Department of Internal Medicine, Japanese Red Cross Nagasaki Genbaku Hospital, Nagasaki, Japan.
J Infect Chemother. 2013 Feb;19(1):166-70. doi: 10.1007/s10156-012-0459-7. Epub 2012 Aug 22.
A 65-year-old man was admitted to our hospital with a temperature of 39.3 °C, cough, sputum, and pharyngeal discomfort that had persisted for 3 days. He had been treated with methotrexate and adalimumab (a tumor necrosis factor-alpha [TNF-α] inhibitor) for rheumatoid arthritis for 2 years, and he had also been treated with S-1 (tegafur, gimeracil, and oteracil potassium) for pancreatic metastasis of gastric cancer for 2 months. Regardless of the underlying pathologies, his general condition was good and he had worked as an electrician until 2 days before admission. However, his appetite had suddenly decreased from the day before admission, and high fever and hypoxia were also evident upon admission. A chest X-ray and computed tomography scan revealed left pleural effusion and consolidation in both lungs. The pneumonia severity index score was 165 and the risk class was V. Accordingly, we started to treat the pneumonia with a combination of levofloxacin and meropenem. Thereafter, we received positive urinary antigen test findings for Legionella pneumophila. After hospitalization, hypoxia was progressed and hypotension was emerged. Despite the application of appropriate antibiotics, vasopressors, and oxygenation, the patient died 8 h after admission. Even after his death, blood cultures were continued to consider the possibility of bacterial co-infection. Although no bacteria were detected from blood cultures, Gimenez staining revealed pink bacteria in blood culture fluids. Subsequent blood fluid culture in selective medium revealed L. pneumophila serogroup 1. Recently, TNF-α inhibitors have been described as a risk factor for Legionnaires' disease. In consideration of the increased frequency of TNF-α inhibitors, we may need to recognize anew that L. pneumophila might be a pathogen of severe community-acquired pneumonia.
一位 65 岁男性因发热 39.3°C、咳嗽、咳痰和咽部不适持续 3 天而入院。他因类风湿性关节炎已接受甲氨蝶呤和阿达木单抗（肿瘤坏死因子-α [TNF-α]抑制剂）治疗 2 年，并且还因胃癌胰腺转移接受 S-1（替加氟、吉美嘧啶、奥替拉西钾）治疗 2 个月。无论潜在的病理学如何，他的一般情况良好，并且在入院前 2 天一直在担任电工。然而，他的食欲从入院前一天开始突然下降，入院时也出现高热和缺氧。胸部 X 射线和计算机断层扫描显示左侧胸腔积液和双肺实变。肺炎严重指数评分 165 分，风险等级为 V。因此，我们开始用左氧氟沙星和美罗培南联合治疗肺炎。此后，我们收到了尿抗原检测结果阳性，提示存在嗜肺军团菌。入院后，缺氧加重，出现低血压。尽管应用了适当的抗生素、升压药和氧疗，患者在入院后 8 小时死亡。即使在他死后，仍继续进行血培养以考虑细菌合并感染的可能性。尽管血培养未检出细菌，但 Gimenez 染色显示血培养液中有粉红色细菌。随后在选择性培养基中进行血培养显示嗜肺军团菌血清群 1。最近，TNF-α 抑制剂被描述为军团病的危险因素。考虑到 TNF-α 抑制剂的使用频率增加，我们可能需要重新认识到嗜肺军团菌可能是严重社区获得性肺炎的病原体。
