 13.6%

Peci A, Winter AL, Gubbay JB Evaluation and Comparison of Multiple Test Methods, Including Real-time PCR, for Legionella Detection in Clinical Specimens. Front Public Health. 2016; 4:175. Epub 2016 Aug 31. EXTRA PULMONARY Legionellosis

Extrapulmonary Legionella disease is rare: v May occur as a complication of Legionella pneumonia or can occur independently. v Most cases have been reported in immunocompromised patients v In contrast with Legionnaires' disease and Pontiac fever, many cases of extrapulmonary Legionella disease are caused by Legionella species other than L. pneumophila Legionnaires’ disease Extrapulmonary Disease

Extrapulmonary Legionella disease v Cellulitis v Native & prosthetic valve endocarditis v Skin & soft tissue abscesses v Peritonitis v Septic arthritis v Pyelonephritis v Prosthetic joint infection v Meningitis v Osteomyelitis v Brain abscesses v Myocarditis v Surgical site infections v Pericarditis The diagnosis of extrapulmonary disease requires detection of Legionella at the affected site, usually by culture or polymerase chain reaction. Early diagnosis and administration of appropriate antimicrobial therapy is associated with improved outcomes in patients with Legionnaires' disease

TREATMENT Legionnaires’ Disease Legionnaires’ Pneumonia Treatment Considerations

Clinical Issue Factoid Immunocompromised Transplant recipients and other immunocompromised patients with patients Legionnaires' disease are at risk for both severe infection and relapse v Either levofloxacin or azithromycin (minimum of 14 days) Adjunctive v May be helpful in patients with severe Legionnaires' disease. glucocorticoid (Secondary to intense inflammatory response) v Not well studied in Legionnaires' disease than in other types of pneumonia Extracorporeal Observational data suggest that survival rates with ECMO use may membrane be as high as 85 percent in patients with Legionnaires' disease oxygenation (ECMO)

Antibiotic treatment for Legionnaires' disease in adults (Legionella pneumonia) 2018 UpToDate® Graphic 117791 Version 1.0 https://www.uptodate.com/contents/image?imageKey=ID%2F117791&source=history_widget Han JH, Nguyen JC, Harada S, Baddour LM, et al. Relapsing Legionella pneumophila cellulitis: a case report Legionnaires’ Pneumonia Treatment

Antibiotic treatment for Legionnaires' disease in adults (Legionella pneumonia) Preferred options Alternative options Ciprofloxin 500 mg PO BID OR: Moxifloxacin 400 mg orally QD OR: Clarithromycin 500 mg PO BID •Azithromycin 500mg QD OR: Erythromycin (base) 500 mg QID Mild pneumonia* •Levofloxacin 750ng QD OR: Roxithromycin 300 mg PO QD OR: Roxithromycin 300 mg 150 mg BID OR Doxycycline 200X1 THEN BID Moderate or Azithromycin 500 mg IV Ciprofloxacin 400 mg IV BID severe or PO QD OR Ciprofloxin 750 mg PO BID Levofloxacin 750 mg IV OR Moxifloxacin 400 mg IV or PO QD pneumonia or PO QD OR Clarithromycin 500 mg IV or PO BID OR Erythromycin (base) 1000 mg IV QID OR Erythromycin (base) 500 mg PO QID Duration of Therapy v Minimum duration of therapy is 5 days for patients (afebrile and clinically stable for 48 hours) v Mild infection generally require 5 - 7 days of therapy. v Severe infection or chronic comorbidities generally require 7 - 10 days of therapy. v Extended courses : Immunocompromised patients /complications (empyema or extrapulmonary)

Antibiotic treatment for Legionnaires' disease in adults (Legionella pneumonia) 2018 UpToDate® Graphic 117791 Version 1.0 https://www.uptodate.com/contents/image?imageKey=ID%2F117791&source=history_widget The image part with relations hip ID rId2 was not found in the file. Bibliography Legionnaires Epidemiology

Environmental exposure risk • Peter Applebom Mist in grocery’s Produce section linked to Legionniares Disease. Archive: New York times https://www.nytimes.com/1990/01/11/us/mist-in-grocery-s-produce-section-is-linked-to-legionnaires-disease.html • Bollin GE, Plouffe JF,Para MF, Hackman B. Aerosols containing Legionella pneumophila generated by shower heads and hot-water faucets. Appl Environ Microbiol. 1985 Nov; 50(5): 1128–1131 • Smith SS, Ritger K, Samala U, Black SR et al. Legionellosis Outbreak Associated With a Hotel Fountain Open Forum Infectious Diseases, Volume 2, Issue 4, 1 December 2015, ofv164, https://doi.org/10.1093/ofid/ofv164 • Dermitzel A, Geuenich HH, Müller HE. [Legionella and other bacteria in air humidifiers and cooling systems of air conditioning units--a survey]. Gesundheitswesen. 1992 Dec;54(12):716-9 • Legionnaires’ Disease in Spa Pools & Hot Tubs Legionella Control. https://legionellacontrol.com/legionella/legionnaires- disease-spa-pools-hot-tubs/ • Stout J, Yu VL, Muraca P.”Isolation of Legionella pneumophila from the cold water of hospital ice machines: implications for origin and transmission of the organism. Infect Control 1985;6:141146. • Legionnaires' Disease Associated With Potting Soil --- California, Oregon, and Washington, May--June 2000 MMWR (CDC) Weekly, September 01, 2000 / 49(34);777-8 • Stephanie Soucheray. Legionella - Common in US outbreaks tied to drinking water, other sources. Legionella News and Perespetive Foodborne Disease, Centers for Infectious Disease Research and Policy (CIDRAP) News. Nov 09, 2017 http://www.cidrap.umn.edu/news-perspective/2017/11/legionella-common-us-outbreaks-tied-drinking-water-other-sources BIBLIOGRAPHY Legonella Legionnaires' Outbreak at Air National Guard Base HARRISON TOWNSHIP, Mich.

AIR NATIONAL GUARD BASE OUTBREAK • William R. Evinger: Directory of Military Bases in the U.S., Oryx Press, Phoenix, Ariz., 1991, p. 14 • Selfridge Air National Guard Base. From Wikipedia, the free encyclopedia. https://en.wikipedia.org/wiki/Selfridge_Air_National_Guard_Base • Julia Blakely. The Short, Soaring Life of Lieutenant Selfridge. Smithsonian Library: Unbound. https://blog.library.si.edu/blog/2015/09/16/the-short-soaring-life-of-lieutenant-selfridge/#.W03Xk7gpBPY • From The Detroit News: http://www.detnews.com/article/20100803/METRO03/8030360/1040/LIFESTYLE03/Selfridge- officials-hunt-source-of-Legionnaires--disease-cases#ixzz0vsnpK6wB • Source of Legionnaires' outbreak found. Sept. 3, 2010 at 10:41 AM UPI https://www.upi.com/Source-of-Legionnaires- outbreak-found/40281283524899/ • Chad Halcom. Nalco Co. gets contract to monitor Selfridge water towers. Craine’s Detroit Business September 02, 2010 12:00 p.m. Updated 3/16/2017 • -Selfridge Completes Legionnaires Investigation. 127th Public Affairs. September 02, 2010. http://www.127wg.ang.af.mil/News/Article-Display/Article/443849/selfridge-completes-legionnaires-investigation/ • -Ambrose J, Hampton LM, Fleming-Dutra KE, et al. Large outbreak of Legionnaires' disease and Pontiac fever at a military base. Epidemiol Infect.2014 Nov;142(11):2336-46. doi: 10.1017/S0950268813003440 BIBLIOGRAPHY Legionella: Pontiac Fever

PONTIAC FEVER • Glick TH, Gregg MB, Berman B, et al. Pontiac fever: an epidemic of unknown etiology in a health department. I. Clinical and epidemiologic aspects, Am J Epidemiol , 1978, vol. 107(pg. 149-60) • Legionella (Legionnaires' Disease and Pontiac Fever) History, Burden, and Trends Centers for disease control and prevention https://www.cdc.gov/legionella/about/history.html • "Epidemiology and clinical management of Legionnaires' disease". The Lancet Infectious Diseases. 14 (10): 1011–1021. doi:10.1016/S1473-3099(14)70713-3. • Paul H. Edelstein Urine Antigen Tests Positive for Pontiac Fever: Implications for Diagnosis and Pathogenesis Clinical Infectious Diseases, Volume 44, Issue 2, 15 January 2007, Pages 229–231, https://doi.org/10.1086/510394 • Kaufmann AF, McDade JE, Patton CM, et al. Pontiac fever: isolation of the etiologic agent (Legionella pneumophila) and demonstration of its mode of transmission, Am J Epidemiol , 1981, vol. 114 (pg. 337-47) • Edelstein PH. Detrick B, Hamilton RG, Folds JD Detection of antibodies to Legionella, Manual of molecular and clinical laboratory immunology7th ed , 2006 Washington, DC ASM Press (pg. 468 -76) • Helbig JH, Uldum SA, Lück PC et al. Detection of Legionella pneumophila antigen in urine samples: recognition of serogroups and monoclonal serogroups, Legionella, 2003 Washington, DCASM Press (pg. 204-6) Bibliography Legionella Pathophysiology

LEGIONNAIRES’ DISEASE 1977 • Fraser DW, Tsai TR, Orenstein W, et al. Legionnaires' Disease — Description of an Epidemic of Pneumonia. December 1, 1977 N Engl J Med 1977; 297:1189-1197 DOI: 10.1056/NEJM197712012972201 • LEGIONNAIRE'S DISEASE: 5 YEARS LATER THE MYSTERY IS ALL BUT GONE, New York Times, Harold M. Schmeck, Jr., Jan. 19, 1982. • Terranova W, Cohen ML, Fraser DW.1974 outbreak of Legionnaires' Disease diagnosed in 1977. Clinical and epidemiological features, Lancet,, July 15, 1978 pages 122-4.

Testing DIAGNOSIS • Legionella (Legionnaires’ Disease And Pontiac Fever) Diagnosis, Treatment, and Prevention. Centers fo Disease Control and Prevention. https://www.cdc.gov/legionella/clinicians/diagnostic-testing.html • Yu V, Plouffe JF, Pastoris MC, et al. Distribution of Legionella species and serogroups isolated by culture in patients with sporadic community-acquired legionellosis: An international collaborative survey. J Infect Dis. 2002;186:127– 8. Urine Legionella antigen • David Murdoch, Stephen T Chambers, Patricia Priest, et al. Clinical manifestations and diagnosis of Legionella infection. UpToDate® June 2018 • Peci A, Winter AL, Gubbay JB. Evaluation and Comparison of Multiple Test Methods, Including Real-time PCR, for Legionella Detection in Clinical Specimens. Front Public Health. 2016; 4:175. Epub 2016 Aug 31. • Diederen BM. Legionella spp. and Legionnaires' disease. J Infect. 2008;56(1):1. Epub 2007 Nov 5. • Shimada T, Noguchi Y, Jackson JL, Miyashita J, et al. Systematic review and metaanalysis: urinary antigen tests for Legionellosis. Chest. 2009;136(6):1576. Epub 2009 Mar 24 Bibliography Legionella Pathophysiology

Pathophysiology Parasitized Amoeba - Bigot R, Bertaux J, Frere J, Berjeaud J-M (2013) Intra-Amoeba Multiplication Induces Chemotaxis and Biofilm Colonization and Formation for Legionella. PLoS ONE 8(10): e77875. https://doi.org/10.1371/journal.pone.0077875 - H.Y. Lau HY, Ashbolt NJ. The role of biofilms and protozoa in Legionella pathogenesis: implications for drinking – Journal of Applied Microbiology 09 July 2009https://doi.org/10.1111/j.1365-2672.2009.04208.x - Figure from: Acanthamoeba Biology and Pathogenesis Acanthamoeba: Biology and Pathogenesis Acanthamoeba: Biology and Pathogenesis | Bookhttps://www.caister.com/hsp/supplementary/acanthamoeba/g4.html - Hagele S, Kohler R, Merkert H, Schleicher M, Hacker J, et al. (2000) Dictyostelium discoideum: a new host model system for intracellular pathogens of the genus Legionella. Cell Microbiol 2: 165–171 - Rowbotham TJ (1980) Preliminary report on the pathogenicity of Legionella pneumophila for freshwater and soil amoebae. J Clin Pathol 33: 1179–1183. - Murga R, Forster TS, Brown E, Pruckler JM, Fields BS, et al. (2001) Role of biofilms in the survival of Legionella pneumophila in a model potable-water system. Microbiology 147: 3121–3126 - Kuiper MW, Wullings BA, Akkermans AD, Beumer RR, van der Kooij D (2004) Intracellular proliferation of Legionella pneumophila in Hartmannella vermiformis in aquatic biofilms grown on plasticized polyvinyl chloride. Appl Environ Microbiol 70: 6826–6833 TRANSMISSION • Kenagy E, Priest PC, Cameron CM, et al Risk Factors for Legionella longbeachae Legionnaires' Disease, New Zealand. Emerg Infect Dis. 2017;23(7):1148 • Benedict KM, Reses H, Vigar M, et al Surveillance for Waterborne Disease Outbreaks Associated with Drinking Water - United States, 2013-2014. MMWR Morb Mortal Wkly Rep. 2017;66(44):1216. Epub 2017 Nov 10. • Berendt RF, Young HW, Allen RG, Knutsen GL Dose-response of guinea pigs experimentally infected with aerosols of Legionella pneumophila. J Infect Dis. 1980;141(2):186 BIBLIOGRAPHY Microbiology, epidemiology, and pathogenesis of Legionella infection

• Murdoch D, Chambers ST, Priest P, et al. EPIDEMIOLOGY Incidence and prevalence. Microbiology epidemiology, and pathogenesis of Legionella infection. UpToDate® (June 2018) • Dooling KL, Toews KA, Hicks LA et al. Active Bacterial Core Surveillance for Legionellosis - United States, 2011-2013. MMWR Morb Mortal Wkly Rep. 2015;64(42):1190. Epub 2015 Oct 30. • NNDSS Annual Report Working Group Australia's notifiable disease status, 2014: Annual report of the National Notifiable Diseases Surveillance System. Commun Dis Intell Q Rep. 2016;40(1):E48. Epub 2016 Mar 3 3 31. • Stout J, Yu VL, Vickers RM, Zuravleff J et. al. Ubiquitousness of Legionella pneumophila in the water supply of a hospital with endemic Legionnaires' disease. N Engl J Med. 1982;306(8):466. • Kanamori H, Weber DJ, Rutala WA. Healthcare Outbreaks Associated With a Water Reservoir and Infection Prevention Strategies. Clin Infect Dis. 2016;62(11):1423. Epub 2016 Mar 1. • Soda EA, Barskey AE, Shah PP, et al. Vital Signs: Health Care-Associated Legionnaires' Disease Surveillance Data from 20 States and a Large Metropolitan Area - United States, 2015. MMWR Morb Mortal Wkly Rep. 2017;66(22):584. Epub 2017 Jun 9. • Yu VL, Plouffe JF, Pastoris MC et al. Distribution of Legionella species and serogroups isolated by culture in patients with sporadic community-acquired legionellosis: an international collaborative survey. J Infect Dis. 2002;186(1):127. • European Center for Disease Prevention and Control. Legionnaires’ disease - Annual Epidemiological Report for 2015. ECDC; Stockholm, 2015 • Marston BJ, Lipman HB, Breiman RF. Surveillance for Legionnaires' disease. Risk factors for morbidity and mortality. Arch Intern Med. 1994;154(21):2417. • Rucinski SL, Murphy MP, Kies KD, et al. Eight Years of Clinical Legionella PCR Testing Illustrates a Seasonal Pattern. J Infect Dis. 2018;218(4):669. BIBLIOGRAPHY Microbiology, epidemiology, and pathogenesis of Legionella infection

LEGONELLA TREATMENT • Heath CH, Grove DI, Looke DF. Delay in appropriate therapy of Legionella pneumonia associated with increased mortality. Eur J Clin Microbiol Infect Dis. 1996;15(4):286. • Levcovich A, Lazarovitch T, Moran-Gilad J, et al Complex clinical and microbiological effects on Legionnaires' disease outcome; A retrospective cohort study. BMC Infect Dis. 2016;16:75. Epub 2016 Feb 10. • Antibiotic treatment for Legionnaires' disease in adults (Legionella pneumonia) 2018 UpToDate® Graphic 117791 Version 1.0 https://www.uptodate.com/contents/image?imageKey=ID%2F117791&source=history_widget • Han JH, Nguyen JC, Harada S, Baddour LM, et al. Relapsing Legionella pneumophila cellulitis: a case report and review of the literature. J Infect Chemother. 2010;16(6):439. Epub 2010 Jun • Sivagnanam S, Podczervinski S, Butler-Wu SM, et al. Legionnaires' disease in transplant recipients: A 15- year retrospective study in a tertiary referral center. Transpl Infect Dis. 2017;19(5) Epub 2017 Sep 28. • Hayashi M, Kuraishi H, Masubuchi T, et al. A Fatal Case of Relapsing Pneumonia Caused by Legionella pneumophila in a Patient with Rheumatoid Arthritis After Two Injections of Adalimumab. Clin Med Insights Case Rep. 2013;6:101. Epub 2013 Jun 12. BIBLIOGRAPHY CLINCIAL LEGIONNAIRES DISEASE

CLINCIAL LEGIONNAIRES DISEASE I • Murdoch D, Chambers ST, Priest P,Ramirez JA, Bond S. Clinical manifestations and diagnosis of Legionella infection. UpToDate® Literature review current through: Sep 2019. | This topic last updated: Oct 03, 2019. • Fraser DW, Tsai TR, Orenstein W et al. Legionnaires' disease: description of an epidemic of pneumonia. N Engl J Med. 1977;297(22):1189 • Kirby BD, Snyder KM, Meyer RD, Finegold. Legionnaires' disease: report of sixty-five nosocomially acquired cases of review of the literature. Medicine (Baltimore). 1980;59(3):188 • Tsai TF, Finn DR, Plikaytis BD et al. Legionnaires' disease: clinical features of the epidemic in Philadelphia. Ann Intern Med. 1979;90(4):509. • Isenman HL, Chambers ST, Pithie AD et al. Legionnaires' disease caused by Legionella longbeachae: Clinical features and outcomes of 107 cases from an endemic area. Respirology. 2016;21(7):1292. Epub 2016 May 19. • Sopena N, Sabrià-Leal M, Pedro-Botet ML. et al. Comparative study of the clinical presentation of Legionella pneumonia and other community-acquired pneumonias .Chest. 1998;113(5):1195 • Woodhead MA, Macfarlane JT. Legionnaires' disease: a review of 79 community acquired cases in Nottingham. Thorax. 1986;41(8):635 • Amodeo MR, Murdoch DR, Pithie AD Legionnaires' disease caused by Legionella longbeachae and Legionella pneumophila: comparison of clinical features, host-related risk factors, and outcomes. Clin Microbiol Infect. 2010;16(9):1405. BIBLIOGRAPHY CLINCIAL LEGIONNAIRES DISEASE

CLINCIAL LEGIONNAIRES DISEASE II • Crain M, Trampuz A, Steffen I, Frei R, Müller B, Schuetz. et al. Clinical predictors for Legionella in patients presenting with community-acquired pneumonia to the emergency department. BMC Pulm Med. 2009;9:4. Epub 2009 Jan 19 • Roed T, Schønheyder HC, Nielsen H. Predictors of positive or negative legionella urinary antigen test in community-acquired pneumonia. Infect Dis (Lond). 2015;47(7):484. Epub 2015 Mar 11 • Roig J, Aguilar X, Ruiz J, Domingo C, Mesalles et al. Comparative study of Legionella pneumophila and other nosocomial-acquired pneumonias. Chest. 1991;99(2):344. • Poirier R, Rodrigue J, Villeneuve J, Lacasse Y Early Radiographic and Tomographic Manifestations of Legionnaires' Disease. Can Assoc Radiol J. 2017;68(3):328. Epub 2017 May 4. • Tan MJ, Tan JS, Hamor RH, et al The radiologic manifestations of Legionnaire's disease. The Ohio Community-Based Pneumonia Incidence Study Group. Chest. 2000;117(2):398. • Gilbert DN. Role of Procalcitonin in the Management of Infected Patients in the Intensive Care Unit. Infect Dis Clin North Am. 2017;31(3):435. BIBLIOGRAPHY Extrapulmonary Legionellosis

EXTRA PULMONARY I

• Qin X, Abe PM, Weissman SJ, Manning SC Extrapulmonary Legionella micdadei infection in a previously healthy child. Pediatr Infect Dis J. 2002;21(12):1174. • Muder RR, Yu VL. Infection due to Legionella species other than L. pneumophila. Clin Infect Dis. 2002;35(8):990 • Han JH, Nguyen JC, Harada S, et al. Relapsing Legionella pneumophila cellulitis: a case report and review of the literature. J Infect Chemother. 2010;16(6):439. Epub 2010 Jun 5 • Kilborn JA, Manz LA, O'Brien M, et al Necrotizing cellulitis caused by Legionella micdadei. Am J Med. 1992;92(1):104 • Loridant S, Lagier JC, La Scola B. Identification of Legionella feeleii cellulitis. Emerg Infect Dis. 2011;17(1):145 • Waldor MK, Wilson B, Swartz M.Clin Infect Dis. 1993;16(1):51. Cellulitis caused by Legionella pneumophila • Padrnos LJ, Blair JE, Kusne S, DiCaudo DJ, Mikhael JR. Cutaneous legionellosis: case report and review of the medical literature. Transpl Infect Dis. 2014;16(2):307. Epub 2014 Mar 17 • Qin X, Abe PM, Weissman SJ, Manning SC Extrapulmonary Legionella micdadei infection in a previously healthy child. Pediatr Infect Dis J. 2002;21(12):1174 Bibliography Extra Pulmonary Legionellosis

EXTRA PULMONARY II • Padrnos LJ, Blair JE, Kusne S, DiCaudo DJ, Mikhael JR. Cutaneous legionellosis: case report and review of the medical literature. Transpl Infect Dis. 2014;16(2):307. Epub 2014 Mar 17 • Qin X, Abe PM, Weissman SJ, Manning SC Extrapulmonary Legionella micdadei infection in a previously healthy child. Pediatr Infect Dis J. 2002;21(12):1174 • Banderet F, Blaich A, Soleman E, et al. Septic arthritis due to Legionella cincinnatiensis: case report and review of the literature. Infection. 2017;45(4):551. Epub 2016 Nov 15 • Thurneysen C, Boggian K Legionella pneumophila serogroup 1 septic arthritis with probable endocarditis in an immunodeficient patient. J Clin Rheumatol. 2014;20(5):297. • Fernández-Cruz A, Marín M, Castelo L, Usubillaga R, et al. GAIO (Group for the Assessment of Osteoarticular Infections) Study Group Legionella micdadei, a new cause of prosthetic joint infection. • J Clin Microbiol. 2011;49(9):3409. Epub 2011 Jun 29 • McClelland MR, Vaszar LT, Kagawa FT. Pneumonia and osteomyelitis due to Legionella longbeachae in a woman with systemic lupus erythematosus. Clin Infect Dis. 2004;38(10):e102. Epub 2004 Apr 28. • Sanchez MC, Sebti R, Hassoun P, et al Osteomyelitis of the patella caused by Legionella anisa. J Clin Microbiol. 2013;51(8):2791. Epub 2013 Jun 12 BIBLIOGRAPHY Extrapulmonary Legionellosis

EXTRA PULMONARY III • Damásio AF, Rodrigues L, Miranda L, et al. Fulminant myocarditis caused by Legionella pneumophila: case report. Rev Port Cardiol. 2014;33(3):185.e1. Epub 2014 Mar 20. • Ishimaru N, Suzuki H, Tokuda Y, et al. Severe Legionnaires' disease with pneumonia and biopsy-confirmed myocarditis most likely caused by Legionella pneumophila serogroup 6. Intern Med. 2012;51(22):3207. Epub 2012 Nov 15 • de Lassence A, Matsiota-Bernard P, Valtier B, et al A case of myocarditis associated with Legionnaires' disease. Clin Infect Dis. 1994;18(1):120 • Armengol S, Domingo C, Mesalles E. Myocarditis: a rare complication during Legionella infection. Int J Cardiol. 1992;37(3):418. • Burke PT, Shah R, 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. • Schaumann R, Pönisch W, Helbig JH et al., Pericarditis after allogeneic peripheral blood stem cell transplantation caused by Legionella pneumophila (non-serogroup 1). Infection. 2001;29(1):51 • Sviri S, Raveh D, Boldur I et al. Legionella feeleii pneumonia and pericarditis. J Infect. 1997;34(3):277. • Scerpella EG, Whimbey EE, Champlin RE, Bodey GP Pericarditis associated with Legionnaires' disease in a bone marrow transplant recipient. Clin Infect Dis. 1994;19(6):1168. BIBLIOGRAPHY Extrapulmonary Legionellosis

EXTRA PULMONARY IV • Fukuta Y, Yildiz-Aktas IZ, William Pasculle A,et al. Legionella micdadei prosthetic valve endocarditis complicated by brain abscess: case report and review of the literature. Scand J Infect Dis. 2012;44(6):414. Epub 2012 Jan 11 • Leggieri N, Gouriet F, Thuny F, et al. Legionella longbeachae and endocarditis. Emerg Infect Dis. 2012;18(1):95 • Patel MC, Levi MH, Mahadevi P ,et al. L. micdadei PVE successfully treated with levofloxacin/valve replacement: case report and review of the literature. J Infect. 2005;51(5):e265. Epub 2005 Jul 5. • Dorman SA, Hardin NJ, Winn WC Jr Pyelonephritis associated with Legionella pneumophila, serogroup 4. Ann Intern Med. 1980;93(6):835. • Perpoint T, Jamilloux Y, Descloux E, et al. PCR-confirmed Legionella non-pneumophila meningoencephalitis. Med Mal Infect. 2013;43(1):32. Epub 2013 Jan 29 • Charles M, Johnson E, Macyk-Davey A, et al Legionella micdadei brain abscess. J Clin Microbiol. 2013;51(2):701. Epub 2012 Dec 5. • Guy SD, Worth LJ, Thursky KA, et al Legionella pneumophila lung abscess associated with immune suppression. Intern Med J. 2011;41(10):715. • Andersen BB, Søgaard I Legionnaires' disease and brain abscess. Neurology. 1987;37(2):333. • Lowry PW, Blankenship RJ, Gridley W, et al A cluster of legionella sternal-wound infections due to postoperative topical exposure to contaminated tap water. N Engl J Med. 1991;324(2):109 • IV Guy SD, Worth LJ, Thursky KA, et al Legionella pneumophila lung abscess associated with immune suppression. Intern Med J. 2011;41(10):715. • Andersen BB, Søgaard I Legionnaires' disease and brain abscess. Neurology. 1987;37(2):333. • Lowry PW, Blankenship RJ, Gridley W, et al A cluster of legionella sternal-wound infections due to postoperative topical exposure to contaminated tap water. N Engl J Med. 1991;324(2):109