A 31-year-old Caucasian female with ulcerative colitis, primary sclerosing cholangitis, and cirrhosis presented with fever, chills, shortness of breath, dry cough, and chest pain for five days after being started on prednisone 40 mg daily and azathioprine 50 mg daily for autoimmune hepatitis two months earlier. She was born and raised in New York state and only travelled to Vermont and Florida. During the prior two weeks, she traveled to a hunting shack in northern New York and had been there twice before becoming ill. She had no personal or family history of tuberculosis and has had several prior negative PPDs during nursing school. On presentation, she was febrile to 102 F, pulse of 120 beats per minute, respiratory rate of 20 breaths per minute, and blood pressure of 96/58 mmHg and required 2 liters oxygen to keep her saturation above 90%. Initial exam was benign with clear lungs. After blood and urine cultures were obtained, vancomycin and meropenem were started empirically. A paracentesis was not performed due to small ascitic fluid pockets. Initial chest X-ray showed trace left-sided pleural effusion without any evidence of infiltrates. Initial lab work showed ALT 62 U/L, AST 87 U/L, alkaline phosphatase 158 U/L, total bilirubin 13.2 mg/dL, INR of 2.9, WBC of 16,000/ul with 14,400/uL neutrophils, hemoglobin 7.8 g/dL, and platelets of 167,000/uL. After a CT chest revealed small bilateral cavitary nodules the following day, vancomycin and meropenem were continued along with amphotericin being started with concern for a fungal infection (Figure 1).
Without clinical improvement, a CT guided biopsy of the necrotic pulmonary nodules was performed by interventional radiology three days after admission. The CT chest of the biopsy showed a new right upper lobe lesion (Figure 1) despite being on meropenem, vancomycin, and amphotericin. A bronchoscopy with bronchoalveolar lavage was performed the following day and Gram stain, fungal stain, and extensive cultures were all negative. With continued deterioration six days after the biopsy, a repeat CT chest showed increasing size and number of pulmonary nodules with ground glass opacities despite treatment with meropenem, vancomycin, and amphotericin. On day eleven of admission, cultures from the CT guided biopsy turned positive for Legionella. The antimicrobials were stopped and levofloxacin was started and continued for 3 weeks with resolution of symptoms. The culture was sent to the New York State Department of Health in Albany, NY, and identified as L. micdadei. Negative tests included normal transthoracic echo, normal head CT, and normal neck ultrasound. Five blood cultures, respiratory viral panel, urine Legionella antigen, Pneumocystis DNA PCR, Legionella culture from BAL, bacterial culture, fungal culture, Aspergillus antigen, and Histoplasma antigen were negative.