(553) Legionella-Induced Pancreatitis

Introduction: Legionella species are gram-negative aerobic intracellular bacteria, typically found in water and less commonly in the soil. Immunocompromised patients, patients in extremes of age, smokers are prone to infection. Most common presentation for Legionella species is atypical bacterial pneumonia although cases have been reported with extrapulmonary disease spread. We describe a rare case of legionella pneumophila serotype –1 induced pancreatitis.

Description: 60-year-old male with no significant past medical history presented with shortness of breath and altered mental status, was intubated for airway protection on arrival. CT chest showed significant left lower lobe consolidation on presentation. Urinary antigens were positive for Legionella. He was started on antibiotic coverage with azithromycin. Patient developed worsening leukocytosis, significant abdominal tenderness on physical examination and worsening pressor requirement later in the course of admission. Lipase was elevated to 958. CT abdomen pelvis showed radiologic findings significant for pancreatitis. Tube feeds were held and was treated with fluid resuscitation. However, the patient's trajectory worsened to multiorgan failure with the development of shock refractory to pressors, AKI, ARDS.

Discussion: Extrapulmonary manifestations of legionnaires disease that have been reported so far include rhabdomyolysis, renal failure, pancreatitis, myocarditis and meningoencephalitis. Pathophysiology associated with this condition can be directly pathogen associated or immunomodulatory response with the release of inflammatory cytokines. Pro inflammatory cytokines such as interleukin-1 beta, IL-6, TNF alpha have been associated with increased vascular permeability and atypical inflammatory response associated with vascular leakage and edema resulting in features of acute pancreatitis. Therefore, patients with atypical bacterial pneumonia and abdominal pain should be evaluated for acute pancreatitis.