Yamauchi T, Yamamoto S, Fukumoto M, Oyama N, Nakano A, Nakayama T, Iwasaki H, Shimizu H, Tsutani H, Lee J D, Okada K, Ueda T
First Department of Internal Medicine, Fukui Medical University.
Kansenshogaku Zasshi. 1998 Mar;72(3):286-92. doi: 10.11150/kansenshogakuzasshi1970.72.286.
Legionellosis is an important cause of severe pneumonia in the community. Inadequate therapy will lead to respiratory distress syndrome, disseminated intravascular coagulation (DIC) and finally fatal multiple organ failure. We encountered a rare case in which early manifestation included septic shock and DIC complicated by acute myocardial infarction (AMI) suspected to be derived from Legionnaires' disease. A 54-year-old healthy female complained of lumbago, high fever and dry cough 10 days after visiting a hot spring spa. She was emmergently admitted due to shock. Physical examination demonstrated hypotension, high fever, course creakle in the right lower lung. Hepatosplenomegaly, lymphadenopathy and eruption were not found. WBC count was 34600/microliters with nuclear shift. CRP elevated. FDP, D dimer and TAT also elevated CPK elevated with dominance of the MB isozyme. Chest roentogenography revealed congestive heart failure, pleural effusion and obscure pneumonic shadow and EKG showed ST segment elevation in leads I, II, III, aVF, V4, V5, and V6. The patient was diagnosed as having septic shock, DIC and AMI. She was treated with gabexate mesilate, high dose methyl prednisolone and dopamine hydrochloride as well as piperacillin, meropenem, isepamycin and fluconzaole. Despite intensive care, the blood pressure fell again and pneumonia had progressed on the 8th hospital day. These antibiotics appeared to be ineffective. Erythromycin was then administered and a dramatic effect. was obtained as the patient recovered. Serum titer of Legionella pneumophila (serogroup 1) rose to 128-fold 2 weeks after the onset. Other serum titers such as Chlamydia psittaci, Rickettsia, Mycoplasma were all negative. Cultures obtained from the sputum, throat swab, urine and blood did not yield any microorganisms. Although the diagnosis could not be confirmed because the titer did not elevate over 256-fold of 4-fold within 2 weeks after the onset, Legionella infection was highly suspected from the clinical features. This is a rare case in which septic shock and DIC with AMI preceded pulmonary symptoms in a non-immunocompromised patient.
军团菌病是社区获得性重症肺炎的重要病因。治疗不当会导致呼吸窘迫综合征、弥散性血管内凝血（DIC），最终发展为致命的多器官功能衰竭。我们遇到了一例罕见病例，其早期表现为感染性休克和DIC，并并发疑似由军团菌病引起的急性心肌梗死（AMI）。一名54岁健康女性在泡温泉10天后出现腰痛、高热和干咳症状。因休克紧急入院。体格检查发现血压降低、高热，右下肺可闻及粗湿啰音。未发现肝脾肿大、淋巴结肿大及皮疹。白细胞计数为34600/微升，伴有核左移。CRP升高。FDP、D-二聚体和TAT也升高，CPK升高，以MB同工酶为主。胸部X线检查显示充血性心力衰竭、胸腔积液及模糊的肺部阴影，心电图显示I、II、III、aVF、V4、V5和V6导联ST段抬高。该患者被诊断为感染性休克、DIC和AMI。给予患者甲磺酸加贝酯、大剂量甲泼尼龙、盐酸多巴胺以及哌拉西林、美罗培南、异帕米星和氟康唑治疗。尽管进行了重症监护，但患者血压在住院第8天再次下降，肺炎病情进展。这些抗生素似乎无效。随后给予红霉素治疗，患者病情显著好转并康复。发病2周后嗜肺军团菌（血清1型）血清滴度升至128倍。其他血清滴度如鹦鹉热衣原体、立克次体、支原体均为阴性。痰、咽拭子、尿液和血液培养均未发现任何微生物。尽管由于发病后2周内滴度未升高至256倍或4倍以上而无法确诊，但根据临床特征高度怀疑为军团菌感染。这是一例罕见病例，在非免疫功能低下患者中，感染性休克、DIC合并AMI先于肺部症状出现。
