Dados do Trabalho

Título

Legionnaire’s disease associated - severe Encephalopathy

RESUMO

A 57-year-old Brazilian man presented to the emergency department with a 3-day history of diarrhea and hiccups. On the next day, he developed incoordination followed by change in speech and vomiting episodes. Symptoms worsened, until he was unable to stand. While waiting for medical attention, he became confused, reporting delusions and hallucinations. He had a past history of smoking, cocaine use and moderate alcohol consumption. On examination, he was drowsy, disoriented in space and time, dysarthric, apparent restriction of vertical upward gaze bilaterally. He had astasia and abasia. In the emergency room, he became agitated and developed tachycardia, tachypnea, fever (40 C) and was intubated and sent to ICU.
Blood screening revealed elevated CK of 18.306 (normal: 39-308), thrombocytopenia high creatinine levels of 1,55, hyponatremia of 124, hypokalemia of 3,3, low ionized calcium of 1,08, mild elevated ALT/AST, elevated troponin of 50 and elevated CRP of 244. Chest TC showed an extensive consolidation affecting almost the entire right lower lobe and minimal bilateral pleural effusion. CSF studies revealed 9 leukocytes (88% lymphocytes, 12% monocytes), 5 erythrocytes, glucose of 88 mg/dL, lactate of 27,5. Culture and viral panel were negative. Brain MRI was normal. Hydratation for rhabdomyolysis, Ceftriaxone and metronidazole were the initial treatment. Because of lack of response Levofloxacin was started with positive response. Positive Legionella Urine confirmed Legionnaire’s disease. After recovering, he was discharged home but with residual ataxia and dysarthria in improvement.
Legionnaire’s disease is an infection caused by Legionella pneumonia that usually manifests with pneumonia. Extrapulmonary manifestations are rare, but meningitis, encephalopathy, which can be from mild to coma, cerebellar dysfunction and focal deficits. Brain MRI can present with hyperintensities at multiple localizations CSF findings are normal in the vast majority of patients, raising the possibility that Legionella does not directly affect the central nervous system. Therefore, pathophysiology is uncertain and it is unknown whether the mechanism is an immune, toxin-mediated or a direct damage by the bacteria.The patient was followed and persisted with ataxia and dysarthria, in slow recovery three months after discharge.

Palavras Chave

Legionnaire’s disease, Legionella pneumonia, ataxia, encephalopathy