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Detection of Legionella Pneumophila, Mycoplasma Pneumoniae and Chlamydophila Pneumoniae As Aetiological Agents of Community – Acquired Pneumonia in Holy Makkah, KSA

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Detection of Legionella Pneumophila, Mycoplasma Pneumoniae and Chlamydophila Pneumoniae As Aetiological Agents of Community – Acquired Pneumonia in Holy Makkah, KSA Egyptian Journal of Medical Microbiology, April 2006 Vol. 15, No 2 Detection Of Legionella Pneumophila, Mycoplasma Pneumoniae And Chlamydophila Pneumoniae As Aetiological Agents Of Community – Acquired Pneumonia In Holy Makkah, KSA. Hassan Bokhary MD 1, Essam El-Gamal MD2, , Suzan El-Fiky MD 3. Al-Noor Specialist Hospital Holy Makkah KSA, Thoracic medicine Department 1. Thoracic Medicine Department, Al-Mansoura University, Egypt 2. Microbiology Department, Alexandria University, Egypt3. Atypical organisms such as Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella pneumophila are implicated in up to 40 percent of cases of community-acquired pneumonia. Culture is labor-intensive, takes several days to weeks for growth, and can be very insensitive for the detection of some of these organisms. Antibiotic treatment is empiric and includes coverage for both typical and atypical organisms.In the present study we investigate the occurrence Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella pneumophila as atypical pathogens responsible for considerable cases of atypical pneumonia.Among 71 bronchoalveolar lavage specimens taken from patients presented clinically with community-acquired pneumonia admitted to Al-noor specialist Hospital Holly Makkah, KSA., PCR results showed that 14 cases (19. 7 %) gave positive results for Mycoplasma pneumoniae,16 cases (22. 5%) gave positive results for Chlamydia pneumoniae and only 4 (5. 6%) cases gave positive results for Legionella pneumophila. All our patients were living in an air conditioned atmosphere due to high temperature in the holly Makkah city. Two(2. 8%) mortality cases from Legionella pneumophila were reported. Because of the non-specificity in clinical presentation of atypical pneumonia, specialized laboratory tests are necessary to establish the diagnosis. The PCR method is a rapid, sensitive and specific technique that has been applied to the detection of many infectious pathogens. Different PCR-based assays for the detection of Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella pneumophila in clinical specimens have been described. INTRODUCTION implicated in up to 40 percent of cases of community-acquired pneumonia. Antibiotic Community-acquired pneumonia treatment is empiric and includes coverage for (CAP) is commonly defined as an acute both typical and atypical organisms(2,3). infection of the lower respiratory tract Mycoplasma pneumoniae is primarily occurring in a patient who has not resided in a a respiratory pathogen that is responsible for hospital or healthcare facility in the previous approximately 15 to 20% of all community- 14 days. Current approaches to the empirical acquired pneumonias. The clinical management of CAP emphasise the type of presentation of patients with M. pneumoniae patient ("community" or "hospital"), rather infection is not significantly different from than the type of symptoms ("typical" or that of patients with infections caused by "atypical")(1,2). other respiratory pathogens such as CAP affects approximately 4. 5 Chlamydia pneumoniae, so diagnosis of million adults in the United States annually. infection relies primarily on laboratory About one third of these adults require testing. M. pneumoniae is, however, a hospitalization. The mortality rate among fastidious organism, requiring a laborious hospitalized patients with CAP varies each effort and 21 days or more for growth in year and can reach 35 percent. Atypical culture. Likewise, serology is lacking in pathogens are responsible for 30 to 40 percent sensitivity, has questionable specificity, and is of cases and may be copathogens in other dependent on specific collection times cases. Even with a knowledge of some of the relative to the onset of illness. DNA probes common characteristics of infections with have also been used, but cross-reactivity atypical organisms, determining the specific between M. pneumoniae and Mycoplasma pathogen on the basis of clinical, radiologic, genitalium has been observed, and methods and laboratory findings is difficult and usually that use these probes also lack sensitivity. done retrospectively, if at all (2). Numerous PCR approaches have been Atypical organisms such as developed to provide a rapid, sensitive Mycoplasma pneumoniae, Chlamydia method for the detection of M. pneumoniae. pneumoniae, and Legionella pneumophila are PCR targets have included the P1 adhesin 437 Egyptian Journal of Medical Microbiology, April 2006 Vol. 15, No 2 gene,the ATPase operon, genomic clones, or person spread has not been reported. a combination of these(4,5,6). Legionellae are found most commonly in M. pneumoniae infection occurs freshwater and man-made water systems. The throughout the year but can cause periodic pathogens also can be found in moist soil, outbreaks within small communities. especially near streams and ponds. Man-made Transmission is by person-to-person contact, systems for heating and cooling water can be and infection spreads slowly, most often prime environments for the proliferation of within closed populations (e. g., households, legionellae, because of conditions such as schools, businesses). Mycoplasma temperatures between 32°C (89.6°F) and pneumoniae causes a wide range of 45°C (113°F), stagnation of water, and the respiratory infections, including pneumonia, presence of scale sediment and amebas. tracheobronchitis, and upper respiratory tract Condensers, cooling towers, respiratory infection. Only 3 to 10 percent of persons therapy equipment, showers, water faucets, infected with M. pneumoniae develop and whirlpools have been associated with pneumonia. Because M. pneumoniae infection outbreaks of legionellosis(11,12). Risk factors becomes more common with increasing age, for the development of legionellosis include it is particularly important to consider this overnight stays outside the home, recent agent in elderly patients. The clinical course home plumbing work, renal or liver failure, of pneumonia caused by M. pneumoniae is diabetes, malignancy, and other conditions usually mild and self-limited. The mortality that compromise the immune system (13,14,15). rate is approximately 1. 4 percent. However, A properly designed PCR assay pulmonary complications can be significant could improve the speed, accuracy, and and include effusion, empyema, sensitivity of diagnosis of legionellosis. A pneumothorax, and respiratory distress PCR assay was developed in which the target syndrome(6,7). for the test is the 16S rRNA gene, which Chlamydia pneumoniae is an obligate exists in multiple copies per genome, thus intracellular organism capable of persistent improving the sensitivity of detection(16). latent infection. Humans are the only known reservoir. Transmission results from contact Because of the non-specificity in with respiratory secretions, with an incubation clinical presentation of atypical pneumonia, period of several weeks. Most cases of C. specialized laboratory tests are necessary to pneumoniae infection are mild, but severe establish the diagnosis. The PCR method is a disease can occur, necessitating admission to rapid, sensitive and specific technique that an intensive care unit. The mortality rate has has been applied to the detection of many been estimated to be 9 percent, and death infectious pathogens. Different PCR-based usually is associated with secondary infection assays for the detection of M. pneumoniae, C. and underlying co-morbid disease (8,9). pneumonia, and L. pneumophila in clinical C. pneumoniae infection has been specimens have been described (4,16,17). detected by serological methods but PCR is currently viewed as an advantageous AIM OF THE WORK alternative since it detects the presence of the This work aimed at; DNA of the organism. This allows for an Diagnosis of community acquired early and clinically relevant diagnosis in pneumonia caused by Legionella contrast to the detection of C. pneumoniae pneumophila, Mycoplasma pneumonia specific antibodies that develop late in the and Chlamydia pneumoniae in course of the infection (9). bronchoalveolar lavage (BAL) samples Like C. pneumoniae, Legionella obtained from population living in air species are intracellular organisms. conditioned atmosphere. Legionella pneumophila is the most pathogenic species, and several serotypes MATERIALS & METHODS have been identified. Serotype 1 has been associated with most reported human cases of Study Population. Makkah has a resident pneumonia caused by L. pneumonphila(1,10). population of 650,000 people. Al Noor Infection occurs from exposure to legionellae Specialist Hospital is a 520-bed, organisms in the environment. Person-to- multispeciality teaching hospital in 438 Egyptian Journal of Medical Microbiology, April 2006 Vol. 15, No 2 Makkah and is managed under a self with occasional vortexing until the pellet was operating program by the Ministry of completely lysed, which usually took 30 min. Health, Saudi Arabia. The hospital serves After lysis of the sample, 200 µl of buffer AL as a referral base for the province of was added to the sample and the mixture was Makkah in the Western region of Saudi incubated for 10 min at 70°C. The mixture Arabia. Between December 2004 to July was then combined with 200 µl of absolute 2005, 71 (37 males & 34 females ) ethanol and mixed by pulse-vortexing for cases were admitted to Al-Noor Specialist 15 s. The mixture was applied to a spin Hospital. The cases were presented column, which holds a silica gel membrane, clinically on admission with signs and and spun for 1 min
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