Legionella Pneumonia Associated with Adult Respiratory Distress Syndrome Caused by Legionella Pneumophila Serogroup 3

Abstract

A 68-year-old man developed pneumonia 2 days after nearly drowning in a bathtub of a hot spring spa. Chest radiography revealed bilateral consolidation shadows associated with adult respiratory distress syndrome. Initial treatment with antibiotics and pulse therapy with methylprednisolone was not effective. The patient died on the 4th hospital day. A urinary antigen test for Legionella was positive. Legionella pneumophila serogroup 3 was recovered from an intratracheal specimen. The same serotype of Legionella was isolated from the hot spring water. Restriction enzyme analysis by pulse-field gel electrophoresis revealed identical restriction fragments. We conclude that the water at the hot spring spa could have been the source of infection.

Legionellosis Associated with Recreational Waters: A Systematic Review of Cases and Outbreaks in Swimming Pools, Spa Pools, and Similar Environments

“…Most cases occurred in Japan (70.6%) [24,25,26,27,28,29,30,31,32,33,34,35], and hot spring/thermal waters (56.2%) were the facilities most involved, followed by private hot tubs (25%). Only two cases occurred in spa centres/public baths [35,36].…”

“…Only two cases occurred in spa centres/public baths [35,36]. Four cases, three of which fatal, were consequent to near drowning [20,32,35,37] and one case involved a 10-year-old girl, subjected to immunosuppressive therapy for hemosiderosis after being exposed several times to the hot tub in her maternal home [38]. …”

“…Only in three events is the water temperature specified, a factor that, in these types of recreational facilities, plays a fundamental role in the development of Legionella spp. and was probably co-responsible for three LD cases associated with near drowning in hot spring spas and public baths [32,35,37]. Lying in or sitting up to the neck in hot water (above 40 °C), especially in combination with alcohol consumption, may cause drowsiness, which may then lead to unconsciousness and, consequently, drowning [70].…”

Current and Emerging Legionella Diagnostics for Laboratory and Outbreak Investigations

“…1). Legionellae are frequently isolated from natural waters, but these sources are typically not implicated in direct transmission, with one possible exception being natural hot springs adapted for human bathing, such as public baths, which are popular in Japan and Taiwan, among other locations (86,(95)(96)(97)(98)(99)(100)(101). Aspiration of water containing Legionella has also been suggested to be a common transmission route (102), although the frequency with which this occurs is unclear.…”

Legionella pneumonia caused by Legionella pneumophila serogroup 2: second case report in Japan

“…7 With regard to L. pneumophila non-SG 1, as reported by Fuse et al 8 in Japan, L. pneumophila SG 6, 5, 3 causes pneumonia in order of frequency, and some severe clinical cases have been reported previously. 7,9 However, there is a small amount of L. pneumophila SG 2 in both clinical and environmental isolates around the world. We therefore found very few formal reports which might give an understanding of the distribution of L. pneumophila SG 2 in Legionella pneumonia patients, potable water, and spa facilities.…”