Muhammad Fuad Bangash, MD, FCCP
Chief, Pulmonary & Critical Care, Medical Director, ICU, Steward Norwood Hospital, Norwood, MA 02062, (USA)
E-mail:
lifesavericu@icloud.com
Since Midwest in USA is very cold during winters, I see many cases of pneumonia. But this was a case of ‘missed pneumonia. Á 49 year old African American male patient was not feeling well for two days and was admitted to the hospital with severe headache and high grade fever. Lumber puncture was performed and the patient was put on inj ceftriaxone and inj vancomycin. Chest x-ray was performed on admission, was unremarkable and did not show any infiltrates. An infectious disease consultant was involved in the care of this patient and on his recommendation ceftriaxone and vancomycin were stopped after 24 h, as there was no evidence of meningitis.
Patient’s condition did not improve and he continued to have fever upto 104
○ F and severe headache. He developed respiratory distress, so was transferred to the ICU and placed on BiPAP. Chest x-ray now showed extensive bilateral infiltrates. Patient was started on inj levofloxacin IV after cultures were obtained. His condition started to improve and he was weaned off BiPAP. Urine legionella antigen came back positive! This patient had legionella pneumonia. The initial ‘clear’ chest x-ray was likely due to dehydration, and the headache was related to the fever.
Legionella pneumonia is a can’t miss critical care catastrophe, which if missed can be fatal. I have seen another case of severe legionella pneumonia in a 22 year old college senior that led to ARDS.
Most guidelines for treating community acquired pneumonia recommend treatment covering ‘atypical’ pneumonia pathogens and this will cover legionella pneumonia. A clear chest x-ray on admission does not exclude pneumonia and if patient’s condition is not improving leading to high clinical suspicion, repeating a chest x-ray after hydration or obtaining a chest CT will be life-saving.