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Yasunari Matsuki, MD*, Yuka Matsuki, MD**, Yoshikazu Yasuda, MD*, Maki Mizogami, MD**, Ko Takakura, MD**, Kenji Shigemi, MD**

*Department of Intensive Care Unit, **Department of Anesthesiology & Reanimatology,

University of Fukui, Faculty of Medicine Sciences, Fukui (Japan)

Correspondence: Yasunari Matsuki, MD, Department of Intensive Care Unit, University of Fukui, Faculty of Medicine Sciences, 23-3 Shimoaizuki, Matsuoka, Eiheijicho, Yoshidagun, Fukui 910-1193 (Japan); Tel: +81-776-61-8391; Fax: +81-776-61-8116; E-mail: tainobu@u-fukui.ac.jp

ABSTRACT

Legionella pneumonia is often complicated by multiple organ failure. Although acute kidney injury is relatively rare in the context of Legionella pneumonia, it is associated with an increase in mortality rate. This report describes a case of a patient with Legionella pneumonia and acute kidney injury who was successfully treated with polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP). We conclude that PMX-DHP may be a useful therapeutic modality in patients with Legionella infection and acute kidney injury.

Key words: Legionella pneumonia; Polymyxin B-immobilized fiber column direct hemoperfusion; Acute kidney injury

Citation: Matsuki Y, Matsuki Y, Yasuda Y, Mizogami M, Takakura K, Shigemi K. Successful treatment of severe Legionella pneumonia and acute kidney injury with polymyxin B-immobilized fiber column direct hemoperfusion. Anaesth Pain & Intensive Care 2013;17(1):88-90

INTRODUCTION

Legionella pneumonia was first described following an outbreak of pneumonia among army veterans attending an American Legion convention in Philadelphia in 1976.¹ This pneumonia is often complicated by multiple organ failure, including acute kidney injury and hepatic dysfunction, that is associated with an increase in mortality rate.^2-3 Polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP) is a useful treatment modality for patients with organ dysfunction due to severe sepsis.⁴ We describe a case of a patient with severe Legionella pneumonia and acute kidney injury who was successfully treated with PMX-DHP.

CASE REPORT

A 70 years old man was admitted to our hospital with diarrhea, high-grade fever and dyspnea. He had been on treatment for malignant lymphoma, and had mitral valvuloplasty in the past. Physical examination on admission to our hospital revealed a temperature of 38.8°C, blood pressure of 65/40mmHg, heart rate of 89/min, SpO₂ of 80% (on 15 L/min of O₂ via reservoir mask) and a respiratory rate of 35/min. Glasgow coma scale was 9/15. Fine crackles were audible in the upper lung fields bilaterally. Laboratory tests showed elevations in leukocytes and C-reactive protein at 13,100/μl and 35.20mg/100 ml respectively. BUN (28 mg/100 ml), Creatinine (1.64 mg/100 ml), AST (1019iu/L), ALT (677iu/L) and LDH (1756iu/L) were also elevated, and the Na level (127 mEq/L) was low. Arterial blood gas analysis (taken while O₂ was being administered at 15 L/min via reservoir mask) showed severe hypoxemia, and metabolic acidosis (pH of 7.06, PaCO₂ of 54 mmHg, PaO₂ of 52 mmHg, HCO₃^– of 14.5 mmol/L). Chest x-ray film showed infiltrative shadows in the left upper lung fields, and a chest CT revealed consolidation and ground-glass opacity in the left upper lung field (Fig 1-A&B).

Fig 1-A: Chest radiograph on admission. There is an infiltrative shadow in the left upper lung field.

Fig 1-B: Chest computed tomography on admission showing consolidation with ground-glass opacities in the left lung field

The patient’s clinical course is summarized in Fig 2. He was admitted to the intensive care unit (ICU) with a blood pressure of 78/42 mmHg despite administration of 5 μg/kg/min of dopamine hydrochloride and 0.1 μg/kg/min of noradrenaline. He was immediately intubated and ventilated with 100% oxygen and was treated with sivelestat sodium hydrate, intravenous fluids of volume and antibiotics (tazobactam/piperacillin, pazufloxacin). A diagnosis of legionellosis was made on the basis of positive specific urinary antigen. Antibiotics were switched to erythromycin, but blood pressure and the PaO₂/FiO₂ (P/F) ratio continued to decrease. He became anuric, and continuous hemodiafiltration (CHDF) (CH-1.0^®; Toray Medical Co., Tokyo, Japan) was started to maintain body water balance. In addition, PMX-DHP (Toraymyxin 20R^®; Toray Medical Co., Tokyo, Japan) was performed for 4 hours on days 1 and 2 to adsorb endotoxin. After the introduction of PMX-DHP, blood pressure and urinary output were gradually increased, and catecholamines were tapered off. The P/F ratio improved from 173 to 386 on day 3, and CHDF was terminated on day 8. The patient was extubated on day 9 after careful weaning from mechanical ventilation.

Fig 2: Clinical course after initiation of PMX-DHP. Catecholamines (noradrenaline and dopamine) were tapered off, and blood pressure and the PaO₂/FiO₂ (P/F) ratio gradually improved.

(Legend: NA: noradrenaline, DOA: dopamine, CHDF: continuous hemodiafiltration, PMX-DHP: polymyxin B-immobilized fiber column direct hemoperfusion, sBP: systolic blood pressure, dBP: diastolic blood pressure)

DISCUSSION

The bacterium, Legionella, got its name after a 1976 outbreak, when many people who went to a Philadelphia convention of the American Legion suffered from this disease, a type of pneumonia (lung infection). Although this type of bacterium was around before 1976, more illness from Legionnaires’ disease is being detected now. The report describes the case of a patient with Legionella pneumonia and acute kidney injury who was successfully treated with PMX-DHP. Legionella pneumophila is one of the three most common causes of severe community-acquired acute pneumonia and comprises 3-6% of all cases of community-acquired pneumonias.^5,6 Although radiologic and clinical findings alone are not sufficient to establish a diagnosis of Legionella pneumonia, if these are accompanied by diarrhea, neurological signs, a temperature >39°C, hyponatremia and hepatic dysfunction, these are strongly suggestive of legionellosis.^7-9 Diarrhea, hyponatremia and hepatic dysfunction were noted in our present case. The patient was ultimately diagnosed with legionellosis on the basis of positive specific urinary antigen.

Although Legionella pneumonia complicated by acute kidney injury is a rare disease, it is associated with a mortality rate greater than 50%.^2,3 In our case, rhabdomyolysis was not observed, and we speculated that direct microbial toxicity,¹⁰ endotoxemia, inflammatory cytokines¹¹ and/or hypotension was the cause of acute kidney injury. L. pneumophila is a Gram-negative aerobic bacterium that is an intracellular parasite, and produces beta-lactamase and many other potential endotoxins.

PMX-DHP can lower the plasma level of endotoxin and inflammatory cytokines,^12,13 and can significantly improve hemodynamics and organ function in patients with severe sepsis and/or septic shock arising from Gram-negative bacterial infections.^4,14 In the present case, early use of PMX-DHP resulted in improved hemodynamics and kidney function. PMX-DHP exerts a therapeutic effect in patients with pneumonia by absorbing cytokines (e.g. IL-8) and neutrophil elastase produced by activated neutrophils PMX-DHP,^15,16 and this was the likely mechanism of therapeutic action in our patient.

CONCLUSION

We conclude that PMX-DHP may be a useful therapeutic modality in patients with Legionella infection and acute kidney injury.

REFERENCES

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