Scientific letter
SARS-CoV-2 and Legionella pneumophila coinfection
Coinfección por SARS-CoV-2 y Legionella pneumophila
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BACT/μl.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Paciente ingresado/Urgencias: ≥50 BACT/μl.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Iris Sharon Pérez-Ramos, Itziar Angulo-López, Mireia de la Peña-Trigueros, José Luis Díaz de Tuesta-del Arco" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Iris Sharon" "apellidos" => "Pérez-Ramos" ] 1 => array:2 [ "nombre" => "Itziar" "apellidos" => "Angulo-López" ] 2 => array:2 [ "nombre" => "Mireia" "apellidos" => "de la Peña-Trigueros" ] 3 => array:2 [ "nombre" => "José Luis" "apellidos" => "Díaz de Tuesta-del Arco" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2529993X22001381" "doi" => "10.1016/j.eimce.2022.06.008" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => 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"The secret in his eyes" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "576" "paginaFinal" => "577" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El secreto de sus ojos" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 759 "Ancho" => 755 "Tamanyo" => 55161 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Chest radiography revealed numerous micronodules uniform in size and widespread in distribution.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Jorge Monasterio Bel, Luis Buzón Martín, Carolina Navarro San Francisco, Carmen Gordón Bolaños" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Jorge" "apellidos" => "Monasterio Bel" ] 1 => array:2 [ "nombre" => "Luis" "apellidos" => "Buzón Martín" ] 2 => array:2 [ "nombre" => "Carolina" "apellidos" => "Navarro San Francisco" ] 3 => array:2 [ "nombre" => "Carmen" "apellidos" => "Gordón Bolaños" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0213005X22000350?idApp=UINPBA00004N" "url" => "/0213005X/0000004000000010/v1_202212020757/S0213005X22000350/v1_202212020757/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "SARS-CoV-2 and <span class="elsevierStyleItalic">Legionella pneumophila</span> coinfection" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "578" "paginaFinal" => "579" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Gemma Argemí, María Somoza, Marta Andrés, Antonia Llunell" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Gemma" "apellidos" => "Argemí" "email" => array:1 [ 0 => "gem_arg@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "María" "apellidos" => "Somoza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Marta" "apellidos" => "Andrés" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Antonia" "apellidos" => "Llunell" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Neumología, Hospital de Terrassa (Consorci Sanitari de Terrassa), Terrassa, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital de Terrassa (Consorci Sanitari de Terrassa), Terrassa, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Coinfección por SARS-CoV-2 y <span class="elsevierStyleItalic">Legionella pneumophila</span>" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 969 "Ancho" => 1250 "Tamanyo" => 96388 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Radiological evolution. (A) At emergency room; (B) 48<span class="elsevierStyleHsp" style=""></span>h post admission; (C) just before patient's discharge; (D) 2 months after hospitalization.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Factors associated with a poorer prognosis of COVID-19 are advanced age, male sex, comorbidities, and laboratory parameters such as lymphopenia and elevated inflammatory markers. Bacterial coinfections have also been associated with a worse prognosis.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Coinfection with <span class="elsevierStyleItalic">Legionella pneumophila</span> has been scarcely reported,<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2–5</span></a> and to the best of our knowledge no cases have been described in Spain. We present a case of community-acquired coinfection by <span class="elsevierStyleItalic">L. pneumophila</span> and SARS-CoV-2 admitted to our hospital.</p><p id="par0015" class="elsevierStylePara elsevierViewall">This is a 35-year-old male patient, non-smoker and with no medical history of interest, who works as a butane cylinder deliverer. He arrived to the emergency room on November 15, 2020 with a 10-day history of fever, myalgia, nausea, diarrhea, anosmia and dysgeusia. A dry cough without dyspnea appeared later. A PCR for SARS-CoV-2 performed in his primary care center two days before admission was positive. Vital signs on admission were as follows: blood pressure 130/93<span class="elsevierStyleHsp" style=""></span>mmHg, heart rate116<span class="elsevierStyleHsp" style=""></span>bpm, axillary temperature 39<span class="elsevierStyleHsp" style=""></span>°C, respiratory rate 26 breaths per minute. Respiratory and cardiac auscultations were normal. The chest X-ray showed a condensation in the right upper lobe (RUL) with air bronchogram (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Blood tests showed the following results: CRP 306<span class="elsevierStyleHsp" style=""></span>mg/L, ferritin 1303<span class="elsevierStyleHsp" style=""></span>ng/mL, procalcitonin 2.81<span class="elsevierStyleHsp" style=""></span>μg/L, sodium 128<span class="elsevierStyleHsp" style=""></span>mmol/L, alanine aminotransferase 26.4<span class="elsevierStyleHsp" style=""></span>U/L, LDH 262<span class="elsevierStyleHsp" style=""></span>U/L, leukocytes 10,510<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/L (85.9% neutrophils), lymphocytes 890<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/L, ferritin 2353<span class="elsevierStyleHsp" style=""></span>ng/ml, and D-dimer 638<span class="elsevierStyleHsp" style=""></span>ng/mL. The baseline arterial blood gas showed: pH 7.56, pCO<span class="elsevierStyleInf">2</span> 21.0<span class="elsevierStyleHsp" style=""></span>mmHg, pO<span class="elsevierStyleInf">2</span> 69.0<span class="elsevierStyleHsp" style=""></span>mmHg, and bicarbonate 18.8<span class="elsevierStyleHsp" style=""></span>mmol/L. The electrocardiogram was normal.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was admitted with a diagnosis of community-acquired bacterial pneumonia and SARS-CoV-2 coinfection. Treatment was started with low-flow oxygen therapy and empirical antibiotic therapy with ceftriaxone and azithromycin. Culture of sputum, pneumococcal urinary antigen test and HIV serology were negative, and the urinary antigen test for <span class="elsevierStyleItalic">Legionella</span> (STANDARD F <span class="elsevierStyleItalic">Legionella</span> Ag FIA, SD BIOSENSOR, Republic of Korea) was positive. At this point, ceftriaxone was withdrawn.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient was still febrile and presented minimal effort cough 48<span class="elsevierStyleHsp" style=""></span>h after admission. The chest X-ray showed an increase in RUL condensation and bilateral peripheral patchy infiltrates, which was interpreted as progression to inflammatory pneumonia due to SARS-CoV-2 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). Treatment with dexamethasone (6<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h) was added. At this point the fever subsided, the tachypnea decreased and low oxygen flow achieved good saturations. The inflammatory parameters progressively decreased and the RUL condensation improved, while the bilateral peripheral infiltrates persisted (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). The patient was discharged on the ninth day after admission, continuing with oral azithromycin until completing 2 weeks of treatment. Follow up was satisfactory, with resolution of the pulmonary infiltrates (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D).</p><p id="par0030" class="elsevierStylePara elsevierViewall">Bacterial coinfection in patients with COVID-19 has been less frequently reported than in other viral infections, such as influenza.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1,6,7</span></a> Coinfection of SARS-CoV-2 with <span class="elsevierStyleItalic">L. pneumophila</span> has been reported in 4 cases, two diagnosed by urinary antigen test and two by culture of respiratory secretions.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2–5</span></a> Another 7 cases<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">8,9</span></a> of possible coinfection with <span class="elsevierStyleItalic">L. pneumophila</span> have been reported, but this diagnosis was based solely on positive IgM, which does not constitute a diagnostic criterion for legionellosis. Three studies that investigated coinfection in more than 1900 patients admitted for COVID-19 did not identify any case of coinfection with <span class="elsevierStyleItalic">L. pneumophila</span>.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">6,7,10</span></a> Our patient was diagnosed of Legionnaires’ disease by a qualitative analysis in a urine sample, using an immunochromatographic assay with a specificity<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>95% in detecting the disease caused by <span class="elsevierStyleItalic">L. pneumophila</span> serogroup 1.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Respiratory and digestive symptoms can coexist in patients with COVID-19, mimicking other diseases such as legionellosis. In SARS-CoV-2 pneumonia, the most common radiological findings are peripheral bilateral infiltrates, while consolidation occurs more rarely. In general, unilobar consolidation suggests bacterial infection and can be found in about 70% of cases of legionellosis. Although pneumonia due to <span class="elsevierStyleItalic">L. pneumophila</span> can progress to bilateral infiltrates, in this case the confirmation of SARS-CoV-2 infection in the previous days and the peripheral distribution of the infiltrates, without signs of airspace consolidation, were highly suggestive of the development of an inflammatory pneumonia due to SARS-CoV-2.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The diagnosis of coinfection in these patients is hampered by the lack of specific symptoms. Consequently, coinfection might be underdiagnosed, and broad-spectrum antibiotics overprescribed.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In Catalonia the reported incidence of Legionnaires’ disease is higher than in other Spanish autonomous communities. Specifically, in our Vallès Occidental area, the incidence rate in 2019 was 9.94 cases/100,000 persons (95%CI 8.11–12.19). In addition, in the two weeks prior to the patient's admission, two other cases of legionellosis were diagnosed in the city where the patient resided, although no common source was identified for the three cases (data obtained from the Health Department, Government of Catalonia). On the other hand, it must be taken into account that, due to his work, the patient entered many homes and commercial premises. These data, together with the season of the year and the clinical picture of a male with a lobar condensation, hyponatremia, diarrhea, and a negative determination of pneumococcal antigen in urine, made it necessary to consider the diagnosis of Legionnaires’ disease. Once the diagnosis was established, treatment with azithromycin was continued, since there is no difference in the observed outcomes for patients with <span class="elsevierStyleItalic">Legionella</span> spp. pneumonia treated with azithromycin <span class="elsevierStyleItalic">vs</span>. levofloxacin.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion, this case demonstrates the importance of making an etiological diagnosis of bacterial coinfection in patients with COVID-19 when there are suggestive clinical and/or radiological findings. We consider that in areas with a relatively high incidence of legionellosis, the urinary antigen test for <span class="elsevierStyleItalic">Legionella</span> should be performed in cases of community-acquired pneumonia with epidemiological suspicion, or with criteria for hospital admission and a negative pneumococcal urinary antigen test. With a specific diagnosis the antibiotic treatment can be targeted, thus reducing the threat of bacterial resistance.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0055" class="elsevierStylePara elsevierViewall">This research did not receive funding from the public, commercial, or not-for-profit sectors.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interests</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interests" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 969 "Ancho" => 1250 "Tamanyo" => 96388 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Radiological evolution. (A) At emergency room; (B) 48<span class="elsevierStyleHsp" style=""></span>h post admission; (C) just before patient's discharge; (D) 2 months after hospitalization.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0065" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Co-infections in people with COVID-19: a systematic review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "L. Lansbury" 1 => "B. Lim" 2 => "V. Baskaran" 3 => "W.S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 8 | 8 | 16 |
| 2024 September | 52 | 12 | 64 |
| 2024 August | 36 | 5 | 41 |
| 2024 July | 26 | 11 | 37 |
| 2024 June | 19 | 9 | 28 |
| 2024 May | 17 | 12 | 29 |
| 2024 April | 17 | 22 | 39 |
| 2024 March | 34 | 29 | 63 |
| 2024 February | 35 | 24 | 59 |
| 2024 January | 32 | 16 | 48 |
| 2023 December | 24 | 9 | 33 |
| 2023 November | 23 | 41 | 64 |
| 2023 October | 39 | 45 | 84 |
| 2023 September | 16 | 17 | 33 |
| 2023 August | 13 | 5 | 18 |
| 2023 July | 19 | 46 | 65 |
| 2023 June | 33 | 6 | 39 |
| 2023 May | 6 | 0 | 6 |
| 2023 April | 3 | 0 | 3 |
| 2023 March | 4 | 2 | 6 |
| 2023 February | 3 | 2 | 5 |
| 2023 January | 8 | 2 | 10 |
| 2022 December | 50 | 11 | 61 |
| 2022 September | 0 | 4 | 4 |
| 2022 August | 0 | 2 | 2 |
| 2022 February | 0 | 1 | 1 |
| 2022 January | 0 | 2 | 2 |
| 2021 November | 0 | 2 | 2 |
Show all
