Air bubbles breaking at the air-water interface can remove bacteria that concentrate in the surface microlayer and eject the bacteria into the atmosphere.
The bacterial concentrations (numbers per milliliter) in the drops ejected from the bubble may depending on the drop size be from 10 to 1000 times that of water in which the bubble burst.
Woodcock found that small droplets in the air were most likely the causative factor in human respiratory irritation associated with high concentrations of plankton in the sea.
He showed that droplets carrying the irritant were easily generated by bubbling through the water rich in plankton.
(Blanchard D C  State University of New York Science 25 Aug 1970)
(Woodcock A H . J Marine Res 7 56 1948)

Community-acquired Legionnaires' disease associated with a cooling tower:

Evidence for longer-distance transport of Legionella pneumophila.
In the period August 10-29, 1986, 29 confirmed cases of Legionnaires' disease occurred in Sheboygan, Wisconsin; two cases were fatal.
No common source of indoor exposure was identified. Water specimens were obtained from all known cooling tower units in Sheboygan; Legionella pneumophila serogroup 1 was isolated at 1 x 10(6) colony-forming units per liter from a specimen obtained August 27 at plant A. This isolate was identical to the only clinical isolate by monoclonal antibody and isoenzyme subgrouping. Of 29 persons with Legionnaires' disease, 21 lived or worked within one mile (1.6 km) of plant A; seven of the remaining eight visited within one to two miles (1.6 to 3.2 km) of plant A from three to seven days before onset of illness. Attack rates were highest for persons living within 0.5 mile (0.8 km) of plant A.
These findings associate a cooling tower with community-acquired Legionnaires' disease and suggest that dissemination of Legionella may occur over longer than previously recognized distances.
(Acute and Communicable Disease Epidemiology Section, Wisconsin Division of Health, Madison 53701-0309. Source Am J Epidemiol, 1989 Sep, 130:3, 557-68)

1957
ADELAIDE, SOUTH AUSTRALIA

Pseudomonas Pyocyanea found in a EVAPORATIVE COOLER Ps. pyocyancea was cultured from the air passing through a cooling unit, which operated on the water evaporation principle. The organism was traced to the water trough, which was heavily contaminated, This evaporative cooler was serving an operating theatre in a Adelaide hospital
(Anderson K, Medical Journal of Australia 1957 page 529 April 18th.)

1970

HYPERSENSITIVITY PNEUMONITIS DUE TO CONTAMINATION OF AN AIRCONDITIONER

In four of 27 office workers, symptoms intermittent chills, fever and dyspnea, or progressive dyspnea alone developed. Pulmonary-function studies indicated restrictive and diffusion detects,and x-ray examination demonstrated diffuse nodular infiltrates in all four patients.
Examination of of their environment revealed contamination of the air-conditioning system with a thermophilic actinomycete known to cause a hypersensitivity pneumonitis such as farmer's lung. Serum specimens of all patients contained high titers of rhaumatoid factor and precipitating antibodies against the offending organism. Inhalation of the antigen by one of the ill workers during an asymptomatic period reproduced all clinical features of the disorder. Treatment with steroids and subsequent avoidance exposure resulted in complete recovery. Hypersensitivity pneumonitis should be suspected in cases of interstitial pneumonitis, even in the absence of clear-cut contact with organic dust.
(E F Banaszak ,W H Thiede, J N Fink, The New England Journal of Medicine 283 August 1970)

1978 Glasgow

POSSIBLE PERSON TO PERSON TRANSMISSION OF LEGIONNAIRES DISEASE. A general practitioner was treated for pneumonia in 1974, The clinical features suggested infection with Mycoplasma pneumoniae,chlamydia B or Coxiella burnetii, but the serlogy was negative, The doctor himself was positive that he had contacted the infection from a patient whom he had attended 2 weeks before and had sent to hospital with sever pneumonia which had developed during a holiday in Benidorm, Sera taken from the patient during his illness have proved, retrospect, that he had Legionnaires disease. No acute-phase serum was available from the general practitioner, but a sample taken more than three years later had an antibody of 1:512 This is a strong circumstantial evidence of a case-to-case transmission.
(W Campbell Love, The Lancet, December 9 1978)

In two previously well nonsmokers fatal pneumonia developed with extensive abscess formation. Legionnaire`s bacillus was the only pathogen isolated. These cases indicate that Legionnella bacillus is capable of causing extensive necrosis of the lungs.
(Lewin S . American Journal of Medicine Citation : 67(2):339-4 1979)

1979
Recurrent I.egionnaires' disease:

An isolated case of legionnaires' disease in a 46 year old Caucasian male Ohio physician was reported. Diagnosis was later confrmed by a fourfold increase in indirect immunofluorescent antibody titer level. Recovery began rapidly after the administration of erythromycin therapy and appeared to be complete. The following year the sarne patient suffered an apparent reinfection once again realizing prompt and total recovery upon receiving erythromycin therapy. Although not commonly reported, the possibility of reinfection with the Legionella bacterium is a reality. The source of human innoculation need not necessarily be a common water supply or large cooling systern reservoir (as was previously thought). Erythromycin continues to be widely regarded as the treatment of choice for infections with the Legionella bacterium even though this case demonstrates that it does not prevent reinfection.
(Skrobot B J -FAMILY PRACTICE RESEARCH JOURNAL 6(2):67-71 1986)

Recurrent Infection of Legionella Pneumonia

A 75-year-old male veteran presented with bilateral pneumonia upon admission. He had an episode of Legionnaires' disease in 1991 with complete treatment oferythromycin 500mg orally every six hours for three weeks. After admission, recurrence of Legionnaires' disease was suspected due to increased serum Legionella antibody ( 1 : I 28) and strong positive sputum Legionella antigen. Erythromycin and other parental antibiotics were administered, but respiratory failure developed promptly, followed by multiple organ failure syndrome that involved the liver, lung, bone marrow and kidney. He died 42 days after admission. We reviewed seven cases that had been reported and found recurrence of Legionella pneumonia possible after a successful treatment, especially for immunocompromised hosts. Early empirical therapy with erythromycin is recommended.
(Yuan-Yuan Ko, Chung=Hua Chen, Chun-Liang Lai, Reury-Perng Perng
Chin Med J (Taipei) 1996;57:365-9.)

1978
WASHINGTON

Allan Blanchard , Washingtons bureau chief of the Detroit New was in intensive care after being diagnosed with the Disease, and died on the 17 September at George Washington Hospital
At the same time another another person died of the disease on 14 September , and a 27 year old man was recovering in hospital after being in a serious condition.
(Ann Intern Med 92 (2 Pt 1): 186-188 (Feb 1980)

1987
DETROIT

Legionnaire`s Disease contributed to the death of Henry Ford 11, who contracted the disease while on holiday in Europe. Ford who was 70 died after a Two and half week battle with the disease
(Source Media)

1990
LOS ANGELES
Puppeteer Jim Henderson sudden death from pneumonia is a reminder that this disease can be fatal.

Fatal pneumonia caused by Legionella pneumophila, serogroup 3: demonstration of the bacilli in extrathoracic organs.
(Watts JC, Hicklin MD, Thomason BM, Callaway CS, Levine AJ)

An immunosuppressed patient with malignant lymphoma died of acute pneumonia caused by Legionella pneumophila. Bacilli of serogroup 3 were detected in areas of pnemonia, in a mediastinal lymph node, and in the liver and spleen by direct immunofluorescence done on tissue obtained at autopsy. That the extrathoracic fluorescent material represented intact bacteria rather than antigenic fragments or antigen-antibody complexes was confirmed by finding intracellular bacilli in the liver by electron microscopy. To our knowledge, this case represents the first example of fatal disease attributed to serogroup 3 L. pneumophila and the first case in which L. pneumophila has been demonstrated in extrathoracic organs.

An 18 year old man was seen in the emergency ward of a district hospital after ingestion of benzodiazepines and phenothiazines in a suicide attempt, He was conscious, and gastric lavage was performed with tap water, 2 hours later he inhaled vomitus and required mechanical ventilation just before transfer to a larger hospital. In the ensueing hours he was feverish, and chest X-ray revealed right-sided alveolar. Retrospective IFA testing for Legionella pneumophila 1 to 6 showed high titres consistent with recent infection by Legionela pneumophila serogroup 3 and/or 6 The serological findings promted us to look for Legionella in the tap water of the hospital where the gastric lavage had been done.

A case report

Simultaneous in Legionella pneumophila and Legionella micdadei in an immunologically intact host.
A reported a case of dual infection with Legionella Pneurnophila and Legionella micdadei in an immunologically intact host. The bacteriological and serological data are compatible with a simultaneous recent infection.
(Fumarola, D. :63(2): 165-6 1984
BOLLETTINO DELL' ISTITUTO SIEROTERAPICO MILANESE )

1984

A grave digger was found to have an acute pneumonia which was Legionnaire`s disease, a seroepidemiologic survey of 45 co-works was performed and cultures of the graveside soil were taken
(Cambridge Scientic N Y State J Med no 5 pp 238-240 1984)



1980
*Legionella in Aquatic Habitats in the Mount Saint Helens Blast Zone*

Illnesses of undiagnosed etiology among researchers exposed to lakes and streams in the Mt. St. Helens blast zone after the 18 May 1980 eruption prompted us to determine the occurrence and potential virulence of Legionella (Legionnaire`s disease bacteria) in aquatic habitats near Mt. St. Helens during the summers of 1981 and 1982. Concentrations of
L.pneumophila. L. mrcdadei, L. gormunii, L. dumoffii. and L. bozemunii, determined by microscopic counts using direct immunofluorescent staining, ranged from < 10/4 to 10/5 cells/l in lakes and rivers outside the
Mt. St. Helens blast zone while the numbers of Legionella in aquatic habitats inside the blast zone were from lO/5to 10/7 cells/1. Legionella numbers were tro- consistently highest in North Coldwater and S irit lakes, which received water from hydrother-mal seeps. Legionelln pneumophila serogroups 4 and 6 were isolated from North Coldwater Lake in 1981 and from South Coldwater Creek in 1982. indicating that potentially virulent of strains of Legionella persist in aquatic habitats in the blast zone of Mt. St. Helens.
(David L. Tison, John A. Baross,t and Ramon J. Seidler,
Current Microbiology V9 pp 345-348 1983)

1984

At the University of Utah and at the University of Pittsburgh, there were outbreaks among kidney transplant patients.
Two elderly cancer patients died at Bethesda Naval Hospital in September and October. After the death of the second patient, colonies of Legionella were found on shower heads and faucets in 17 of about 90 spots checked in the hospital and surrounding buildings.

Last September, Legionnaires' disease was ruled a major contributing factor in the deaths of two men at Downstate Medical Center in Brooklyn. A hospital unit was closed after the organism was found in a nearby air conditioning tower.

One of the patients who died had come into the hospital with the disease, and apparently had contracted the disease at home. The other apparently contracted it in the hospital. But both were being treated with drugs that weakened their immune systems, making them susceptible to the bacteria.

"It is nothing like an epidemic, it doesn't have implications generally speaking for healthy people or for people whose immune systems are not compromised.

Legionnaire`s Disease Acquired within the Homes of Two Patients

Link to the Home Water Supply

Two patients with sporadic community-acquired legionnaires' diseass are described. Legionella pneumophila was isolated from sputum specimens, and sercconversion of antibody titers was demonstrated for both patients. Legionslla pneumophila was also recovered from the residential water supply of both patients. In each case, the serogroup of the environmental organism matched that of the infecting organism. In one patient, serogroup 3 was isolated-a rare cause of legionnaires' disease, and in the second case, monoclonal antibody testing confirmed that the serogroup 1 organisms isolated from sputum and residential water supply samples were identical. The incubation period of legionnaires' disease is presumed to be up to two weeks. Because of medical problems, both patients had been confined to their homes for the entire two weeks before the onset of symptoms. This is the first report that links acquisition ot community-acquired legionnaires' disease to contaminated water supplies within the homes ot susceptible patients.
(Janet E. Stout, MS; Victor L. Yu, MD; Paul Muraca, MS: JAMA 257 1215-7 1987)

BRISTOL ENGLAND 1985

Health authorities said yesterday that they were temporarily closing a 44- bed private hospital in Bristol in southwestern England after a part-time nurse died from Legionnaires' disease. A hot-water tap at the hospital was found to be contaminated.

Health authorities in two cities miles away in southern England have reported Legionnaires' fatalities. In Bristol, a 64-year-old woman died of the disease May 2.

St. Mary's Hospital Portsmouth 1985
One person has died and another was treated, administrators plan to close seven wards today and to move 120 patients to rid the hospital of any suspicion of being the cause.

1986 Sweden

A previously healthy 50 year old greenhouse repairman fell ill with pneumonia, this report is the first probable case of Legionella longbeachae infection in Sweden.
(Eitrem R, Scandinavain J of Infectious Diseases, 1987 19 381-382)

NEWARK, N.J.

Health officials are surveying 450 lawyers and judges who attended a conference in the Virgin Islands for symptoms of Legionnaires' disease, following a conferee's death from the ailment.

Pennsylvania and New Jersey health officials said they began making inquiries last week after Stephen P. Laffey, 70, a Pittsburgh magistrate, died Dec. 2. Laffey became ill after he returned from the U.S. Court of Appeals for the 3d Circuit conference,
held Oct. 23-26 at St. Thomas, Virgin Islands.

Officials said they have no other cases. But authorities said another conferee is recovering from pneumonia, which can be a symptom of the disease.

LONDON

The Times reported that between the 29 December 1995 to 1 January 1996 levels of the Legionella bacteria found in the House of Commons London were at a very high and unacceptable level.
The paper said that engineers had tried to clean the hot water system at the Commons but tests had shown that traces of the bacteria remained.

1993
MAY

It was reported that the fountains in Trafalgar Square were dry and nearby cooling towers were shut down while a search was being made to find the source of an outbreak of Legionnaire`s Disease in London, it was reported that at least one person had died.

First case of Legionella maceachernii 71 year old carpenter died 25 days after admission to hospital
(Merrell, Medical J Australia 1991 September. 155 415-417)

1985
Innsbruck
From 1985 until 1993 14 cases of legionella puemonia were diagnosed in the surgical transplantation unit on Innsbruck University Hospital, All isolates from the patients and from the building hot water system were found to be contaminated with Legionella pneumophila serogroup 1, They were indistinguishable from each other by monoclonal antibody subtype and restriction fragment lengtsh polmorphism pattern, This indicaited a series of infections originating from the same source during a period of eight years.

1991
*****MERSEY LIVERPOOL***** MERSEY HEALTH AUTHORITY ON NOVEMBER 5th 1991 DEFENDED ITS DECISION TO KEEP QUIET ABOUT AN OUTBREAK OF LEGIONNAIRES DISEASE AT A $6 MILLION UNIT OPENED FOUR MONTHS BEFORE.
(GUARDIAN NEWSPAPER, NOVEMBER 6th 1991)
****(WHY)*****

1989 COLORADO (LAMA)

On October 16 1989 the Colorado Health Department was notified by a local physician of an elderly patient who was hospitalized with pneumonia after attending a high school class reunion at a local hotel/motel in Lamar, Colorado on September 22-24 , After the patient reported that other members of the reunion group had also developed pneumonia, and that two had died. After futher investigation it was found that the Evaporative Airconditioning(COOLER) Units on the roof were the cause of the outbreak of Legionnaires disease.Twenty cases were reported with THREE deaths. Although Colorado reported 33 sporadic cases of Legionnaire`s disease between 1986 and 1988, this is the first recognized outbreak in Colorado.

1993 Germany

A 64 year old man died from a travel-associated legionella pneumonia six weeks after the onset of the disease. A shower nozzel, contaminated with legionellae, in a German hotel room was traced to the source of the infection. The concentration of legionellae in the shower water was 15,000 per ml.
(Muhlenberg W, Gesundheitswesen, 1993 55 653-656)

Legionella pneumophila in a neonatal intensive care unit

A premature child received continuous mechanical ventilation in a neonatal intensive care unit.
On day 10 of his life he developed pneumonia due to Legionella pneumophila serogroup 1 monoclonal subtype Bellingham.The strain was cultured From a tracheal secretion taken on day 10. Legionella pneumophila serogroups 1 and 6 (l0(2)-4 x lU{4) cful)) were cultured from both central and peripheral hot water systems.Four unrelated Legionella strains of the same monoclonal subgroup Bellingham studied for comparison.Legionellae were also isolated from two other incubators, but no clinical or microbiological indications of legionellosis were found in the neonates hospitalised there.
Serogroup I strains isolated from the patient and from the hot water systems and serogroup 6 isolates from the hot water supply were able to rnultiply in cultured Acanthamoeba castellanii cells and in guinea pigs.
(Luck P C. Eur J Clin Microbiol Dis 13: 7 July 565-7 1994)

A 64 year old man who developed pneumonia after a laryngectomy, Legionella pneumophila serogroup Leiden-1 was isolated from his sputum.
Investigation revealed that infection followed exposure to an aerosol from a mechanical humidifier
(Kaan J A Journal of Infection 11(2) 145-8 1985)

The translation of the Japannese Code of Practise for Legionnaire`s Disease states that a person who accidentally stumbled into a Hot Spring and swallowed the water contracted Legionnaire`s Disease, When the water was tested it was found to contain Legionella

A Case of successful therapy of a neonatal Legionellosis with Erythromycin.
On his 6th day of life a full term newborn with normal weight was affected by severe pneumonia.
This was at first resistant to therapy and required mechancal ventilation. Daignosis of Legionella pneumonia serogroup 1 was made by culture from bronchial lavage.
Only a few cases of neonatal Legionellosis have been reported until now, in three cases diagnosis was made post mortem.
(Ahrens F . Monatsschrift Kinderheilkunde 141 (9) 711-3 1993)

A case of Legionnaire`s Disease in a previously healthy 3 1/2-year-old girl
(Békássy AN; Garwicz S; Larsson B; Laurin S; Ivancev K; Olin C Source Lakartidningen, 1985 Aug 21, 82:34, 2794-5)

Long-term surviving child with acute lymphoblastic leukemia complicated with legionellosis
An 11 year-old girl was diagnosed as acute lymphoblastic leukemia (ALL) on November 26th 1979 and was induced into complete remission with vincristine and prednisolon. After consolidation therapy with daunomycin, vincristine and prednisolone, she developed pneumonia on January 21st 1980. No cause of pneumonia was found by sputum culture or serologic tests. Treatment with cefmetazol (CMZ), sulbenicillin (SBPC) and minocycline (MINO) was not effective but 9 g/day of LCM made a remarkable effect. Indirect immunofluorescence assay of antibody showed x 512 titers on January 22nd and in her recovery period, the titers showed eight times increased up to x 4,000. The diagnosis of Legionellosis was made on CDC's criteria. She recovered completely with sequential lincomycin (LCM) and erythromycin (EM) therapy. On October 1989, she is still in the first complete remission of ALL for more than 8 years.
(Tanabe N; Ohno R; Saito H; Nakura E Address First Department of Internal Medicine, Nagoya University School of Medicine. Source Rinsho Ketsueki, 1990 Apr, 31:4, 502-5)

Legionnaire's pneumonia complicating a thermal burn.
Abstract The report describes a patient with 45 per cent BSA burns who developed Legionnaire's disease 3 days after the acute injury. The diagnosis of this life-threatening complication was late because most of its signs and symptoms can be encountered in the burned patient. This delay could have been fatal to the patient and required the evacuation of the burn centre for disinfection.
(Signorini M; Grappolini S; Lo Cicero S; Candiani P; Klinger M; Donati L Address Department of Plastic Surgery and Postgraduate School of Plastic Surgery, Milan University Medical School, Italy. 1989 Dec, 15:6, 397-8 )

Legionnaire`s Disease combined with erythema multiforme in a 3-year-old boy.

A case of Legionnaires' disease (LD) is described in a 3-year-old boy. He had fulminant disease with typical signs like bilateral pneumonia, gastrointestinal symptoms, and somnolence indicating involvement of the central nervous system. There was no premorbidity. An outstanding development was erythema multiforme, which has never previously been described in LD. The basic disease was caused by Legionella pneumophila. This is evidenced by specific serum IgM at admission and a subsequent significant rise in titers against L. pneumophila. At an early stage respiratory syncytial virus (RSV) was isolated from the patient's throat, although there was no antiviral serological response at the outset of erythema multiforme or 3 weeks after onset of disease; anti-RSV appeared later. The prolonged course of the disease can be explained by the successive occurrence of two infections. The possibility that the virus could have contributed to the development of erythema multiforme cannot be ruled out. The role of concomitant medication cannot be separated out, but on the basis of general knowledge of their immunogenicity and the fact that immunosuppressive cortisone was given at the time it is less likely that the antibiotics contributed significantly.
(Signorini M; Grappolini S; Lo Cicero S; Candiani P; Klinger M; Donati L Address Department of Plastic Surgery and Postgraduate School of Plastic Surgery, Milan University Medical School, Italy. Source Burns, 1989 Dec, 15:6, 397-8)

Fatal legionellosis in an infant treated with ACTH

A new case of fatal systemic legionnaires' disease is reported in an infant. This 8 month-old boy was given a protracted treatment with adrenocorticotropic hormones for infantile spasms. Legionella pneumophila type I was found in tracheal secretions and there was multivisceral involvement at autopsy. The mode of contamination and the severity of the disease are discussed in the light of the immunosuppressive properties of the glucocorticoids administered over a period of 4 weeks.
(Lefrancois C, Casadevall I, Betremieux P, Donnio PY, Jouan H, Laisney N, Le Marec B
Unite de Reanimation Pediatrique, Hopital Pontchaillou, Rennes. Arch Fr Pediatr 46 (8): 591-593 (Oct 1989)

Severe Legionella pneumopathy in an immunologically normal infant:

A case of legionnaires' disease is described in a 9 months old boy. He had a rapidly extensive bilateral pneumoniae. There was no premorbidity. The diagnosis was made by demonstrating legionella pneumophila serogroup 1 in pulmonary biopsy and pleural liquid, by direct immunofluorescence assay and positive culture. There was no seroconversion. An adenovirus type 2 was also isolated in pulmonary biopsy, with an strong seroconversion. The course was favorable, with Doxycycline therapy.
(Hartemann E; Berthier JC; Barrois S; Saudin F; Bornstein N; Souillet G; Gilly J; Bovier-Lapierre M Source Pediatrie, 1983 Sep, 38:6, 393-9)

Legionellosis in children with leukemia in relapse

Two children with legionellosis complicating a relapse of acute lymphoblastic leukemia are reported. A 5-year-old boy with pneumonia had Legionella pneumophila cultured from a tracheal aspirate following a rapid deterioration in his respiratory status and intubation. This child had severe and irreversible granulocytopenia and died in spite of therapy with erythromycin and rifampin added five days later. Combination antimicrobial therapy is suggested for immunosuppressed children with legionellosis if resolution of neutropenia is not readily anticipated. Culture of Legionella sp from respiratory tract secretions or sputum, as reported for the first time in the pediatric literature, should be attempted in all children in whom this infection is suspected. A 13-year-old boy with pneumonia recovered in spite of therapy with antimicrobial agents not proven to be effective against the legionellae. Clinical improvement coincided with increase in absolute granulocyte count. A retrospective diagnosis was made when seroconversion to Legionella micdadei (less than 1:16 to 1:1,024) was determined during a survey of unselected sera from 255 hospitalized children. This is the first documented case of Pittsburgh pneumonia described in a child.
(Kovatch AL; Jardine DS; Dowling JN; Yee RB; Pasculle AW Source Pediatrics, 1984 Jun, 73:6, 811-5)

Unusual progression of a Legionella pneumophila infection in a young child

A 2 8/12-year-old boy showed an unusual course of a Legionella pneumophila infection with severe dyspnea, longterm loss of conscience (5 days) and permanent persistence of pulmonary obstruction.
(Beyer P; Kahn D; Horbach J; Schmid H; Graf W; Weber B Source Eur J Pediatr, 1984 Jan, 141:3, 173-5)

Nosocomial infection with Legionella pneumophila serogroup 1 and 8 in a neonate.

A case of pneumonia related to 2 serogroups (1 and 8) of Legionella pneumophila (Lp) in a 10-day-old boy is described together with the epidemiological survey in the maternity ward which made it possible to establish its nosocomial origin. Rodshaped bacteria reacting with an Lp genus-specific monoclonal antibody and serogroup 1 and 8 polyclonal sera were detected in bronchoalveolar lavages (BAL) collected on day 13. Serogroups 1 and 8 were recovered from cultures of BAL collected on days 12 and 13. Fourfold or more antibody rises to serogroups 1, 5, 8 and 10 of Lp were observed in sequential serum specimens. Water samples collected from the tank and mixer of the maternity ward grew serogroups 1 and 8 of Lp. Serogroup 1 was detected in large amounts in water samples taken at several points of the hot water supply system and from the oxygen nebulizers and the feeding-bottle heater. Analysis of the Lp serogroup 1 strains isolated from the water by subgroup-specific monoclonal antibodies revealed the presence of 4 different subgroups, one of which was identical to the Lp 1 subgroup isolated from the neonate's BAL. This latter subgroup, reactive with McKinney monoclonal antibody Mab 2, has been described as highly virulent. No other case of legionellosis was recorded in the maternity ward.
(Aubert G; Bornstein N; Rayet I; Pozzetto B; Lenormand PH Address Department of Bacteriology, University Hospital of Saint-Etienne, France.Source Scand J Infect Dis, 1990, 22:3, 367-70)

Fatal nosocomial Legionnaire`s Disease:

Relevance of contamination of hospital water supply by temperature-dependent buoyancy-driven flow from spur pipesThe investigation, epidemiology, and effectiveness of control procedures during an outbreak of Legionnaires' disease involving three immunosuppressed patients are described. The source of infection appeared to be a network of fire hydrant spurs connected directly to the incoming hospital mains water supply. Removal of these hydrants considerably reduced, but failed to eliminate, contamination of water storage facilities. As an emergency control procedure the incoming mains water was chlorinated continuously. Additional modifications to improve temperature regulation and reduce stagnation also failed to eliminate the legionellae. A perspex test-rig was constructed to model the pre-existing hospital water supply and storage system. This showed that through the hydraulic mechanism known as 'temperature buoyancy', contaminated water could be efficiently and quickly exchanged between a stagnant spur pipe and its mains supply. Contamination of hospital storage tanks from such sources has not previously been considered a risk factor for Legionnaires' disease. We recommend that hospital water storage tanks are supplied by a dedicated mains pipe without spurs.
(Patterson WJ; Seal DV; Curran E; Sinclair TM; McLuckie JC Address Glasgow Royal Infirmary, Edinburgh. Source Epidemiol Infect, 1994 Jun, 112:3, 513-25)

Nosocomial legionnaires disease in a children's hospital.

Between August 1982 and December 1985, seven patients at a children's hospital developed hospital-acquired pneumonia caused by Legionella pneumophila. Demographic data included the following: mean age 12.3 years (range 9 months to 20.5 years); male/female ratio 5:2; all patients were white. Some previously identified risk factors present in our patients included high-dose corticosteroid therapy (five patients), other immunosuppressive therapy (four), and chronic lung (five) or kidney (three) disease. Symptoms and signs included rapid onset, fever, cough, pleuritic chest pain, dyspnea, abdominal pain, diarrhea, and headache. Rhinitis, myalgia, and neurologic abnormalities were not noted. Chest roentgenograms revealed single-lobe consolidation in three patients, diffuse bilateral alveolar infiltrates in three, and pleural effusion in three. All patients were treated with erythromycin; three patients also received rifampin. Tracheal intubation and mechanical ventilation were required by four patients. Six patients improved after therapy. One child died of persistent lung disease 1 month after the onset of legionnaires disease. L. pneumophila was isolated from potable water in the hospital. Aerosol equipment cleansed with tap water and the showers were implicated as means of exposure by patients to contaminated potable water. No new nosocomial cases were seen after immunocompromised children were prohibited from taking showers, and sterile water was used to cleanse equipment for administering aerosol medications.
(Brady MT Address Department of Pediatrics and Preventive Medicine, Ohio State University College of Medicine, Columbus. Source J Pediatr, 1989 Jul, 115:1, 46-50)

Piccadilly Circus legionnaires' disease outbreak.

An outbreak of legionnaires' disease occurred in central London in January and February 1989. An Infection Control Committee was established to investigate the outbreak and institute control measures. The objective of this paper is to describe the investigation and control of the outbreak. METHODS: An epidemiological survey and case-control study were carried out. The subjects were cases of community acquired pneumonia associated with central London with onset of illness in January and February 1989. RESULTS: Thirty-three confirmed cases, including five deaths, and ten suspected cases, including three deaths, were identified with dates of onset from 1 January to 11 February. A clustering of visits by cases to the vicinity of Piccadilly Circus was noted, and a case-control study demonstrated a strong association between illness and visits to this area in the two weeks before onset of symptoms. The causative organism, Legionella pneumophila serogroup 1, was isolated from six patients. Legionella pneumophila of the same serogroup was isolated from water samples from five wet cooling systems (cooling towers) in the area under investigation, but in only two systems was the organism indistinguishable by subtyping from the patients' strains. Many of the cooling towers examined were inadequately maintained, including one of the two above a building adjacent to Piccadilly Circus from which a strain indistinguishable from the outbreak strain was isolated. All cooling towers in the area were shut down until inspected, and only allowed to restart after appropriate maintenance had been instigated. CONCLUSIONS: This outbreak showed the continuing risk of legionnaires' disease posed by wet cooling systems, including cooling towers, and highlighted the need to assess this risk so that appropriate maintenance is carried out. Regulations have recently been introduced, under the Health and Safety at Work Act, requiring notification of all wet cooling systems to the local authority to facilitate the investigation of outbreaks of legionnaires' disease.

(Gabbay J; Maguire H; Boyle M; Bruce J; Tomlinson M; Lee J; Harrison TG; Uttley A; et al Watson JM; Mitchell E;Address PHLS Communicable Disease Surveillance Centre, London. J Public Health Med, 1994 Sep, 16:3, 341-7)

Title Nosocomial Legionnaires' disease in England and Wales, 1980-92.

Two hundred and eighteen nosocomial cases of Legionnaires' disease with 68 deaths were reported to the National Surveillance Scheme for Legionnaires Disease between 1980 and 1992, representing 15% of the reported infections acquired in England and Wales. Twenty-two nosocomial outbreaks accounted for 135 (62%) of these cases, the remainder occurring as single cases either in hospitals where other single cases or outbreaks had been reported in different years or as 'sporadic' cases in hospitals from which no other cases were reported. A clinical history prior to onset of Legionnaires' disease was available for 124 patients, 61 of whom had undergone recent transplant therapy or were immunosuppressed for other reasons. Sixty cases (27%) were diagnosed by culture of the organism and isolates from 56 patients were typed; 25 (42%) were non L. pneumophila serogroup 1 infections. Methods for prevention and control of nosocomial outbreaks are discussed, in particular the susceptibility to Legionnaires' disease of certain groups of hospital patients.
(Joseph CA; Watson JM; Harrison TG; Bartlett CL Address PHLS Communicable Disease Surveillance Centre, Central Public Health Laboratory, London, UK. Epidemiol Infect, 1994 Apr, 112:2, 329-45)

1979-1982
Legionnaire`s Disease in the Caribbean
An outbreak associated with a resort hotel.

Outbreaks of legionnaires' disease (LD) in tourists visiting Italian and Spanish resorts have been recently reported. An unusual number of reports of LD in tourists visiting the US Virgin Islands prompted an investigation of risk factors for development of LD in this area. Twenty-seven cases of LD were identified between 1979 and 1982 through press reports, personal communication, the national LD surveillance system, a review of hospital records, and a mail survey. Twenty-four of 27 persons with the disease had visited St Croix and 12 of them had stayed at a single hotel in 1981. Available evidence suggested that infection was due to Legionella pneumophila serogroup 1; L pneumophila serogroups 1 and 3 and several new Legionella species were isolated from the potable water system at the hotel. Following hyperchlorination of the potable water system, no further cases of LD in hotel visitors have been identified to date.
(Schlech WF 3d; Gorman GW; Payne MC; Broome CV Source -Arch Intern Med, 1985 Nov, 145:11, 2076-9 )

1986-1990
Title Six cases of travel-associated Legionnaire`s Disease in Ischia involving four countries.

The detection of travel-associated legionellosis can be extremely difficult; hence, an extensive case investigation is recommended in pneumonia-striken travellers and tourists, who are particularly at risk of acquiring the disease. On the Island of Ischia (Isola d'Ischia, Naples, Italy) a total of six cases of Legionnaires' disease occurred from 1986 to 1990. All patients (one man and two women from Germany, one Austrian woman, one Swiss man, and one Italian woman) had taken thermal baths and stayed in local hotels; they all experienced severe pneumonia, and three of them died. These cases were associated with hotels, and the hot-water supply was presumed to have transmitted the infection. Remedial procedures were applied to the hot-water plumbing of the hotels according to the WHO recommendations and were proved to be effective. The occurrences described in this paper stress the importance of rapid and accurate reporting of diagnosed cases to the country where the infection was probably acquired, in order to ensure early detection of endemic foci and emerging clusters of legionellosis.
(Castellani Pastoris M; Benedetti P; Greco D; Volpi E; Billo N; Fehrenbach FJ; Hohl P; Horbach I; Wewalka G Address Laboratorio di Batteriologia e Micologia Medica, Istituto Superiore di Sanità, Rome, Italy. Source Infection, 1992 Mar-Apr, 20:2, 73-7)

Bacterial colonization and occurrence of Legionella pneumophila in warm and cold water,
in faucet aerators, and in drains of hospitals.

Warm and cold water as well as water from wash basin drains and faucet aerators was examined to determine the number of viable and dead bacteria by culture and by staining and to establish the spectrum of species with special consideration of Legionella pneumophila. The relation between the number of Legionella pneumophila, the temperature, and the iron content of the water was determined in three separate warm water systems. High colony counts (up to 8.9 X 10(5) colony-forming units), were detected in both warm and cold water at certain sampling sites. The most prevalent genera were Pseudomonas, Bacillus, Flavobacterium, Acinetobacter, and Moraxella. Legionella pneumophila was found in every building in 35 of 150 warm samples and in 1 of 43 cold water samples. The highest water temperature of a sample containing Legionella pneumophila was 64 degrees C. The correlation between high colony counts and the occurrence of Legionella pneumophila in the samples was not significant. High iron concentrations, however, appear to have a positive effect on the growth of Legionella pneumophila.
(Botzenhart K; Heizmann W; Sedaghat S; Heeg P; Hahn T Source Zentralbl Bakteriol Mikrobiol Hyg [B], 1986 Dec, 183:1, 79-85)

The outcome of nosocomial legionnaires' disease in three patients who were isolated in the same sterile unit after allogeneic bone marrow transplantation. In all three cases the disease presented with dramatic pulmonary symptoms, and diagnosis was ascertained by direct immunofluorescence on bronchoalveolar fluids. None of the patients underwent seroconversion. This report draws attention to:
(1) the fact that bacteriological filters do not ensure absolute security;
(2) the need for frequent monitoring of the two factors governing legionella growth, water temperature and chlorination; and
(3) the effectiveness of quinolones as a curative and prophylactic treatment of legionnaires' disease in transplanted patients avoiding pharmacological cyclosporin interaction.
Address Department of Haematology, Hôpital Jean-Bernard, CHRU, Poitiers, France. Bone Marrow Transplant, 1991 Jan, 7:1, 61-3

Pneumonia due to Legionella bozemanii: first report of a case in Europe

Pneumonia caused by Legionella bozemanii and acquired by a 75-year-old man while on holiday in Majorca is described. This appears to be the first report of such a case from Europe. Despite artificial ventilation and intravenous erythromycin the patient died. The causative organism was isolated from part of the lung obtained post mortem. Examination of a single sample of serum by means of an indirect immunofluorescence test gave a titre of 32 in respect of L. bozemanii antigen.
(Mitchell RG; Pasvol G; Newnham RS. J Infect, 1984 May, 8:3, 251-5)

A minor epidemic due to Legionella pneumophila serogroup 1

Ten days after starting military service in a police barracks a 25-year-old man developed left middle and lower lobe pneumonia which did not respond to ampicillin (8 g daily) and gentamycin (120 mg daily). Parenteral administration of doxycycline (100 mg daily) was equally ineffective. However, the fever fell on administration of cefotiam (4 g daily). Antibody tests demonstrated Legionella pneumophila serogroup 1 as the causative organism. Because of the confined accommodation of the conscripts the source of the infection was thought to be the hot water system in the barracks. In two other policemen the demonstration of antibodies and of urine antigens confirmed Legionella infection as cause of an acute respiratory illness (Pontiac disease). Legionella pneumophila serogroup 1 subtype Philadelphia, 1-8 colony-forming units per ml, was isolated from six of 14 hot water samples in the barracks. This subtype possesses a virulence-associated antigen which is found in the majority of patient isolates of Legionella pneumophila serogroup 1.
(Luck PC, Rasch R, Schmidt C, Helbig JH, Ehret W, Stockmann B, Witzleb W
Institut fur Medizinische Mikrobiologie, Medizinische Akademie Dresden.)

A family cluster of Legionella pneumophila infections.

Three members of one single family of 4, the father, a son and a daughter, showed seroconversion against Legionella pneumophila serogroup 1 (Lp SG1). The son had a severe pneumonia, whereas the father and the daughter did not develop any other illness than mild and transient fever. A fourth member, the mother, remained seronegative. Lp SG1 was detected by a direct immunofluorescence test in water samples from the shower at home, in tap water in the family's butcher shop, and in condensation water from the ventilator of refrigerator cells in the shop. Two different sources of infection appear to have occurred: showering at home and an aerosol of contaminated condensation water. Reports of more than one case of legionella infection within a family seem to be extremely rare and have not been found in the literature.
****(see article below)
(Castellani Pastoris M, Vigano EF, Passi C
Department of Bacteriology and Medical Mycology, Istituto Superiore di Sanita, Rome, Italy. Scand J Infect Dis 20 (5): 489-493 1988)

The New York City Health Department says one man who worked in Manhattans Garment District has died of Legionnaire`s Disease, and they suspect the disease may have killed another man and hospitalized three more employed there.

Three of the five affected are brothers,*******(see above article) authorities said, and all worked in the vicinity of W. 35th St. and 7th Ave. in the Garment District, where teams of sanitarians and epidemiologists have been interviewing employers and co- workers.

A Health Department spokesman yesterday said a 31-year-old man who was stricken was admitted to St. John's Hospital in Brooklyn on Aug. 11 experiencing the standard symptoms of the disease.

He died Aug. 25, and tests later confirmed " Legionnaire`s Disease" as the cause of death, The dead man's two brothers, ages 26 and 29, became ill Aug. 20. They were admitted to Kings County Hospital in Brooklyn four days later, and both are ''doing well," Marr said.In the other death believed attributable to the disease, a 44-year-old man was admitted to Bellevue Hospital Aug. 27. He died Monday, and an autopsy was being performed to determine the cause of death.
Another possible case, a 48- year-old man was admitted to Lincoln Hospital Bronx on Aug. 17. He was reported in critical condition.
(Source Media)

SCHILMARK, Mass.

Federal medical detectives today continued checking leads to determine whether an illness that felled seven people vacationing together on Martha's Vineyard island is Legionnaire's Disease.

Epidemiologists were interviewing people and collecting soil and water samples near the Chilmark Pond cottage where the people stayed on this resort island off the southern Massachusetts coast.

Investigators said it would be at least a week before results are known. Blood samples have also been sent to the federal center and the state Department of Public Health for testing.

MARTHA'S VINEYARD Hospital spokesman Curtis Collison said three diagnoses are being considered: Mycoplasma, Legionnaire's Disease, and as yet unidentified illness. But, he added, "To our knowledge there have been no further cases on the Vineyard or in the towns where the people now reside."

Those stricken earlier this month include six members of one family and a friend.

Within a few days after leaving the island for different parts of the country, each member of the group experienced fever, chest pains and pneumonia-like symptoms characteristic of Leionnaire's Disease.
One was identified as Daniel Robinson, who remained in critical condition at St. Anthony's Hospital in Denver - his breathing assisted by a respirator.

Nosocomial legionellosis associated with use of oxygen bubble humidifiers and underwater chest drains.

In 1 year 12 of 48 patients who developed fatal pneumonia following admission with non-respiratory disorders to the Hospital Molinette, Torino, yielded Legionella pneumophila serogroup 1 from lung at autopsy. Patients were hospitalized on seven different wards for different conditions; only two of the wards had air conditioning but legionellas were not isolated from these. All patients were in poor health or immunocompromised. Some patients had inhaled humidified oxygen from piped supplies and three had undergone surgery. Legionella pneumophila serogroup 1 was detected in the water of oxygen bubble humidifiers and an underwater chest drain. The contaminated devices had been filled with tap or distilled water and the hospital water supply was found to be contaminated with L. pneumophila serogroup 1. Our findings suggest that filling bubble humidifiers or underwater chest drains with tap water is a potential hazard and should be avoided.
(J Hosp Infect 10 (1): 47-50 (Jul 1987) Moiraghi A, Castellani Pastoris M, Barral C, Carle F, Sciacovelli A, Passarino G, Marforio P
Institute of Hygiene, University of Torino, Italy.)

Legionellosis and cot death
(Nigro G, Castellani Pastoris M, Mazzotti Fantasia M, Midulla M 4th
Lancet 2 (8357): 1034-1035 Oct 29 1983)

Legionnaires' disease imported from Spain in a patient with beta-thalassaemia minor.

The Authors report a rare case of Legionnaires' disease imported from Spain in a patient with beta-thalassaemia minor. This condition as predisposing factor for Legionella pneumophila infection is discussed, with particular emphasis on the therapeutic implications.
(Libanore M, Bicocchi R, Pantaleoni M, Sighinolfi L, Ghinelli F
Divisione Malattie Infettive, Arcispedale S. Anna, Ferrara. Boll Ist Sieroter Milan 69 (1): 353-355 (1990)

Legionnaires' disease--report of Singapore's first local case.

A previously healthy 27 year-old male plumber presented with six days of fever, nausea, vomiting, malaise and headache. The subsequent development of cough, dyspnoea and pleuritic pain coincided with the simultaneous development of progressive bilateral cavitary pneumonia with pleural effusion. Leucocytosis, thrombocytopenia, hyponatraemia, hypoalbuminaemia, hypophosphataemia and hypoxaemia were the main laboratory abnormalities. Clinical suspicion of Legionnaires' disease was confirmed by the presence of serum antibody to Legionella pneumophila (titre 1:512) by an indirect fluorescent antibody test. Treatment with erythromycin and rifampicin resulted in clinical recovery with minimal residual bilateral pleural effusion six months after presentation. This patient is the first to acquire Legionnaires' disease in Singapore.
(Lim HS, Tham MK, Chua KLAnn Acad Med Singapore 15 (4): 610-616 (Oct 1986)

A cluster of legionella sternal-wound infections due to postoperative topical exposure to contaminated tap water
(Lowry PW; Blankenship RJ; Gridley W; Troup NJ; Tompkins LS Address Department of Medicine, Stanford University School of Medicine, Calif. N Engl J Med, 1991 Jan 10, 324:2, 109-13)

Legionnaires' disease: first case in London.

(Ashford RF, Edmonds ME, Lant AF, Shanson DC J R Soc Med 71 (10): 778-779 (Oct 1978)

Outbreak of legionnaires' disease from a cooling water system in a power station.

In September and October 1981 six cases of pneumonia occurred among men working in a power station under construction. Three were identified as cases of legionella pneumonia and two others had serology suggestive of legionella infection. In a sample of 92 men from the site 10 had low levels of antibodies to legionella; a similar sample of men working on an adjacent site showed none with positive serology. In a case control study it was found that cases of pneumonia were more likely than controls to have worked on a part of the site where four small capacity cooling towers were located. Legionella pneumophila serogroup 1 was isolated from the water systems of these four towers but was not found in samples from any other cooling towers or hot or cold water outlets on the site. It would appear that there was airborne spread of the organism from these cooling water systems which had not received conventional treatment to inhibit corrosion and organic growth. This is the first outbreak of legionnaires' disease to be recorded in an industrial setting in the United Kingdom. No cases of legionella infection have occurred on the site since the introduction of control measures
(. Morton S, Bartlett CL, Bibby LF, Hutchinson DN, Dyer JV, Dennis PJ Br J Ind Med 43 (9): 630-635 (Sep 1986)

1988
LONDON

A 32 year-old HIV-antibodv positive male attempted suicide by jwnping into the River Thames from Waterlon Bridge. 11 days later he was admitted gravely ill. Percutaneous lung aspiration yielded a moderate growth of Legionella pneumophila , later identified as serogroup 10, Legionnaire`s disease has seldon been reported in HIV-antibody positive patients. L.pneumophila serogroup 10 is a rare cause of legionnaire`s disease, and aspiration of contamineted water probahly caused this patients infection. A survey of the river water near Waterioo bridge, 1 month later the patient's admission revealed no evidence of Legionella ssp.
(Farrant JM Lancet vol2 no 8608 p 460 1988)

Legionellosis as a polyvalent disease picture

This article reports on the course of four cases of legionellosis confirmed by a positive fluorescence titre of 1:128. The dramatic course was characterized by severe pneumonia in only a single case. Common features of all four patients were alcohol abuse, cholestatic hepatitis, progressive azotaemia and leukocytosis above 30 x 10(9)/l, or an ESR above 110 (Westergren). In view of the doubtful prognosis of the disease, the care-providing physician should not wait for a significant increase in titres before starting treatment with tetracyclines or erythromycins.
(Dundalek E Pneumologie 44 Suppl 1: 554-555 (Feb 1990)
St. Vincenz Krankenhaus, Innere Abteilung, Menden.)

LEGION BACTERIA CLEANUP AT CENTRE 1996
Three sites at the Federal Aviation Administration's technical center, where found to have high levels of the bacteria that causes Legionnaires' disease.

There have been no confirmed cases of the disease among the centre`s 2,500 employees and contractors, 1,200 people were tested this week after very high levels of the bacteria were found in an air-conditioning system cooling Tower near two main office and laboratory buildings on the facility.

BROOKLYN BUS DRIVER DIES OF LEGIONNAIRE`S DISEASE

August 1979
A Brooklyn bus driver has died of Legionnaires' disease, the first death from the mysterious illness in the city this year The unidentified man, was admitted to Victory Memorial Hospital in Brooklyn on the 8th Aug. and died on the Sunday. ----- 1979 It was confirmed that a man was admitted to Helene Fuld Medical Center on the 7th Aug. is suffering from Legionnaire's disease.

AUGUST 1979
TRENTON

A truck driver, is in the intensive care unit, suffering from the lung damage commonly associated with the disease.
An investigation into a possible outbreak of Legionnaires' disease at Scott Paper Co.'s Dover, Del., plant has shown inconclusive results,
A Scott employee was diagnosed with Legionnaires' disease last month, returned to work Wednesday. The nature of his illness was the reason for the investigation.

1994
NEW YORK

A 68-year-old bus driver who was a passenger on a cruise ship where Legionnaire's disease bacteria was found has died,
He died a week after being admitted to a hospital near his home on Long Island
An autopsy was performed but the results will not be known for about two weeks, Shiebler said. If confirmed as Legionnaire's disease, it would be the first death from the cruise ship infections.

JANUARY, 1989
SCHOOL AIDE HAS LEGIONNAIRE`S DISEASE

Classes were held at Hunterdon Central Regional High School despite the diagnosis of Legionnaires' disease in a second staff member. Everything has been sanitized in case there was any bacteria around. The two men have only the school that is the common place they have been. The 33-year-old man with the first confirmed case was released from Warren Hospital in Phillipsburg on Saturday, Riley said. The second custodian, who is 48, remains in satisfactory condition at Hunterdon Medical Center in Raritan Township, she said.

1994
RAISING THE DEAD By Richard Selzer

On a spring day in 1991, Richard Selzer began a long, painful journey into the twilight land where life and death meet.
Raising the Dead is an extraordinary first-person account of retired surgeon Selzer's very close brush with death after contracting Legionnaires' disease,

LEGIONNAIRE'S DISEASE SIDELINES 'DEAN' OF STATE SENATE

JUNE 1991

State Sen. Clarence D.Bell, 77, has spent the past few weeks in the Crozer-Chester Medical Center, a few blocks from his Victorian-style home on 24th Street, recovering from what has been diagnosed as Legionnaires' disease, a life-threatening form of pneumonia. Although he stopped short of making a connection between his ailment and the air-conditioning system in the Capitol building in Harrisburg, he feels certain he first got sick while working in the building's Senate chambers.

TAP WATER, LEGIONNAIRES' CASES TIED
MARCH 1987

Scientists said yesterday that they had linked two cases of Legionnaires' disease in Pennsylvania to household water, and suggested that the finding may explain hundreds of isolated cases of the pneumonia reported every year.

The Centers for Disease Control said the report does not justify monitoring community reservoirs or home hot-water tanks for Legionnaires' bacteria - Legionella pneumophila which they said can be found in most water supplies and pose no threat to the general public.

AT&T OFFICE TESTED FOR BACTERIUM
MAY 1986

The American Telephone & Telegraph Co. has started testing its King of Prussia marketing center for a deadly bacterium after an employee contracted Legionnaires' disease, None of the 300 other employees at AT&T's Montgomery County location has contracted the disease, the company said in a prepared statement.

PATIENT HAD LEGIONNAIRES' DISEASE
MAY 1988

Veterans Administration officials have determined that a patient at the Coatesville VA Medical Center was suffering from Legionnaires' disease, The patient, with pneumonia-like symptoms but otherwise not identified, has since been transferred to the VA center in Wilmington, according to Coatesville hospital

Coatesville officials began a massive water-testing and staff- education program after tests indicated that several patients had been exposed to the disease.

Legionnaire`s Disease affects two
SEPTEMBER 1978
DALLAS

Health officials have confirmed two non-fatal cases of Legionnaires' Disease among the 35,000 persons who attended a national Veterans of Foreign Wars convention in late August .Dallas County Health Director Dr. Lowell Berry refused to disclose the names of the two persons who had the disease and recovered.

Six other persons attending the convention were known to have had recent case of pneumonia and those persons were being checked to determine if they too had contracted Legionnaires' Disease,

MAY 1985
DETROIT

Two people who attended a banquet last month at a suburban hotel are the second and third confirmed cases of Legionnaires' disease in a recent outbreak, and 15 others are showing symptoms,

One suspected victim was hospitalized and another was listed in critical condition,

The first confirmed victim of the disease, the Rev. Green Moore of Detroit, died May 18 of cardiopulmonary arrest at Detroit Osteopathic Hospital. The two latest victims were among 10 people hospitalized after an April 27 banquet by the Pentecostal Temple Church at the Airport Hilton Inn in Romulus, The Health Department also reported 15 of 30 people who had blood tests were suffering fever and respiratory ailments that are among Legionnaires' symptoms.

DEATH FROM LEGIONNAIRES' DISEASE REPORTED AT STATE MENTAL HOSPITAL

AUGUST 1984

A case of Legionnaires' disease, caused the death of a resident of Trenton Psychiatric Hospital, The commissioner, who said he did not learn about the death until Tuesday, ordered an immediate investigation. The 34-year-old male who had been in the state psychiatric institution for the last 16 years, Albanese said. The man was not identified.

HOSPITAL'S WATER CHECKED FOR DISEASE
NOVEMBER 1984

Officials are checking the water supply for bacteria at Bethesda Naval Hospital after the deaths of two elderly cancer patients from Legionnaires' disease.

After the death of the second paient last month, colonies of the bacterium Legionella were found on shower heads and faucets in 17 of more than 91 spots checked in the hospital and surrounding buildings.

OUTBREAK OF LEGIONNAIRES' KILLS
NOVEMBER 1987

The death of an elderly Bethlehem man is the second linked to a recent outbreak of Legionnaires' disease in Vermont, health officials said, and the investigation into sources of the bacteria was continuing. It was confirmed that the man died Monday night in St. Luke's Hospital after being admitted weeks ago with severe pneumonia. He is believed to have contracted pneumonia during an October bus trip to Vermont's Mount Snow region.

Another person who went on the trip remains in guarded condition at Muhlenberg Hospital Center, Jahre said. In all, five people who went on the trip, which originated in Bethlehem, were hospitalized with respiratory problems after they returned home. The first death was that of a New Brunswick, N.J., woman, earlier this month.

A fit 44-year-old accountant with no history of heart trouble, boarded a plane with flu. An hour later he suffered a fatal heart attack mid-flight. The cause of death was found to relate to a combination of his flu and changes in air pressure, which put his heart under strain. Much of the recent research focuses on the internal air quality that may encourage some viruses and bacteria to proliferate. About 50 percent of the air is recycled in most large aircraft. This "scrubbed air" may contribute to the exhaustion associated with jet lag, also causing a reduction in mucus production, prompting eye, nose and skin irritation. "Aircraft can speed up a cough or cold," says Dunne . Jonathan Partridge, a 38-year-old cameraman, boarded his London-to-Cape Town flight with a mild dose of flu. His and six other passengers' conditions deteriorated alarmingly while in the air, and he was also later diagnosed as suffering from Legionnaires' disease. "The specialist told me that the Legionnella was spread through the aircraft's filtration system and that I contracted it because my defense mechanisms were run down as a result of my flu," Partridge says.

One Percent Independent researchers say it is "unlikely but not impossible" for Legionnella to be spread in this way, but manufacturers dismiss the risk. "Airplanes use the High Efficiency Particle Airtight system, which is extremely efficient in trapping micro particles such as bacteria and viruses,"' says Dick Kenny, spokesperson for Boeing. "It is certainly as safe as the systems used in hospital operating rooms. At least 99 percent of airborne microbes are captured." Which, presumably, still leaves 1 percent—and Kahn adds that the danger increases if the filtration system is not cleaned and maintained regularly. More widely recognized are the risks to pilots, crew and frequent flyers from exposure to ionizing radiation (high altitude solar radiation) during long-distance flights. According to Spengler, this can be 100 times higher than at ground level and can cause cancer. In addition, as a result of flying through the ozone layer, the intrusion of ozone often occurs at higher levels than conventional health warnings suggest is safe. It has been known to prompt severe respiratory irritation—though most airlines are introducing catalytic converters to eliminate this risk.

1992
TEXAS
HOUSTON

Officials played down the fact that Legionnaires Disease had been reported at the Fire Station No1, and said that the inspection of the station was routine procedure.

1993
ILLINOIS
A Kidney Transplant patient died at the University of Illinois Hospital in June 1993 after getting Legionnaire1s Disease, The Bacteria was found in the hospitals water supply

1994
VANCOUVER

Legionnaire`s Disease victim Lillain McKendrie dies

1994
NAPERVILLE II

Tests failed to determine the source of Legionella which resulted in the death of Janet Lazzari who was 42.
This was the third death from Legionnaire`s Disease since 1991 in DuPage County.
How Janet Lazzari got Legionnaire`s Disease is a mystery, all tests carried out at her home proved negative

I was diagnosed with Legionnaire's pneumonia September 1996. Hospitalized for 18 days and for the first 4 or 5 days no one knew what sort of pneumonia it was. I remember nothing from the time I entered the emergency room until I woke up in the ICU/CCU, days later. I was told it was "touch and go" for a while but, as I said before, I remember nothing.

Interestingly enough, I was a smoker of 40 years when I entered the hospital, yet I left the hospital a non-smoker. I never experienced withdrawal; slept through the whole thing. My family did it for me I guess.

To this day I have no idea how I got the disease. While I was at a wedding reception I began to feel "out of it." Asked my husband to take me home. Took a couple of aspirin and went to bed. Woke up the next morning, took my temperature (102) and wondered how the heck that happened. I wasn't feeling THAT sick. A while later I took my temp again and it was up to 103. I vomited and became anxious about dehydrating. I then asked my husband to take me to emergency (it was a holiday). I was sure that I'd begin to feel better as soon as they started pumping fluids in. Triage nurse put a hospital bracelet on my wrist and that that was it!

When I returned home from the hospital the Health department called and asked questions about where and when and if... It ended up that I was an isolated case and I probably will never know how I contacted the disease. I think I'm out of the woods now. I'm back to work and pretty much back to doing what I did before, with the exception of smoking. Good luck with your research.

1997
MARCH
I was diagnosed with L. Disesase the last of March and treated with 18 days of Erythromyacin (sp?). I am still somewhat weak, get out of breath easily, and find my brain functioning slower than usual. Treatment now is slow progreess on the treadmill, extra protein in my diet, and more sleep. I could be doing better on the diet and sleep, but wonder if there is something else I should be doing. And wonder if my continuing weakness is typical. I don't know anyone else who has had this, to ask. Thanks for your help, and I'll tell you more about my case if you want.

1996
ADELAIDE
SOUTH AUSTRALIA
A Woman who had been looking to buy a SPA for her home after visting many Spa outlets and purchasing a Spa, spent three weeks in a coma while her Spa was being installed, she was found to be suffering from Legionnaire`s Disease, it was suspected that she got the disease from one of the spa outlets that she had visted, no spa outlet was found to have Legionella in their stores, at the same time there was an outbreak on Kangeroo Island and the Spa was believed to be the cause two people died.

1997

A case of fatal pneumonia caused by Legionella pneumophila serogroup 6 developed after drowning in a public bath

A 57-year-old male was admitted to our hospital because of high fever, productive cough and dyspnea. Six days prior to admission he had an episode of drowning in a public bath. On admission chest X-ray showed wide-spread pneumonia causing severe respiratory distress for which mechanical ventilatory support was started. Despite chemotherapy including erythromycin and rifampicin his condition continued to deteriorate. Chemistry showed marked elevation of CPK and findings of acute renal failure. He eventually passed away with septic shock. During the course Legionellae remained negative with culture of broncho-alveolar lavage fluid. L. pneumophila serogroup 1 (SG1) antigen in the urine was not detected, and no elevation of serum antibody titer was noted. Culture of the material obtained from the lung abscess at autopsy revealed L. pneumophila SG6 and serum antibody titer against SG6 also was found to be extremely high. With this evidence we concluded that this case of pneumonia was caused by L. pneumophila SG6. We believe this is the first reported case of the SG6 pneumonia in Japan. Another remarkable feature of this case was massive rhabdomyolysis pathologically confirmed after autopsy. Although the pathogenesis of this process has not been clarified, there are several case reports of rhabdomyolysis complicated with Legionnaire's Disease in the past. Therefore, we should bear in mind and pay careful attention while coping with this disease.
( Tokuda H; Yahagi N; Kasai S; Kitamura S; Otsuka Y Kansenshogaku Zasshi 1997 Feb;71(2):169-74)

FIRST REPORT OF LEGIONELLA SPECIES IN HUMAN DISEASE

A bacterium from the Legionella family, not previously associated with human disease, has been identified as the cause of pneumonia in a woman in France. Researchers from the Hopital Paul Brousse in Villejuif, France, report this first case in the July 1997 issue of the Journal of Clinical Microbiology.

The researchers report on a 34-year-old woman who, 4 weeks after a liver transplant, developed severe pneumonia. She suffered neurological deterioration and eventually went into a coma. After several weeks of various antibiotic treatments and a second liver transplant, she recovered.

The cause of her pneumonia was found to be the bacterium Legionella parisiensis. This bacterium was first identified in a cooling tower in Paris in 1985 and since then no further isolations of this organism have been reported until this case. The family Legionellaceae comprises 42 species among which 18 have been isolated from patients with pneumonia. The most well known species is Legionella pneumophila, the cause of Legionnaire's disease, which accounts for nearly 90% of Legionella infections.

(F.L. Presti, S. Riffard, F. Vandenesch, M. Reyrolle, E. Ronco, P. Ichai, and J. Etienne. 1997. The first clinical isolate of Legionella parisiensis from a liver transplant patient with pneumonia. Journal of Clinical Microbiology. 35:1706-1709.)

Nosocomial Legionellosis Traced to a Contaminated Ice Machine

CASE PATIENT

A ventilator-dependent 66-year-old male developed nosocomial pneumonia due to Legionella pneumophila serogroup 6 after 3 months in an intensive-care unit (ICU). The patient had no intake of potable water except for ice chips from an ice machine in the ICU.

RESULTS

Cultures revealed L pneumophila serogroup 6 in the ice (4.3 colony-forming units/mL) and ice machine cold water (too numerous to count). Cultures from adjacent hot and cold taps, plus taps located near the patient, all were negative; ice machines and cold water on seven other patient units also were negative. Only sterile water had been used for tube feedings, mouth care, suctioning, and ventilator humidification. Hospital hot water previously had been colonized with L pneumophila serogroup 6, but all surveillance water cultures had been negative since chlorination of the hot-water system began the previous year; cold-water cultures had never before grown Legionella.

The ice machine was disinfected with a 2-hour flush of 2.625% sodium hypochlorite. The supply line to the ice machine was replaced, and the cold-water pipe from the floor below was treated with 83 ppm sodium hypochlorite for 48 hours. All follow-up surveillance cultures of the ice machine remained negative through mid-1996. No additional cases of nosocomial legionellosis occurred.

CONCLUSIONS

Ice machines may be reservoirs of L pneumophila in hospitals. Both ice and water dispensed from these machines may be contaminated, and nosocomial transmission may occur. Successful long-term decontamination and control can be accomplished with shock chlorination
(Infect Control Hosp Epidemiol 1997;18:637-640). Paul S. Graman, MD; Gail A. Quinlan, BS, RN, CIC; June A. Rank, BS, RN, CIC

AUTHORS

From the Infectious Diseases Unit and Infection Control Program, Department of Medicine, Strong Memorial Hospital, and the University of Rochester School of Medicine and Dentistry, Rochester, New York.

Presented in part at the Sixth Annual Meeting of the Society for Healthcare Epidemiology of America; April 21-23, 1996; Washington, DC. Abstract 2.

Address reprint requests to Paul S. Graman, MD, Infectious Diseases Unit, University of Rochester Medical Center, 601 Elmwood Ave, Box 689, Rochester, NY 14642.

96-OA-153. Graman PS, Quinlan GA, Rank JA. Nosocomial legionellosis traced to a contaminated ice machine. Infect Control Hosp Epidemiol 1997;18:637-640.

Infect Control Hosp Epidemiol 1997 Sep;18(9):637-640

Nosocomial legionellosis traced to a contaminated ice machine.

Graman PS, Quinlan GA, Rank JA

Department of Medicine, Strong Memorial Hospital, Rochester, New York, USA.

OBJECTIVE: To investigate a case of nosocomial legionellosis, identify pathways of transmission, and effect control of the environmental source. DESIGN: Case investigation and environmental culture surveillance. SETTING: A 720-bed university teaching hospital. CASE PATIENT: A ventilator-dependent 66-year-old male developed nosocomial pneumonia due to Legionella pneumophila serogroup 6 after 3 months in an intensive-care unit (ICU). The patient had no intake of potable water except for ice chips from an ice machine in the ICU. RESULTS: Cultures revealed L pneumophila serogroup 6 in the ice (4.3 colony-forming units/mL) and ice machine cold water (too numerous to count). Cultures from adjacent hot and cold taps, plus taps located near the patient, all were negative; ice machines and cold water on seven other patient units also were negative. Only sterile water had been used for tube feedings, mouth care, suctioning, and ventilator humidification. Hospital hot water previously had been colonized with L pneumophila serogroup 6, but all surveillance water cultures had been negative since chlorination of the hot-water system began the previous year; cold-water cultures had never before grown Legionella. The ice machine was disinfected with a 2-hour flush of 2.625% sodium hypochlorite. The supply line to the ice machine was replaced, and the cold-water pipe from the floor below was treated with 83 ppm sodium hypochlorite for 48 hours. All follow-up surveillance cultures of the ice machine remained negative through mid-1996. No additional cases of nosocomial legionellosis occurred. CONCLUSIONS: Ice machines may be reservoirs of L pneumophila in hospitals. Both ice and water dispensed from these machines may be contaminated, and nosocomial transmission may occur. Successful long-term decontamination and control can be accomplished with shock chlorination.

April 24, 1998.

Sergio Motta, 57, Brazil Official Leading Communications Selloff Sergio Motta, the Minister of Communications who oversaw the breakup of the Brazilian telecommunications monopoly, died on Sunday of complications from Legionnaires' disease. He was 57. Mr. Motta wielded great influence, both as a Cabinet minister an ...

The Journal of Hospital Infection
Abstract

Pseudoepidemic of Legionella pneumophila serogroup 6 associated with contaminated bronchoscopes

D H Mitchell, L J Hicks, R Chiew, J C Montanaro, S C Chen

An investigation of a pseudoepidemic of Legionella pneumophila serogroup 6 contaminating bronchoalveolar lavage specimens traced the source to contaminated tap water used to rinse disinfected bronchoscopes. The problem recurred despite plumbing changes and the installation of filters in the endoscopy unit water system because of inadequate maintenance of the filters.

Volume 37 Number 1, p 19-23, September 1997

July 16, 1998 (Canada CDR, Vol. 24 / No. 14, July 15)

INVESTIGATION OF LEGIONNAIRE DISEASE IN A LONG-TERM CARE FACILITY - QUEBEC

Introduction: On 17 February 1997, a case of Legionnaire disease was reported to the Direction de la santé publique de Montréal-Centre following the death of an 87-year-old male patient residing in a long-term care facility (LTCF). An autopsy on 8 February indicated the cause of death as bronchopneumonia. A diagnosis of Legionnaire disease was confirmed following biopsy of a pulmonary tissue culture which revealed an abundant growth of Legionella pneumophila.

No other case of pneumonia had been reported in the weeks prior to the death of this patient. Since the patient had been confined to his room because of dyspnea and serious eye problems, an investigation was undertaken in an attempt to identify the source of contamination...

Discussion: When a case of Legionnaire disease is reported to public-health officials, the case's workplace and the time spent in a hospital or hotel during the 2 weeks prior to the onset of the disease is investigated. The assumption is that one is dealing with a sentinel case, and that the investigation will identify associated cases and a common environmental source of the infection. In general, the majority of reported cases of Legionnaire disease are sporadic. Investigating the environmental source of infection is usually not recommended for an isolated case, unless one is dealing with a nosocomial infection. A health-care institution, such as an LTCF, can harbour potential sources of Legionnaire disease, and such an institution usually accepts patients who are at high risk for acquiring the infection.

For this particular case, it was decided to carry out an epidemiologic and environmental investigation for the following reasons.

It was evident that the disease had been acquired in the LTCF (nosocomial Legionnaire disease). It was necessary to exclude the possibility that an environmental source could expose other residents to the infection (enclosed area, increased vulnerability of residents). It was necessary to ensure that preventive mesures were in place (i.e. adequate water-heater temperature).

In spite of the dissimilarity between the environmental and clinical strains, the most likely source of infection was the oxygen condenser. In order to establish any connection and molecular homology between the environmental and clinical strains, phenotypical methods such as serogrouping, serotyping, or subgrouping were used (the use of monoclonal antibodies reveals the existence of 12 subtypes of L. pneumophila, serogroup 1). The differences between the subtypes of clinical and environmental strains found during the investigation can be explained by i) fluctation over time in the proportion of subtypes colonizing the water system, and ii) the delay in obtaining an envionmental sample, in particular, when the time between the death of the patient and the time at which the sample was taken from the tank of the oxygen condenser is considered.

The following six factors helped to piece together the events.

1. Various sources of Legionella-contaminated water have been linked to nosocomial cases of Legionnaire disease such as hot water distribution systems (taps, showers, tubs), portable respiratory treatment equipment, and individual humidifiers.The investigation showed that the hot water formed a pool for contamination by Legionella present in water from the water heater.

2. Portable respiratory equipment provides a preferred growth environment for Legionella (production of a semi-permanent biologic film) and quickly gives rise to a pool of infectious bacteria. Within 24 hours, Legionella spp. can multiply sufficiently to become a possible source of infection for patients undergoing respiratory therapy. It is possible that the contamination of the tank of the humidifier acted as an amplifier. In fact, the tank was full of non-sterile water; it was rinsed with hot tap water and occasionally cleaned, but it was never disinfected.

3. Contaminated aerosols have been associated with Legionnaire disease. By producing contaminated aerosols, the humidifier of the portable condenser became the mechanism by which Legionnaire disease was transmitted to the patient.

4. The strain transmitted to the patient was pathogenic (Lp1, Mab-2 marker).

5. Inhalation of L. pneumophila led to the bacteria infecting the lungs.

6. Finally, the host was receptive to the infection and presented a number of characteristics which rendered him prone to the illness. The presence of a positive influenza A virus cell, confirmed by immunofluorescence, suggests that the patient, while having been vaccinated for influenza, had nonetheless been infected by the virus and then superinfected by L. pneumophila.

The investigation detected no other possible source of infection.

Recommendations: The following preventative measures were recommended.

1. Use sterile water in the tank of any type of oxygen condenser used for respiratory tract treatment; clean and disinfect the equipment on a daily basis; use sterile water for any type of activity associated with respiratory therapy such as the rinsing of tubes or tank; and fill the tank just prior to use.

2. Use vapour humidifiers rather than humidifiers that give rise to the formation of aerosols from non-sterile water (e.g. ultrasonic humidifiers).

3. Maintain the water-heater temperature at a minimum of 55 o C and make sure that the hot-water temperature remains above 50 o C at all distribution points.

Source: P Pilon, MD, M Tremblay, MD, MSc, L Valiquette, MD, MSc, Direction de la santé publique, Régie régionale de la Santé et des Services sociaux de Montréal-Centre; F Bernier, MSc, Department of Microbiology and Immunology, University of Montreal, Montreal, QC.

Hi,

I was reading through your list of unusual cases involving Legionnaire's disease and have this to add:
My 71-year old father (who was fit and had no history of lung trouble) boarded a flight (with me) from Delhi, India - did fine on the Delhi-Singapore leg and on the Singapore-Hongkong-San Francisco (the longest leg of the flight) he started developing chills and fever (could have been >104F) and eventually passed away on 8th March. Diagnosis indicated lobar pneumonia though I did not know enough at the time (until I saw this website) to indicate that it may have been Legionnaires` Disease When he first experienced chills on the flight,
I asked him to switch seats with my wife so he could lie down - at that time we did notice that the particular plane had a draft of cold air right at the spot he had been sitting (did not have one of those neat knobs which allow you to control the fan air flow as you see in domestic US airlines).

Regards Sunil

2nd April 2000