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Review
. 2018 Sep 17;18(1):467.
doi: 10.1186/s12879-018-3378-0.

Disseminated extrapulmonary Legionella pneumophila infection presenting with panniculitis: case report and literature review

Maria N Chitasombat  1 , Natta Ratchatanawin  2 , Yingluck Visessiri  3
Affiliations
Review

Disseminated extrapulmonary Legionella pneumophila infection presenting with panniculitis: case report and literature review

Maria N Chitasombat et al. BMC Infect Dis. .

Abstract

Background: Legionellosis is a well-known cause of pneumonia. Primary cutaneous and subcutaneous infection caused by Legionella pneumophila is rare and the diagnosis is challenging.

Case presentation: A 38-year-old Thai woman with systemic lupus erythematosus and myasthenia gravis treated with prednisolone and azathioprine presented to our hospital with low-grade fever, diarrhea, and indurated skin lesions on both thighs. Initial examination showed plaques on both inner thighs. Magnetic resonance imaging showed myositis and swelling of the skin and subcutaneous tissue. Diagnosis of panniculitis due to L. pneumophila was carried out by histopathology, Gram stain, and 16S rRNA gene sequencing method of tissue biopsy from multiple sites on both thighs. Myocarditis was diagnosed by echocardiography. The final diagnosis was disseminated extrapulmonary legionellosis. Treatment comprised intravenous azithromycin for 3 weeks and the skin lesions, myositis and myocarditis resolved. Oral azithromycin and ciprofloxacin were continued for 3 months to ensure eradication of the organism. The patient's overall condition improved.

Conclusions: To our knowledge, we report the first case of L. pneumophila infection manifesting with panniculitis, possible myositis, and myocarditis in the absence of pneumonia. The diagnosis of extrapulmonary Legionella infection is difficult, especially in the absence of pneumonia. A high index of suspicion and appropriate culture with special media or molecular testing are required. Initiation of appropriate treatment is critical because delaying therapy was associated with progressive infection in our patient.

Keywords: Legionella pneumophila; Lupus; Myocarditis; Myositis; Panniculitis.

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Conflict of interest statement

Ethics approval and consent to participate

This study was approved by the Committee on Human Rights Related to Research Involving Human Subjects, Faculty of Medicine Ramathibodi Hospital, Mahidol University.

Consent for publication

The patient gave written consent for publication of her potentially identifying information (including individual details and images).

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Multiple erythematous indurated plaques on the proximal right thigh, multiple healed crusted papules on the right lower extremity, and whitish striae (before treatment)
Fig. 2
Fig. 2
a. Coronal T2-weighted MRI of the thighs. b. Axial T2-weighted MRI of the thighs demonstrating enhancement of subcutaneous tissue and muscle. MRI, magnetic resonance imaging
Fig. 3
Fig. 3
Histopathology of subcutaneous tissue of right thigh. Photomicrograph revealed neutrophil infiltration in the deep dermis to subcutaneous tissue and fat necrosis (200×, hematoxylin and eosin)
Fig. 4
Fig. 4
Proximal right thigh showed resolution of indurated plaque after 8 days of treatment for Legionella, biopsy stiches, healed scar of varicella lesions, and whitish striae
See this image and copyright information in PMC

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