Abnormal Radiological Findings and a Decreased Carbon Monoxide Transfer Factor Can Persist Long after the Acute Phase of Legionella pneumophila Pneumonia

Clinical Infectious Diseases, Mar 2004

Pulmonary abnormalities may persist long after the acute phase of legionnaires disease (LD). In a cohort of 122 survivors of an outbreak of LD, 57% were still experiencing an increased number of symptoms associated with dyspnea at a mean of 16 months after recovery from acute-phase LD. For 86 of these patients, additional evaluation involving high-resolution computed tomography (HRCT) of the lung revealed pulmonary abnormalities in 21 (24%); abnormal HRCT findings generally presented as discrete and multiple radiodensities. Residual pulmonary abnormalities were associated with a mean reduction of 20% in the gas transport capacity of the lung. This latter sign could not be used to explain the increased symptoms of dyspnea reported by patients. Receipt of mechanical ventilation during the acute phase of LD, delayed initiation of adequate antibiotic therapy, and chronic obstructive pulmonary disease were identified as risk factors for the persistence of lung abnormalities.

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Abnormal Radiological Findings and a Decreased Carbon Monoxide Transfer Factor Can Persist Long after the Acute Phase of Legionella pneumophila Pneumonia

R. E. Jonkers () 2 3 4 K. D. Lettinga 1 2 4 T. H. Pels Rijcken 0 2 4 J. M. Prins 1 2 4 C. M. Roos 2 3 4 O. M. van Delden 0 2 4 A. Verbon 1 2 4 P. Bresser 2 3 4 H. M. Jansen 2 3 4 0 Department of Radiology, Academic Medical Center , Amsterdam , The Netherlands 1 Department of Internal Medicine, Division of Infectious Diseases , Tropical Medicine, and AIDS 2 Received 27 June 2003; accepted 7 October 2003; electronically published 17 February 2004. Financial support: Ministry of Health, The Netherlands (grant CSG/PP 1074808). Pulmonology Dept., Academic Medical Center , PO Box 22700, 1100 DE Amsterdam , The Netherlands 3 Department of Pulmonology 4 We thank Dr. G. J. Weverling, Department of Clinical Epi- demiology and Biostatistics, Academic Medical Center (Am- sterdam, The Netherlands) , for statistical advice Pulmonary abnormalities may persist long after the acute phase of legionnaires disease (LD). In a cohort of 122 survivors of an outbreak of LD, 57% were still experiencing an increased number of symptoms associated with dyspnea at a mean of 16 months after recovery from acute-phase LD. For 86 of these patients, additional evaluation involving high-resolution computed tomography (HRCT) of the lung revealed pulmonary abnormalities in 21 (24%); abnormal HRCT findings generally presented as discrete and multiple radiodensities. Residual pulmonary abnormalities were associated with a mean reduction of 20% in the gas transport capacity of the lung. This latter sign could not be used to explain the increased symptoms of dyspnea reported by patients. Receipt of mechanical ventilation during the acute phase of LD, delayed initiation of adequate antibiotic therapy, and chronic obstructive pulmonary disease were identified as risk factors for the persistence of lung abnormalities. - In a survey of 31 survivors of the classic 1976 outbreak of legionnaires disease (LD) in Philadelphia, a considerable proportion still had respiratory symptoms or a reduced carbon monoxide diffusion capacity (DLCO) after a follow-up period of 2 years [1]. Additional information on the persistence of such pulmonary symptoms and signs in survivors of LD is scarce. In one study, abnormal radiological findings were observed for at least several months after recovery from acute-phase LD [2]. In 2 small series, analysis of lung biopsy specimens obtained shortly after acute-phase LD revealed structural changes and fibrosis of the lung parenchyma [3, 4]. Taken together, these observations suggest that residual abnormalities in the lung parenchyma (hereafter, pulmonary abnormalities) resulting in functional disturbances may persist long after the clinical resolution from the acute phase of LD. It is unknown which factors predispose patients to such long-term pulmonary abnormalities. In March 1999, a large outbreak of LD occurred among individuals who visited a flower exhibition in The Netherlands [5]. This offered a unique opportunity to expand the knowledge on the long-term pulmonary sequelae of LD. We evaluated 122 survivors 1319 months after resolution of the acute phase of LD for the presence of persistent abnormal radiological and functional findings and tried to correlate these with symptoms of shortness of breath. In addition, we tried to identify risk factors associated with the persistence of pulmonary abnormalities. PATIENTS AND METHODS Patients. After detection of the outbreak, local municipal health services and hospitals were requested to report every suspected case of LD. Six months after the outbreak, 318 patients with suspected LD had been reported. Written informed consent was obtained from 202 patients or their relatives; 161 had confirmed or probable LD. Our definitions of confirmed and probable cases of LD have been described elsewhere [6]. Eighteen patients died during the acute phase of the disease, and 1 died shortly thereafter. Of the remaining survivors, 130 were contacted for our follow-up study 1319 months after the acute phase of the disease, and 122 participated. All participants completed a questionnaire, and 86 consented to visit our hospital for additional radiological examination and lung function testing. This study was approved by the medical ethics committee of the Academic Medical Center in Amsterdam, The Netherlands. Radiological examination and lung function testing. Participants were screened for pulmonary abnormalities using standard chest radiography and tests that measured the vital capacity (VC), the forced expiratory volume in 1 s (FEV1), and the single-breath DLCO of the lung (expressed as a percentage of the predicted value). All chest radiographs were evaluated by 2 radiologists blinded to the patients medical records; consensus was required for inclusion of findings in our analysis. Focal increases in radiodensity anywhere in the lung parenchyma were considered to be signs of residual abnormalities. Participants with no abnormal chest radiograph findings were suspected of having residual p (...truncated)


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R. E. Jonkers, K. D. Lettinga, T. H. Pels Rijcken, J. M. Prins, C. M. Roos, O. M. van Delden, A. Verbon, P. Bresser, H. M. Jansen. Abnormal Radiological Findings and a Decreased Carbon Monoxide Transfer Factor Can Persist Long after the Acute Phase of Legionella pneumophila Pneumonia, Clinical Infectious Diseases, 2004, pp. 605-611, 38/5, DOI: 10.1086/381199