Abstract Introduction Legionella pneumophila is a significant yet underrecognized cause of severe community-acquired pneumonia (CAP), accounting for 1-9% of cases. Severe infection may lead to respiratory failure, multiorgan dysfunction, and high mortality, particularly when diagnosis or treatment is delayed. Environmental exposure through aerosolized contaminated water sources remains a key risk factor. We report a case of fulminant Legionella pneumonia with rapid progression to multiorgan failure and death, temporally associated with use of a portable air-conditioning unit. Case Presentation A 54-year-old female with a history of epilepsy (not on antiepileptics), substance use disorder, bipolar disorder, type 2 diabetes, prior cerebrovascular accident, and an indeterminate renal mass was found unresponsive at home; last known well was two hours prior. She was febrile to 40.4 °C, tachycardic to 151 bpm, hypertensive at 150/108 mmHg, tachypneic at 44 breaths/min, and minimally responsive. She was intubated for airway protection due to seizure-like activity and inability to protect her airway.Arterial blood gas showed acute hypoxic hypercapnic respiratory failure (pH 7.17, pCO2 61 mmHg). Labs were notable for acute kidney injury (Cr 1.39 from baseline 0.5-0.8), lactic acidosis (4.5 mmol/L), thrombocytopenia (70 K/µL), elevated CK (7,018 U/L), and marked transaminitis (AST 1,232 U/L, ALT 421 U/L). Chest CT revealed dense bilateral lower lobe consolidations.Urinary Legionella antigen returned positive. Family reported she had been feeling unwell for two weeks and that symptoms began after introduction of a portable air conditioner in their poorly ventilated apartment. She was allergic to doxycycline and azithromycin and was started on levofloxacin. Despite ventilatory support, vasopressors, and CRRT for anuric renal failure, she deteriorated and expired. Autopsy confirmed bilateral edematous, heavy lungs (right 1470 g; left 1080 g) with postmortem culture positive for Legionella pneumophila. Small pleural effusions were noted (right 150 mL; left 50 mL). Discussion This case highlights the potential for rapidly fatal Legionella pneumonia acquired from contaminated in-home cooling devices. Legionella should be strongly considered in severe CAP, especially with neurological symptoms, hyponatremia, transaminitis, rhabdomyolysis, or environmental exposure to aerosolized water sources. Early recognition, prompt diagnostic testing, and rapid initiation of appropriate therapy are critical to reduce morbidity and mortality. This abstract is funded by: None
Khalid et al. (Fri,) studied this question.