Legionnaires' Disease

Overview

By Tina Shahian, PhD

Legionnaires' disease is a lung infection (pneumonia) that is caused by the Legionella pneumophila (commonly referred to as Legionella) bacterium. It is named after the first recorded outbreak at the 1976 American Legions Convention in Philadelphia, which led to 34 deaths. Legionnaires' disease is contracted by inhalation and not transmitted from person to person. The bacteria live in warm water and soil, but can also thrive inside poorly sanitized water systems. Water sprays, air conditioning units, spas and other equipment that produce a fine mist can spread the bacteria and contaminate breathable air.

Legionella pneumophila bacteriaLegionnaires' disease is fairly common in the United States and is linked to 8,000 - 18,000 hospitalizations each year. The majority of those contracting the disease do not become ill, while others require hospitalization and antibiotic treatment. Life-threatening pneumonia may develop in smokers, those with weakened immunity and other high-risk individuals. Similar to other types of pneumonia, Legionnaires' disease has a 15% chance of death. The Legionella bacterium is also responsible for a milder flu-like disease called Pontiac fever, which does not affect the lungs and clears without treatment.

 

Causes and Risk Factors

Legionnaires' disease is caused when Legionella bacteria enters the lungs through microscopic water droplets. Transmission usually happens though the nose (inhalation), and less often, the oral cavity (aspiration) – for example, when coughing reroutes some ingested fluid down the respiratory tract.

Legionella is found in soil and natural bodies of water, but in such low levels that there is little risk to humans. Water systems (in particular heated systems) that are not properly cleaned can harbor high levels of Legionella. When contaminated water is vaporized, sprayed or forced out through vents, it produces small droplets that can be inhaled. Water systems that can harbor and transmit Legionella include:

  • Hot tubs
  • Cooling towers 
  • Hot water tanks
  • Domestic plumbing
  • Air conditioning units
  • Public pools and decorative water features.

The body’s immune system can clear Legionella with little or no symptoms. However, roughly 5% of those who become exposed develop severe illness. The risk factors include:

  • Smoking. The most important risk factor for Legionnaires' disease is smoking. Long-term smoke inhalation (which can also be through second-hand smoking and other sources) damages the bronchioles of the lung making it difficult to clear the bacteria.
  • Weak immunity. Diseases (e.g. HIV/AIDS, cancer) and immunosuppressive medication (e.g. for organ transplant recipients) weaken the immune system and increase the risk of developing Legionnaires' disease. 
  • Chronic lung disease. Emphysema, chronic obstructive pulmonary disease (COPD), cancer and other chronic lung diseases are high risk factors for Legionnaires' disease.
  • Age. People over the age of 50 are at increased risk.

Symptoms

Symptoms of Legionnaires' disease begin anytime between two days to two weeks after exposure and are similar to those associated with other pneumonias.
Early symptoms include:

  • Low-grade fever
  • Headache
  • Joint and muscle pain
  • Fatigue
  • Poor appetite.

Late symptoms include:

  • High fever (up to 104°F)
  • Coughing up mucus
  • Difficulty breathing
  • Chest pain
  • Vomiting
  • Abdominal pain.

Diagnosis and Treatment

Legionnaires' disease is diagnosed by evaluating the lungs for pneumonia and confirming the Legionella infection.

  • X-ray. An X-ray image of the chest cavity allows doctors to assess the presence and severity of pneumonia in the lungs.
  • Urine test. This test detects antigen (or a protein) that belongs to the Legionella bacteria. 
  • Culture. As an alternate method for confirming infection, the Legionella bacteria can be acquired from sputum or lung biopsy and grown in the laboratory.
  • Blood test. Elevated levels of circulating antibodies in the blood are a non-specific indication of an existing infection.

Legionnaires' disease is treated with antibiotics and often requires hospitalization. Early treatment helps prevent serious complications, including death.

Prevention

Proper cleaning and disinfecting of pools, hot tubs, and other water systems that can harbor Legionella is the most effective way of preventing transmission. Avoiding smoking reduces the lung’s susceptibility to all pneumonias, including Legionnaires' disease.

Sources

  • Legionella ". Centers for Disease Control and Prevention (CDC). Retrieved Apr 9, 2015. http://www.cdc.gov/legionella/about/index.html.
  • “Legionnaires' disease". Mayo Clinic Foundation. Retrieved Apr 9, 2015. http://www.mayoclinic.org/diseases-conditions/legionnaires-disease/basics/definition/con-20028867.
  • “Section I: What is Legionnaires' disease?” United States Department of Labor. Retrieved Apr 9, 2015. https://www.osha.gov/dts/osta/otm/legionnaires/disease_rec.html#risk.