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Year : 2011  |  Volume : 54  |  Issue : 2  |  Page : 381-383
High ferritin and myoglobin level in legionella pneumonia: A case report and review of literature

Department of Infectious Diseases and Clinical Microbiology, Sakarya Training and Research Hospital, Turkey

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Date of Web Publication27-May-2011


Legionella pneumophila is a cause of both community- and hospital-acquired pneumonia and might cause high morbidity and mortality. Therefore, early diagnosis and treatment with appropriate antibiotics is crucial. Many clinical and laboratory abnormalities can be observed in the course of Legionella pneumonia. In this study, we aimed to present simultaneously increased serum ferritin and myoglobin level in a legionella case with reference to the relevant literature.

Keywords: Ferritin, legionella pneumonia, myoglobin

How to cite this article:
Karabay O, Tuna N, Ogutlu A, Gozdas HT. High ferritin and myoglobin level in legionella pneumonia: A case report and review of literature. Indian J Pathol Microbiol 2011;54:381-3

How to cite this URL:
Karabay O, Tuna N, Ogutlu A, Gozdas HT. High ferritin and myoglobin level in legionella pneumonia: A case report and review of literature. Indian J Pathol Microbiol [serial online] 2011 [cited 2020 Jul 5];54:381-3. Available from: http://www.ijpmonline.org/text.asp?2011/54/2/381/81651

   Introduction Top

Legionella pneumophila is a microorganism, settling and reproducing in water distribution systems found in hotels, hospitals, and cooling towers. It might create clinical manifestations ranging from asymptomatic infections to severe pneumonia. Clinical and radiologic findings do not differ from any other bacterial and viral pneumonias. In addition to classical pneumonia symptoms (temperature > 38.7°C, chest pain, hypoxia, and confusion), many different laboratory changes may accompany legionella pneumonia, such as hyponatremia, hypophosphatemia, microscopic hematuria, and raised transaminase elevations. [1],[2]

A slight increase in serum ferritin levels might be observed in many infectious diseases. However, high levels exceeding two times of its normal limit can only be observed in certain infections, such as Legionellosis, West Nile encephalitis, HIV infection, active tuberculosis, Cytomegalovirus, and Pneumocystis jiroveci. [3],[4],[5] During our literature review, we could reach only two reports in the English literature reporting the possibility of an increase in myoglobin levels in legionella infections due to muscle damage and rhabdomyolysis. However, we could not find any researches reporting simultaneously increased serum ferritin and myoglobin levels during the course of legionella. In this report, we aimed to present high ferritin and myoglobin levels in a severe legionella pneumonia case.

   Case Report Top

A 41-year-old male patient was admitted to the outpatient clinic with complaints of fever, muscle pain, fatigue, lack of appetite, 10 kg weight loss within 2 weeks, and diarrhea lasting for about a week. During physical examination, blood pressure was found as 100/70 mmHg, pulse 96/min, and respiratory rate as 20/min. Laboratory findings of the patient were summarized in [Table 1]. Ferritin level was considered to be extremely high and myoglobin level was found 4-5 times of the normal upper limit. Anti-CMV IgG was positive and anti-HIV was negative in this patient.
Table 1: Laboratory findings of the patient

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Chest radiography [Figure 1] and computerized tomography scan [Figure 2] showed pneumonic infiltrates in the middle and lower lobe of the right lung.

Urine sample for L. pneumophila antigen was taken on the 4th day of administration. Legionella urinary antigen was investigated with commercial ELISA test (BIORAD DSX ELISA) and it was reported positive on the 13th day of administration.
Figure 1: Chest radiographic appearance of pneumonic infiltrates

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Figure 2: Computerized tomography imaging appearance of pneumonic infiltrates

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This severe clinical manifestation of pneumonia accompanied with diarrhea and hyponatremia has led to consideration of legionellosis, and empirically 400 mg levofloxacin was started to be administered. Hypersensitivity reaction was seen in this patient on the 5th day of levofloxacin treatment. Then, levofloxacin was ceased to be administered and treatment was switched to azithromycin (1× 500 mg). The patient was discharged after his complaints were diminished and the patient thereafter completely recovered.

   Discussion Top

L. pneumophila is a Gram-negative aerobic bacteria, it has beta-lactamase and many potential toxins. This bacterium is responsible for 2%-9% of community-acquired pneumonias. [6] It causes pneumonia with a severe course requiring to be hospitalized in 15% of the cases. Radiologic and clinical findings are not sufficient to rule out the diagnosis of legionella pneumonia. However, pneumonia accompanied with hyponatremia and diarrhea would probably suggest legionellosis. [6],[7]

Many infectious and noninfectious diseases might cause high serum ferritin levels. Ferritin may increase as an acute-phase response in many diseases. [5],[8] It was reported that legionellosis should be considered in patients with serum ferritin levels of more than two times of the normal upper limit. [9] Accordingly, in our case ferritin level was more than 2000 ng/mL.

Gastroenteritis, acute tubular necrosis, acute tubulointerstitial nephritis, muscle damage, and rhabdomyolysis can be observed during the course of legionella infections. In these cases, serum myoglobin level may increase due to muscle damage or rhabdomyolysis. Myoglobinuria and rhabdomyolysis can lead to acute renal failure or acute tubulointerstitial nephritis. In our case, myoglobin level was slightly elevated. During our literature review, we could review only two reports of an increase in myoglobin levels in the course of legionella. [10],[11]

Slightly increased myoglobin level in this case might be related to rhabdomyolysis, and also myoglobin levels might have been increased in the natural course of legionella infections. However, this test hasn't been researched in detail until now on patients with Legionella infection.

As a result, many changes can be seen in clinical and laboratory findings during the course of legionella infection. We think, this is the first case report, indicating simultaneously increased myoglobin and ferritin levels during legionella pneumonia. To our knowledge, legionella should be considered in pneumonia patients with simultaneously elevated serum ferritin and myoglobin levels in the existence of diarrhea and hyponatremia. However, more comprehensive studies are needed to confirm this hypothesis.

   References Top

1.Cunha BA. Severe Legionella pneumonia: Rapid presumptive clinical diagnosis with Winthrop-University Hospital's weighted point score system (modified). Heart Lung 2008;37:311-20.   Back to cited text no. 1
2.Cunha BA. Hypophosphatemia: Diagnostic significance in legionnaire's disease. Am J Med 2006;119:e5-6.  Back to cited text no. 2
3.Krol V, Cunha BA. Diagnostic significance of serum ferritin levels in infectious and non-infectious diseases. Infect Dis Pract 2003;27:199-200.  Back to cited text no. 3
4.Ramírez C, Rubio C, Fernández de la Puebla RA, Aguilera C, Espejo I, Fuentes F. Clinical significance of increased serum ferritin levels. Med Clin (Barc) 2004;122:532-4.  Back to cited text no. 4
5.Cunha BA, Sachdev B, Canario D. Serum ferritin levels in West Nile encephalitis. Clin Microbiol Infect 2004;10:184-6.  Back to cited text no. 5
6.Stout JE, Yu VL. Legionellosis. N Engl J Med 1997;337:682-7.  Back to cited text no. 6
7.Katz DS, Leung AN. Radiology of pneumonia. Clin Chest Med 1999;20:549-62.  Back to cited text no. 7
8.Rocha LA, Barreto DV, Barreto FC, Dias CB, Moysés R, Silva MR, et al. Serum ferritin level remains a reliable marker of bone marrow iron stores evaluated by histomorphometry in hemodialysis patients. Clin J Am Soc Nephrol 2009;4:105-9.   Back to cited text no. 8
9.Cunha BA. Highly elevated serum ferritin levels as a diagnostic marker for Legionella pneumonia. Clin Infect Dis 2008; 46:1789-91.  Back to cited text no. 9
10.Shimura C, Saraya T, Wada H, Takata S, Mikura S, Yasutake T, et al. Pathological evidence of rhabdomyolysis-induced acute tubulointerstitial nephritis accompanying Legionella pneumophila pneumonia. J Clin Pathol 2008;61:1062-3.   Back to cited text no. 10
11.Sposato B, Mariotta S, Ricci A, Lucantoni G, Schmid G. Legionnaire's pneumonia with rhabdomyolysis and acute renal failure: A case report. Recenti Prog Med 2003;94:391-4.  Back to cited text no. 11

Correspondence Address:
Oguz Karabay
Department of Infectious Diseases and Clinical Microbiology, Sakarya Training and Research Hospital
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0377-4929.81651

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