Probable caso de reinfección grave por SARS-CoV-2 con coinfección por Legionella pneumophila / Probable case of severe SARS-CoV-2 reinfection with Legionella pneumophila co-infection

Resumen La inmunidad conferida luego de una primera infección por SARS-CoV-2 y el riesgo consiguiente de infección persistente o reinfección no están completamente dilucidados. Existen reportes internacionales de casos de reinfección, incluyendo el primer caso publicado en Sudamérica. Por otra parte, las comunicaciones de casos de coinfecciones han ido en aumento, incluyendo las asociadas a Legionella pneumophila . Presentamos el caso de un varón de 47 años de edad, personal de salud, que luego de cuatro meses de una primera infección por SARS-CoV-2, presenta una neumonía grave, certificándose una nueva infección por SARS-CoV-2 y una coinfección por L. pneumophila mediante detección de antígeno urinario. Fue tratado en UCI, requiriendo ventilación mecánica, dexametaxona y moxifloxacino, con buena respuesta clínica. Actualmente se encuentra en rehabilitación respiratoria y motora.

Abstract The immunity conferred after a first SARS-CoV-2 infection and the consequent risk of persistent infection or reinfection are not fully elucidated. There are reports both in Europe and in North America of reinfection cases, recently highlighting the first case published in South America. On the other hand, reports of co-infections have been increasing, including those associated with Legionella pneumophila . We present the case of a 47-year-old male, health personnel who, after four months of a first SARS-CoV-2 infection, suffers a severe pneumonia certifying a new SARS-CoV-2 infection and a L. pneumophila co-infection by urinary antigen detection. He was treated in the ICU, requiring mechanical ventilation, dexamethasone, and moxifloxacin, with a good response. He is currently in respiratory and motor rehabilitation.

Legionella pneumophila: un patógeno emergente en Argentina / Legionella pneumophila: an emerging pathogen in Argentina

La enfermedad del Legionario es causada por bacterias pertenecientes al género Legionella, siendo la especie pneumophila el principal agente etiológico de esta patología. Esta bacteria se describió por primera vez en 1977 como causa de un brote de neumonía grave registrado en 1976 en un centro de convenciones en los Estados Unidos de América. La enfermedad se presenta como una neumonía atípica, responsable del 1 al 15 % de los casos de neumonías adquiridas en la comunidad (NAC), del 5 al 10% de neumonías del adulto y del 1% en menores de 15 años. Los miembros de la familia Legionellaceae son bacilos aeróbicos gramnegativos que crecen lentamente y se encuentran ampliamente distribuidos en cuerpos de agua. La forma más común de transmisión de Legionella spp es la inhalación de aerosoles contaminados generados a partir de fuentes de agua artificiales. Se asocian con la aparición de brotes esporádicos y epidémicos en la comunidad y en infecciones nosocomiales. Las especies pertenecientes al género Legionella se consideran patógenos emergentes transmitidos por el agua. El objetivo de este trabajo es realizar una revisión sobre las manifestaciones y presentaciones clínicas de la infección causada por L. pneumophila, en virtud de que es considerado mundialmente un patógeno emergente y por existir evidencias de su presencia en sistemas de almacenamiento de agua tratada en la región nordeste de la República Argentina, razón primordial para alertar y actualizar conocimientos al respecto

Legionnaires' disease is caused by bacteria belonging to the genus Legionella, being the pneumophila specie the main etiological agent of this pathology. This bacterium was first described in 1977 as the cause of a severe pneumonia outbreak in 1976 at a convention center in the United States of America. The disease presents as an atypical pneumonia, responsible for 1% to 15% of cases of community-acquired pneumonia (CAP), 5% to 10% of pneumonia in adults and 1% in children under 15 years of age. Members of the Legionellaceae family are aerobic, gram-negative rods that grow slowly and are widely distributed in water bodies. The most common way of transmission of Legionella spp is the inhalation of contaminated aerosols generated from artificial water sources. They are associated with the appearance of sporadic and epidemic outbreaks in the community and in nosocomial infections. Species belonging to the genus Legionella are considered emerging waterborne pathogens.The aim of this work is to carry out a review on the manifestations and clinical presentations of the infection caused by L. pneumophila, due to that it is considered an emerging pathogen worldwide and because there is evidence of its presence in storage systems of treated water in the Northeast region of the Argentine Republic, primary reason to alert and update knowledge in this regard.

Identificação molecular de amostras de Legionella pneumophila provenientes de fontes ambientais / Molecular identification of samples of Legionella pneumophila from environmental sources

Legionella pneumophila (Lp) é uma bactéria Gram negativa encontrada em ambientes aquáticos naturais e artificiais nos quais a inalação de aerossóis contaminados pode causar uma pneumonia severa conhecida como Doença dos Legionários com taxa de mortalidade de 10% em indivíduos saudáveis. No Brasil há poucas informações a respeito deste patógeno, mas sabe se que a Pneumonia Adquirida na Comunidade foi responsável por 598.668 hospitalizações e 52.776 mortes só no ano de 2017 e acredita-se que uma porcentagem significativa desses casos seja causada pela Lp. Além disso, os casos de legioneloses vêm crescendo ao redor do mundo e um dos fatores associados a isto é o aumento de sistemas artificiais de água e da exposição humana a fontes contaminadas. A única forma de prevenir a doença dos legionários é pelo controle e tratamento destes ambientes artificiais, especialmente aqueles em grandes edifícios. Sendo assim, o objetivo deste estudo foi caracterizar amostras de Legionella spp. provenientes de fontes ambientais previamente identificadas pela Conforlab. O estudo contou com 50 amostras de Legionella spp. isoladas em meio BCYE a partir de diversas fontes ambientais em nove estados brasileiros fornecidas pela empresa Conforlab. A identificação molecular das amostras foi realizada pela técnica Sequence-based Typing que consiste no sequenciamento e análise de sete genes para a obtenção de um Sequence Type (ST)As amostras foram obtidas de amostras provenientes de hotéis, centros comerciais, laboratórios, empresa e indústria. Cerca de 70% das amostras são da região sudeste do país e 50% do estado de São Paulo. Foram identificados 11 STs entre 34 amostras, dos quais oito são previamente descritos e três STs novos (ST2960, ST2962 e ST2963). Dois complexos clonais foram identificados CC-ST1 e CC-ST1642. O novo ST2960 foi identificado em quatro diferentes torres de resfriamento. O sequenciamento genômico foi realizado em duas amostras de Legionella spp. no qual a sequência da amostra 20935 corresponde a espécie Lp enquanto o outro genoma apresentou maior similaridade com a espécie Legionella anisa, sendo essa a segunda espécie do gênero mais encontrada em amostras de água. Como esperado ST1 foi prevalente, pois é amplamente distribuído na maioria dos países, e os outros STs previamente descritos estão associados às legioneloses em outros países. Dado o grande número de casos de pneumonia anualmente, estima-se que ocorra no Brasil cerca de seis mil óbitos por ano devido à doença dos legionários. Portanto, é necessário que medidas de vigilância e controle da presença de Legionella spp. sejam implementadas, além da realização de mais estudos para a maior compreensão deste patógeno no país. (AU)

Evaluación de la viabilidad de Legionella pneumophila en muestras de agua / Evaluation of the viability of Legionella pneumophila in water samples

Introducción: Legionella pneumophila se sitúa entre los principales agentes causales de neumonía adquirida en la comunidad y de origen nosocomial. La inhalación de aerosoles potencialmente contaminados con la bacteria, producto de la colonización de redes y otros sistemas que utilizan agua, representa un peligro para la salud de los individuos expuestos. Objetivo: evaluar la viabilidad de L. pneumophila en muestras de agua almacenadas en diferentes intervalos de tiempo para el diagnóstico por cultivo microbiológico de Legionella spp. Métodos: Se contaminaron artificialmente muestras de agua con dos cepas de L. pneumophila de serogrupos diferentes y la conformación de una mezcla de ellas, para un total de 15 muestras. Los frascos contaminados fueron procesados a las 24 h, 72 h, 7 días, 14 días y 21 días. Se realizó cultivo microbiológico según ISO 11731: 2004 y PNO 03-013: 2015. Resultados: Se demostró viabilidad de la bacteria en muestras almacenadas hasta 21 días. El método de concentración por filtración resultó tener los mayores recobrados del microorganismo. Conclusiones: El tiempo de almacenamiento de las muestras afecta la viabilidad de L. pneumophila. Sienta las bases para estudios posteriores de robustez del diagnóstico de L. pneumophila como parte del servicio que presta el Centro de Investigaciones Científicas de la Defensa Civil en los programas de prevención y control Legionella spp. en instalaciones de interés turístico e industrial(AU)

Introduction: Legionella pneumophila is one of the main causative agents of community- and hospital-acquired pneumonia. Inhalation of sprays potentially contaminated with the bacterium, due to the colonization of networks and other systems using water, is a hazard to the health of exposed individuals. Objective: Evaluate the viability of L. pneumophila in samples of water stored at various time intervals for the microbiological culture diagnosis of Legionella spp. Methods: Water samples were artificially contaminated with two strains of L. pneumophila from different serogroups and a mixture of them, for a total of 15 samples. The contaminated vessels were processed at 24 h, 72 h, 7 d, 14 d and 21 d. Microbiological culture was performed in compliance with ISO 11731: 2004 and PNO 03-013: 2015. Results: The bacterium was found to be viable in samples stored up to 21 days. The filtration concentration method obtained the greatest amount of the microorganism. Conclusions: Storage time of the samples affects the viability of L. pneumophila. The study lays the foundations for further research about the validity of L. pneumophila diagnosis as part of the service offered by the Civil Defense Scientific Research Center in Legionella spp. prevention and control programs for tourist and industrial facilities(AU)

Legionelosis ocupacional en mayores de 18 años: revisión sistemática / Occupational legionella in adults over 18 years pf age: a systematic review

Resumen El objetivo es revisar la literatura científica sobre los problemas de salud derivados de la exposición laboral a Legionella spp. Revisión sistemática de la literatura científica recogida en las bases de datos MEDLINE (Pubmed), ISI-Web of Science (Institute for Scientific Information), Cochrane Library Plus, Literatura Latinoamericana de Información en Ciencias de la Salud (LILACS) y SCOPUS, hasta febrero 2015. Los descriptores utilizados fueron: "Legionnaires' Disease" "Legionellosis" "Occupational Exposure" "Occupational Diseases". Se obtuvieron 222 referencias, que tras aplicar los criterios de inclusión y exclusión, se seleccionaron 13 artículos a texto completo. De ellos 9 artículos describen la aparición de neumonía, 4 Fiebre de Pontiac, 1 legionelosis o presunta legionelosis y 3 muerte. El principal agente causal en los profesionales expuestos fue Legionella pneumophila serogrupo 1. La infección por legionela está ligada a las profesiones donde existe nebulización por agua, principalmente en los trabajadores sometidos a largas exposiciones o incluso a la re-exposición. Los brotes se producen de forma estacional, sobre todo en los meses más cálidos.

Abstract The scope of this paper is to review the available scientific literature about the effects on health of occupational exposure to Legionella spp. A systematic review of the scientific literature retrieved from the MEDLINE (via PubMed), ISI-Web of Science (Institute for Scientific Information), Cochrane Library, LILCAS and SCOPUS databases through February 2015 was conducted. The key words used were ««Legionnaires' Disease¼ «Legionellosis¼ «Occupational Exposure¼ «Occupational Diseases¼. Two hundred and twenty-two references were retrieved of which, after applying inclusion/exclusion criteria, 13 complete articles were selected. Of these, 9 describe pneumonia, 4 list Pontiac Fever, 1 reveals legionellosis and 3 result in death. The main causative agent of disease in workers exposed was Legionella pneumophila serogroup 1. Legionella spp infection is closely related to professions where there is nebulization with water, mainly among workers subjected to long exposure or even re-exposure. Outbreaks occurs seasonally, especially in the hottest months.

Epidemiology of Legionella and Climatic Variables in Seoul, Korea

Legionella species are abundant in the built environment and are increasingly recognized as a cause of Legionnaires' disease (LD). As the number of cases of Legionnaires' disease acquired by local communities in the Seoul metropolitan area in Korea has been increased, there was concern that changes in environmental factors could affect disease outbreaks. We described the association between climatic variables and occurrence of legionellosis in Korea and Legionella detection rate in Seoul area. A total of 418 cases of legionellosis were reported between 2014 and 2017. There was a seasonal peak in summer. LD continuously occurred from early spring to winter every year and rapidly increased in summer. In the regression analysis, the primary variables of interest- PM2.5 (µg/m³), NO₂ (ppb), and a number of the date of issue O₃ warning were not significant except for average temperature (R²=0.8075). The Legionella detection rate in Seoul, Korea showed a trend similar to precipitation (P=0.708, ANOVA). A relatively high proportion of Legionella detection rate was shown, especially cooling tower (17.7%) and public bath (19.3%). This finding is in line with current understanding of the ecological profile of this pathogen and supports the assertion that legionellosis occurs through contamination of water sources.

An investigation of virulence factors of Legionella pneumophila environmental isolates

ABSTRACT Nine Legionella pneumophila strains isolated from cooling towers and a standard strain (L. pneumophila serogroup 1, ATCC 33152, Philadelphia 1) were analyzed and compared in terms of motility, flagella structure, ability to form biofilms, enzymatic activities (hemolysin, nucleases, protease, phospholipase A, phospholipase C, acid phosphatase, alkaline phosphatase and lipase), hemagglutination capabilities, and pathogenicity in various host cells (Acanthamoeba castellanii ATCC 30234, mouse peritoneal macrophages and human peripheral monocytes). All the isolates of bacteria appeared to be motile and polar-flagellated and possessed the type-IV fimbria. Upon the evaluation of virulence factors, isolate 4 was found to be the most pathogenic strain, while 6 out of the 9 isolates (the isolates 1, 2, 3, 4, 5, and 7) were more virulent than the ATCC 33152 strain. The different bacterial strains exhibited differences in properties such as adhesion, penetration and reproduction in the hosts, and preferred host type. To our knowledge, this is the first study to compare the virulence of environmental L. pneumophila strains isolated in Turkey, and it provides important information relevant for understanding the epidemiology of L. pneumophila.

Community-acquired Legionnaires’ Disease in a Newly Constructed Apartment Building / 예방의학회지

OBJECTIVES: Legionnaires' disease (LD) is a severe type of pneumonia caused by inhalation of aerosols contaminated with Legionella. On September 22, 2016, a single case of LD was reported from a newly built apartment building in Gyeonggi province. This article describes an epidemiologic investigation of LD and identification of the possible source of infection. METHODS: To identify the source of LD, we interviewed the patient's husband using a questionnaire based on the Legionella management guidelines from the Korea Centers for Disease Control and Prevention. Water samples from the site were collected and analyzed. An epidemiological investigation of the residents and visitors in the apartment building was conducted for 14 days before the index patient's symptoms first appeared to 14 days after the implementation of environmental control measures. RESULTS: Legionella pneumophila serogroup 1 was isolated from the heated-water samples from the patient's residence and the basement of the apartment complex. Thirty-two suspected cases were reported from the apartment building during the surveillance period, yet all were confirmed negative based on urinary antigen tests. CONCLUSIONS: The likely source of infection was the building's potable water, particularly heated water. Further study of effective monitoring systems in heated potable water should be considered.

A case of Legionella pneumonia with multiple organ failure / 中南大学学报(医学版)

Legionella pneumonia (LP) is a rare systemic infectious disease, which is often misdiagnosed by clinicians due to the atypical symptoms. A middle-aged man who suffered from fever and dyspnea was diagnosed as community acquired pneumonia (CAP) in Changsha Central Hospital in March 2015. The treatment was unsatisfied firstly. The patients showed further symptoms of rhabdomyolysis, acute liver and renal failure, and impaired neural functions, who was diagnosed as LP with multiple organ failure based on a positive test for Legionella antibody. The patient was recovered after treated with moxifloxacin combined with azithromycin and continuous renal replacement therapy. LP should be paid attention when patient was diagnosed as CAP and failed to be treated. The satisfied outcome is achieved after application of macrolide, quinolones and comprehensive treatments.

Factores pronósticos en adultos hospitalizados por neumonía causada por Legionella pneumophila / Prognostic factors in adult patients hospitalized for pneumonia caused by Legionella pneumophila

Introduction: Legionellosis is a multisystem bacterial disease, which causes pneumonia with high mortality in patients with comorbidity and admitted in intensive care units (ICU). Objective: Determine predictors of mortality or ICU admission. Methods: Retrospective follow-up of patients diagnosed with Legionella pneumophila pneumonia in Complexo Hospitalario Universitario de A Coruña. Period 2000-2013 (n = 240). Analysis of multivariate logistic regression was performed. Results: Mean age was 57.2 ± 15.4 years old, 88.3% were male. Average score of comorbidity (Charlson score) was 2.3 ± 2.3. There was a clear seasonal variation. Predominant symptoms were fever (92.5%), dry cough (38.1%) and dyspnea (33.9%). Creatinine clearance was lower than 60 mL/min/1.73 m² in 29.7% and sodium < 135 mEq/l in 58.3%. Admission to ICU rate was 16.3% and 10.8% needs mechanical ventilation. Inhospital mortality rate was 4.6%, rising to 23.1% in patients admitted to ICU. Variables associated to predict ICU admission were age (OR = 0.96), liver disease (OR = 7.13), dyspnea (OR = 4.33), delirium (OR = 5.86) and high levels of lactatedehydrogenase (OR = 1.002). Variables associated with inhospital mortality were Charlson index (OR = 1.70), mechanical ventilation (OR = 31.44) and high levels of lactatedehydrogenase (OR = 1.002). Discussion: Younger patients with liver disease, dyspnea and confusion are more likely to be admitted to ICU. Comorbidity, mechanical ventilation and elevated LDH levels are associated with higher mortality rate.

Introducción: La legionelosis es una enfermedad bacteriana multisistémica, causante de neumonías con mortalidad elevada en pacientes con comorbilidad e ingresos en Unidad de Cuidados Intensivos (UCI). Objetivo: Determinar factores pronósticos de mortalidad o ingreso en UCI. Material y Métodos: Estudio de seguimiento retrospectivo de pacientes diagnosticados de neumonía por Legionella pneumophila en Complexo Hospitalario Universitario de A Coruña (España). Período 2000-2013 (n = 240), con análisis de regresión logística multivariada. Resultados: La edad media fue 57,2 ± 15,4 años, 88,3% fueron hombres. La puntuación media de comorbilidad (score Charlson) fue 2,3 ± 2,3. Existe clara estacionalidad. La clínica predominante fue fiebre (92,5%), tos seca (38,1%) y disnea (33,9%). El 29,7% presentó aclaramiento de creatinina < 60 mL/min/1,73 m² y el 58,3% sodio < 135 mEq/l. Un 16,3% ingresó en UCI, precisando ventilación mecánica invasiva el 10,8%. La mortalidad global fue 4,6% y de 23,1% en ingresados en UCI. Variables asociadas para predecir ingreso en UCI fueron menor edad (OR = 0,96), hepatopatía (OR = 7,13), disnea (OR = 4,33), síndrome confusional (OR = 5,86) y lactato deshidrogenasa elevada (OR = 1,002). Las variables asociadas a mortalidad intrahospitalaria fueron índice de Charlson (OR = 1,70), ventilación mecánica invasiva (OR = 31,44) y cifras elevadas de lactato deshidrogenasa (OR = 1,002). Discusión: Pacientes jóvenes, con hepatopatía, disnea o confusión tienen más probabilidad de ingresar en UCI. Comorbilidad, ventilación mecánica y lactato deshidrogenasa elevada se asocian a mortalidad.

Pneumonia por Legionella após uso de Infliximabe em paciente com Artrite Reumatoide / Legionella pneumonia after infliximab in a patient with Rheumatoid Arthritis

Os antagonistas do fator de necrose tumoral (anti-TNF) têm sido utilizados com sucesso em várias doenças inflamatórias crônicas, como artrite reumatoide (AR), mas alguns estudos observaram a ocorrência de infecções por patógenos intracelulares em pacientes medicados com anti-TNF. Relatamos um caso de paciente mulher com diagnóstico prévio de AR durante 16 anos e que estava sendo medicada com várias drogas antirreumáticas modificadoras de doença (DARMDs), tendo como resultado o insucesso terapêutico, sendo em seguida tratada com infliximab. Depois de transcorridos 15 dias da segunda dose, a paciente foi acome- tida por dor torácica ventilatório-dependente, tosse seca e dispneia. Foi hospitalizada, e o diagnóstico de pneumonia por Legionella pneumophila foi confirmado pela presença do antí- geno de Legionella na urina. TNF é uma citocina inflamatória que também promove inibição do crescimento bacteriano de patógenos intracelulares, e sua inibição parece aumentar a sensibilidade a essas infecções em alguns pacientes.

The antagonists of tumour necrosis factor (anti-TNF) have been successfully used in several chronic inflammatory diseases such as Rheumatoid Arthritis (RA), but some studies have observed the development of infections by intracellular pathogens in patients using anti-TNF. We report a case of a female patient with previous diagnosis of RA for 16 years that used several disease-modifying anti-rheumatic drugs (DMARDs) that resulted in treatment failure, and then was treated with infliximab. After fifteen days of the second dose, the patient developed ventilatory-dependent chest pain, dry cough and dyspnea. She was hospitalized, and the diagnosis of pneumonia by Legionella pneumophila was confirmed by the presence of Legionella antigen in an urine test. TNF is an inflammatory cytokine that also acts inhibiting the bacterial growth of intracellular pathogens, and its inhibition seems to increase susceptibility to these infections in some patients.

Molecular Characterization of Legionellosis Drug Target Candidate Enzyme Phosphoglucosamine Mutase from Legionella pneumophila (strain Paris): An In Silico Approach

The harshness of legionellosis differs from mild Pontiac fever to potentially fatal Legionnaire's disease. The increasing development of drug resistance against legionellosis has led to explore new novel drug targets. It has been found that phosphoglucosamine mutase, phosphomannomutase, and phosphoglyceromutase enzymes can be used as the most probable therapeutic drug targets through extensive data mining. Phosphoglucosamine mutase is involved in amino sugar and nucleotide sugar metabolism. The purpose of this study was to predict the potential target of that specific drug. For this, the 3D structure of phosphoglucosamine mutase of Legionella pneumophila (strain Paris) was determined by means of homology modeling through Phyre2 and refined by ModRefiner. Then, the designed model was evaluated with a structure validation program, for instance, PROCHECK, ERRAT, Verify3D, and QMEAN, for further structural analysis. Secondary structural features were determined through self-optimized prediction method with alignment (SOPMA) and interacting networks by STRING. Consequently, we performed molecular docking studies. The analytical result of PROCHECK showed that 95.0% of the residues are in the most favored region, 4.50% are in the additional allowed region and 0.50% are in the generously allowed region of the Ramachandran plot. Verify3D graph value indicates a score of 0.71 and 89.791, 1.11 for ERRAT and QMEAN respectively. Arg419, Thr414, Ser412, and Thr9 were found to dock the substrate for the most favorable binding of S-mercaptocysteine. However, these findings from this current study will pave the way for further extensive investigation of this enzyme in wet lab experiments and in that way assist drug design against legionellosis.

Chest radiographic characteristics of community-acquired Legionella pneumonia in the elderly / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Legionella is an important community-acquired pneumonia pathogen. Although the elderly are especially susceptible to Legionella, few studies have looked at comparative radiographic features of Legionella pneumonia in this population. The aim of this study was to explore the chest radiographic characteristics of community-acquired Legionella pneumonia in the elderly.</p><p><b>METHODS</b>Serial chest radiographs obtained in 34 patients hospitalized with serologically proven Legionella pneumonia were retrospectively reviewed. Chest X-ray features of an aged group of ≥ 65 years were assessed and compared with a non-aged group of <65 years old with regard to initial patterns and distributions of pulmonary abnormalities, accompanying signs, and progression.</p><p><b>RESULTS</b>The most common initial presentation was a patchy alveolar infiltrate involving a single lobe, most often the lower lobe. There was no middle or lingular lobe involvement in the aged group patients, but bilateral pleural effusion was significantly more common in this group. In the aged group patients, radiographic progression following adequate therapy, despite a clinical response, was more often noted and the radiographs were less likely to have returned to the premorbid state at discharge, but the differences were not significant between the two groups.</p><p><b>CONCLUSION</b>The discrepancy between imaging findings and clinical symptoms seems more prominent in community-acquired Legionella pneumonia in the elderly.</p>

Application of three uniplex polymerase chain reaction assays for the detection of atypical bacteria in asthmatic patients in Kuwait

Respiratory infections are known to exacerbate wheezing in many asthmatic patients. We aimed to use molecular methods for the fast detection of Mycoplasma pneumoniae, Chlamydia pneumoniae and Legionella pneumophila in respiratory specimens from asthmatic patients in Kuwait. We used uniplex PCR assays to detect the three atypical bacteria in clinical specimens from 235 asthmatic and non-asthmatic patients in Kuwait. A regression analysis was used to identify the risk factors related to the bacterial type. Group comparisons for similarity were conducted and correlation coefficients were calculated using SPSS statistical software. The detection limits using uniplex PCR for C. pneumoniae, L. pneumophila and M. pneumoniae were approximately 1 pg, 2.4 fg and 12 pg of DNA, respectively. M. pneumoniae PCR positivity was more common in asthmatic patients [15%] than in non-asthmatic subjects [9%] [P < 0.05]. A marked difference was observed between patients with acute asthma exacerbation [11%] and patients with chronic [stable] asthma [7%] among Kuwaiti patients; these percentages were 16% for non-Kuwaiti acute asthma patients and 14% for non-Kuwaiti chronic asthma patients [P < 0.201]. There was a weak positive correlation between asthma severity and PCR positivity for M. pneumoniae. The PCR results for C. pneumoniae and L. pneumoniae were found to be statistically insignificant. The results of this study suggest that infection with M. pneumoniae may be related to the exacerbation of asthma symptoms and could possibly be a factor that induces wheezing

Endogenous lipoid pneumonia associated with Legionella pneumophila serogroup 1

Endogenous lipoid pneumonia is an uncommon condition. This is a report of a 29-year-old woman diagnosed with endogenous lipoid pneumonia associated with Legionella pneumophila serogroup 1 infection. The patient's endogenous lipoid pneumonia resolved completely after treatment for Legionella pneumophila infection. This suggests that early diagnosis and aggressive treatment of the underlying infection may prevent any long-term sequelae of lipoid pneumonia.

Detección por PCR múltiple de gérmenes atípicos en pacientes con neumonía adquirida de la comunidad que concurrieron al INERAM / Multiplex PCR for detection of atypical bacteria in community-acquired pneumonia patients attending INERAM Hospital

La neumonía adquirida en la comunidad (NAC) es una causa relevante de morbilidad y mortalidad. Los métodos convencionales fracasan en la detección de Mycoplasma pneumoniae, Chlamydophila pneumoniae y Legionella pneumophila. Estas bacterias pueden generar procesos infecciosos crónicos y no responden a ciertos antibióticos empleados en el tratamiento empírico de la NAC. Nuestro objetivo fue detectar de forma simultánea, mediante métodos moleculares, M. pneumoniae, C. pneumoniae y L. pneumophila en muestras respiratorias de pacientes con NAC, y describir los gérmenes comunes aislados por métodos microbiológicos convencionales. Estudio observacional descriptivo de corte trasverso realizado en el año 2011, en el que se analizaron 60 muestras respiratorias provenientes de pacientes con NAC atendidos en el INERAM (Instituto de Enfermedades Respiratorias y del Ambiente). Para la PCR múltiple se emplearon primers específicos para genes de los tres microorganismos citados. El protocolo de estudio fue aprobado por los comités científico y ético del IICS y se mantuvieron en estricta confidencialidad los datos personales de los pacientes. La PCR múltiple permitió la amplificación de los genes específicos de estos microorganismos con límites de sensibilidad comprendidos entre 0,05 y 0,001 ng/µL de ADN. M. pneumoniae y C. pneumoniae estuvieron presentes respectivamente en el 18,3% y 1,7% del total de muestras analizadas. No se detectó la presencia de L. pneumophila. Los gérmenes comunes más frecuentemente aislados fueron estreptococos del grupo viridans y Candida spp.La técnica de PCR múltiple permitió detectar M. pneumoniae, C. pneumoniae y L. pneumophila, siendo el primero de los tres el más frecuentemente detectado en pacientes con NAC

Multiple regression as a preventive tool for determining the risk of Legionella spp / La técnica de regresión múltiple como herramienta preventiva para determinar el riesgo de Legionella sp / A técnica de regressão múltipla como uma ferramenta preventiva para determinar o risco de Legionella sp

Objective. To determine the interrelationship between health & hygiene conditions for prevention of legionellosis, the composition of materials used in water distribution systems, the water origin and Legionella pneumophila risk. Material and methods. Include a descriptive study and multiple regression analysis on a sample of golf course sprinkler irrigation systems (n=31) pertaining to hotels located on the Costa del Sol (Malaga, Spain). The study was carried out in 2009. Results. Presented a significant lineal relation, with all the independent variables contributing significantly (p<0.05) to the model's fit. The relationship between water type and the risk of Legionella, as well as the material composition and the latter, is lineal and positive. In contrast, the relationship between health-hygiene conditions and Legionella risk is lineal and negative. Conclusion. The characterization of Legionella pneumophila concentration, as defined by the risk in water and through use of the predictive method, can contribute to the consideration of new influence variables in the development of the agent, resulting in improved control and prevention of the disease.

Objetivo. Determinar el riesgo de Legionella pneumophila en relación a las condiciones higiénico- sanitarias para la prevención de la legionelosis, la composición de los materiales conductores de agua y el origen de la misma. Material y métodos. Incluyen un estudio descriptivo y análisis de regresión múltiple realizado sobre una muestra de sistemas de riego por aspersión de campos de golf (n=31) correspondientes a hoteles ubicados en la Costa del Sol (Málaga, España). El estudio se realizó en el año 2009. Resultados. Mostraron una relación lineal significativa, contribuyendo todas las variables independientes significativamente (p<0,05) al ajuste del modelo. La relación entre el tipo de agua y el riesgo de Legionella y de la composición del material con esta última, es lineal y positiva. En cambio, es lineal y negativa para la relación entre las condiciones higiénico- sanitarias y el riesgo de Legionella. Conclusión. La caracterización de la concentración de Legionella pneumophila definida a través del riesgo de la misma en el agua y mediante el empleo del método predictivo, contribuye a la consideración de nuevas variables de influencia en el desarrollo del agente y a un mejor control y prevención de la enfermedad.

Objetivo. Determinar o risco de Legionella pneumophila em relação às condições higiénicas e sanitárias para a prevenção da legionelose, a composição dos materiais condutores da água e a origem da mesma. Materiais e métodos. Incluem uma pesquisa descritiva e uma análise de regressão múltipla realizada em uma amostra de sistemas de irrigação por aspersão de campos de golfe (n = 31) para os hotéis situados na "Costa del Sol" (Málaga, Espanha). O estudo foi realizado em 2009. Resultados. Mostraram uma relação linear significativa, contribuindo todas as variáveis independentes significativamente (p <0,05) ao ajuste do modelo. A relação entre o tipo de água e o risgo de Legionella, assim como a composição do material com esta última, é linear e positiva. Por outro lado, é linear e negativa para a relação entre as condições higiénicas e sanitárias e o risco de Legionella. Conclusão. A caracterização da concentração de Legionella pneumophila definida através do risco da mesma na água e mediante o uso do método preditivo, contribui para a consideração de novas variáveis que influenciam no desenvolvimento do agente e a um melhor controle e prevenção da doença.

Comparison of Sputum and Nasopharyngeal Swab Specimens for Molecular Diagnosis of Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Legionella pneumophila

BACKGROUND: Differentiation of atypical pathogens is important for community-acquired pneumonia (CAP). In this study, we compared sputum and nasopharyngeal swabs (NPS) for use in detection of Mycoplasma pneumoniae (MP), Chlamydophila pneumoniae (CP), and Legionella pneumophila (LP), using Seeplex PneumoBacter ACE Detection Assay (PneumoBacter; Seegene). METHODS: Sputum and NPS specimens were collected from patients in 15 hospitals. DNA was extracted from sputum using QIAamp DNA Stool Mini Kit (Qiagen) and from NPS using easyMAG (bioMerieux). Both types of specimens were evaluated by multiplex PCR using PneumoBacter. To determine the diagnostic performance of this assay, sputum samples were also tested using BD ProbeTec ET Atypical Pneumonia Assay (APA; Becton Dickinson). RESULTS: Among 217 sputum and NPS, 20 (9.2%), 2 (0.9%), and 0 sputum were positive for MP, LP, and CP, respectively, whereas 8 (3.7%) NPS were positive for MP. The sputum APA test yielded 186, 206, and 204 interpretable results for MP, LP, and CP, respectively. Of these, 21 (11.3%) were positive for MP, 2 (1.0%) were positive for LP, and 0 samples were positive for CP. Compared to APA, the sensitivity and specificity of the sputum assay for MP were 95.2% and 100.0%, respectively, whereas for the NPS assay, these were 38.1% and 93.9%. Sputum testing was more sensitive than NPS testing (P=0.002). For LP and CP diagnosis, PneumoBacter and APA tests agreed 100%. CONCLUSIONS: Specimen type is crucial and sputum is preferred over NPS for simultaneous detection of MP, LP, and CP using multiplex PCR in CAP.

[Detection of Legionella pneumophila by sputum culture, direct immunofluorescence and PCR]

Community acquired pneumonia [CAP] is the main cause of mortality and morbidity world wide. Legionella pneumophila is identified as the fourth agent that causes CAP. The aim of this study was to define the prevalence of L. pneumophila among hospitalized children by culture, direct immune-fluorescence, [DFA] and PCR. In this study 210 sputum samples were collected from hospitalized children diagnosed with CAP. Samples were cultured on selective buffered charcoal-yeast extract agar [BCYE]. Existence of L. pneumophila among sputum samples was confirmed by culture, direct immunefluorescence and PCR. Our results for 210 hospitalized children showed that the sputum of 12 children, [5.7%] with acute respiratory infections was positive for L. pneumophila. Of the 12 positive samples 3, [25%] were detected by culture; 5 by DFA, [41.6%]; and 9 by PCR, [75%]. PCR is more sensitive than culture and DFA for detection of Legionella pneumonia in sputum samples