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Internal Medicine, General Hospital
Legionnaire's disease is a disease caused by the bacteria Legionella pneumophila, that lives in contaminated water circuits such as water pipes, water tanks or reservoirs, cooling towers, swimming pools and jacuzzis.
It is contracted through the inhalation of contaminated water droplets, whether physically in the water or merely close by, due to the fact that it can spread from the water to the surrounding environment.
It normally causes a respiratory infection similar to pneumonia which if not diagnosed and treated early can be serious and life-threatening.
Legionnaire's disease causes the same symptoms as pneumonia (fever, chest pain, difficulty breathing), along with severe muscle pain and major impact on the feeling of general wellness.
Legionnaire's disease can affect anyone who has come into contact with the bacteria which cause it, but it is more common among the elderly or people with a compromised immune system who have either come into contact with or breathed the vapour of water contaminated with legionella.
A diagnosis is reached through detection of the bacteria or its antibodies in the blood, once suspected due to the clinical characteristics of the patient (age of onset, fever, major impact on general wellness, muscle pain) or radiographies (indirect pulmonary pneumonia indirectly affecting the lungs). Isolation of the bacteria is relatively recent, as it requires special culture processes.
In fact, legionella was not identified as the cause of respiratory infection until 1976 during a pneumonia epidemic in the American Legion Convention in Philadelphia, to which it owes its name.
Legionnaire's disease responds well to specific antibiotic treatment.
Early treatment is very important.
Chest x-ray, determination of legionella antibodies in the blood, specific cultures for the identification of legionella.
Epidemiological surveillance of detected cases (water pipes, air conditioning towers, swimming pools or jacuzzis involved) is very important for disinfection.
When a case of Legionnaire's disease is detected, public health authorities must initiate an investigation in order to find the source and eradicate it.
Legionella is not resistant to high temperatures and can usually be eliminated by intermittent increasing of the temperature of the pipes. This should always be carried out by a professional to ensure the proper elimination of the bacteria.
Infectious endocarditis involves the presence of a microbial infection in the endocardial surface (internal surface of the heart). It is the most frequent cardiovascular infection and it is very important because of its potential severity and its different forms of presentation.
Infectious endocarditis mainly affects cardiac valves, whether natural or artificial, although sometimes it can occur in other structures of the heart.
It is classified according to the time the infection has been established (days, weeks or months) and according to the bacteria or microorganism (yeast, fungus) that causes it.
The characteristic lesion of infectious endocarditis is endocardial vegetation. It is made up of the completely abnormal presence of an aggregate of platelets, fibrin, bacteria and inflammatory cells that adhere to the internal surface of the heart, usually on the surface of a cardiac valve, and which is susceptible to breaking off, causing an infectious embolism at a distance in another organ (skin, nervous system, limb).
It is considered a serious illness and although in most cases it is cured, it also has significant complications and mortality despite treatment. In many cases, patients must be subjected to surgical intervention in order for it to be definitively cured, eliminating the affected tissue and inserting a new artificial heart valve.
In its most acute form infectious endocarditis can produce high fever, chills, prostration and severally affect the patient's general condition in a short time period (hours-days). In subacute forms it may evolve over weeks or months, with a clinical presentation of tiredness, lack of appetite and low-grade fever. In these cases, infectious skin manifestations may also occur as nodules or characteristic spots, which do not always appear.
In patients with severe cardiac valve involvement, the valves themselves may not function correctly, which may result in symptoms of heart failure such as severe shortness of breath and swelling of the lower limbs
Infectious endocarditis has a global incidence of 2-3 cases per 100,000 population per year, and so it is estimated that in Catalonia around 200 cases are diagnosed every year. Its incidence increases greatly with age, reaching 15-30 cases/per 100,000 population/year in over 65s, or 10 times higher than that of the younger population.
The cause of infectious endocarditis has changed a lot in recent decades. In recent years the most frequent causal bacterium has been streptococcus, especially a species called viridans. There is currently a great variety of causal agents, although staphylococci are the most frequent, followed by streptococci and enterococci. It is, however, advisable to note that any microorganism that circulates through the blood can adhere to a heart valve, especially if it has previous injuries or is an artificial valve.
The diagnosis of endocarditis is based essentially on:
- blood cultures to identify the bacterium that causes the infection and allow the most suitable specific antibiotic treatment to be chosen.
- echocardiogram that allows the endocardial vegetations typical of the disease to be located. It also informs doctors about the function of the valve affected and contributes significantly to assessing the need for surgical treatment in some patients.
- in some cases it is necessary to carry out other explorations (such as CAT or scintigraphy) to rule out the existence of peripheral embolisms, which are very common at the time of diagnosis or during the course of treatment of the disease.
The treatment of infectious endocarditis is antibiotic, but specifically targeting the microorganism that causes it. The doses are high and prolonged over time because the vegetations typical of the disease are not very vascularised and antibiotics must penetrate through diffusion from circulating blood. In patients who do not respond adequately to this antibiotic treatment or who have major valve damage as a consequence of the infection, it is necessary to assess the need for valve replacement surgery.
Blood cultures and echocardiogram, both at the time of diagnosis and to monitor the evolution of the illness.
When an alteration of a person's heart valve is recognised, antibiotic prevention must be administered before any dental or gum treatment is given, following specialised consultation.
Preventive measures must also be taken in the case of endoscopes, especially of the upper gastrointestinal tract (gastroscopy), with the antibiotic and guidelines indicated by the doctor.
This prevention is very important because the presence of bacteria in the blood, as a result of the intervention or exploration, carries a significant risk of infectious endocarditis.
Blood smear - making a small prick in a finger in order to assess cell morphology. This prick is used to conduct a morphological examination of blood cells, allowing a first approximation and examination of possible diagnoses.
A blood smear or peripheral blood test is performed by obtaining a blood sample through a finger prick (a puncture in the fingertip with a very fine needle) or a venipuncture (extraction from a vein), and carefully spreading a drop of blood on a glass slide until it forms a very thin film. The cells are then stained and the morphology of the cells is analysed under an optical microscope.
Microscopic study of a peripheral blood smear allows the cells present in the blood sample to be seen directly and their morphological characteristics analysed (shape, size and cell organelles such as the nucleus or granulation characteristic of some cells, and also inclusions, deposit of substances, and even microorganisms such as parasites or bacteria).
Using this test, we can check if the cells have a normal or altered appearance. If any alterations are detected, they can be described and an overall interpretation of the exam can be drawn. This allows the suspicion of various diseases to be ruled out or confirmed, both blood and non-blood-related conditions. It also allows observation of the effects that other conditions within the body have on blood cells, such as infections, haemorrhages, trauma, etc.
If the blood smear suggests the presence of a blood or bone marrow disease, it may be necessary to conduct bone marrow aspiration and/or biopsy to confirm the diagnosis.
This is a puncture and aspiration of the bone marrow using a fine needle under local anaesthesia. Bone marrow material is aspirated through the needle (in the case of aspiration) or a small, cylindrical sample is obtained from the bone marrow inside the needle (in the case of biopsy).
This technique serves to study the bone marrow. It is essential for the diagnosis and monitoring of many blood diseases, as well as screening for other conditions. A bone marrow exam enables diagnosis of bone marrow or blood cell diseases such as leukaemia, lymphoma, myeloma, myelodysplastic syndrome, as well as non-haematological diseases that may affect the bone marrow, such as tumours from other origins, deposit diseases, etc. Following treatment of these diseases, bone marrow exams also help to evaluate treatment efficacy.
The area is sterilised with iodine and then local anaesthesia is applied. A fine needle puncture is then performed and the bone marrow (material from inside the bones) is aspirated. It is a simple technique that is usually practised on the hip bone (iliac crest) or the sternum. The aspirated material is subjected to different diagnostic procedures such as smears to assess cell morphology, microbiological cultures, immunophenotyping techniques, cytogenetic and molecular studies.
Aspiration and biopsy are simple techniques that are performed as out-patient procedures (they do not require admission to hospital) and under local anaesthesia and/or sedation. The total duration of the procedure is approximately 30 minutes, and at the end the patient can go home, needing only minor oral analgesia in case of local discomfort. A small bruise may occur at the puncture site, but this is not common.
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