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Mitch St. Clair, Matthew J. Crowley, Daniel Sexton, Legionella as a Cause of Hyperpyrexia, Clinical Infectious Diseases, Volume 49, Issue 4, 15 August 2009, Pages 646–647, https://doi.org/10.1086/603594
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To the Editor—A recent article by Assimacopoulos et al [1] notes that Staphylococcus aureus infection may cause extreme pyrexia (temperature, >41.7°C). These authors are correct in noting that hyperpyrexia secondary to infectious causes is uncommon. The authors did not discuss other infectious causes of hyperpyrexia in their case report. A patient who was recently admitted to our medical center with extreme, protracted hyperpyrexia illustrated the important lesson that other infectious agents, such as Legionella pneumophila, may also cause hyperpyrexia. L. pneumophila, first identified at an American Legion convention in Philadelphia in 1976, is an important cause of community-acquired pneumonia with high fever [2], as well as other illnesses that present with hyperpyrexia alone, such as Pontiac fever and culture-negative endocarditis [3]. It is well documented that Legionella species can cause high fever [4–6].
A 63-year-old man was admitted to the Durham Veterans Affairs Hospital with a 4-day history of fever and confusion. His temperature at the time of admission was 40.0°C. The patient denied cough, dysuria, hemoptysis, or diarrhea. His medical history was significant for alcohol abuse, and he reported that his last drink was 4 days before admission. Findings on chest radiograph were normal. Computed tomographic imaging of his head showed no acute process, and lumbar puncture revealed normal cerebrospinal fluid. Empirical therapy with vancomycin, ampicillin, ceftriaxone, and acyclovir was begun. His fever was treated with nonsteroidal anti-inflammatory agents and acetaminophen, but hyperpyrexia persisted. When his temperature reached 41°C, he was transferred to the intensive care unit, where cooling blankets, in addition to antipyretic therapy, were used. A urinary Legionella antigen test result was positive, and his antibiotic treatment regimen was changed to azithromycin. He subsequently developed acute respiratory distress syndrome and required intensive care for 33 days. During his stay in the intensive care unit, he developed rhabdomyolysis, acute renal failure, diarrhea, hematuria, thrombocytopenia, and disseminated intravascular coagulation and had persistent leukocytosis. He also continued to have a temperature >39°C for ∼15 days. He was eventually discharged to a rehabilitation facility, where he continued to improve.
