28 2012 1) 2) 2) 1) 1) 1) 2) 1) 2) 23 3 28 23 12 16 1995 74 18.2 2/11 10.0 1/10 (BALF) 40.0 6/15 Legionella pneumophila 2 43.5 20/46 16.7 7/42 52.6 10/19 BALF 70.0 14/20 88.2 60/68 Key words: Legionella, Gimenez stain, culture, urinary antigen test, bronchoalveolar lavage 4.0 1) 2, 3) 2003 1999 4 4 1999 25 2003 68 2008 96 4, 5) 362 0806 818 TEL: 048 722 1111 4112 FAX: 048 722 1129 E-mail: hiroakiyoshioka@cancer-c.pref. saitama.jp 1995 2011 3 74 2) I. 1. 1995 2011 3 74 2. B-CYEα WYOα Binax NOW 1995 1999 12 2001 12 28 Vol. 22 No. 1 2012.
29 1 20 ml 100 mmhg 1 50 ml 3 6) 4 7) 8) 2008 7 2009 3 Reverse transcriptase-polymerase chain reaction 9) II. 1. (Table 1) 74 61 64.5 14.0 30 36 41 21 12 7.5 6.3 (JRS) 5 13 37 19 / (ATS/IDSA) 38 362 10, 11) 2. (Fig. 1) 19992004 24 50 3. (Table 2) 43.5 20/46 (BALF) 88.2 60/68 4. 1) 24 32.4 13 9 BALF5 1924 Table 1. Characteristics of the 74 patients Age 64.5 14.0 Sex (male) 61 Smoking history (Current : Ex : Never) 41 : 21 : 12 Underlying diseases Pulmonary diseases 30 COPD 10 Bronchial asthma 7 Interstitial pneumonia 6 Postoperative lung cancer 4 Old tuberculosis 4 Nontuberculous mycobacteria 4 Bronchiectasis 3 Chronic aspergillosis 2 Pneumoconiosis 1 Sarcoidosis 1 Systemic diseases Diabetes mellitus 16 Hypertension 9 Chronic liver disease 4 Cerebral vascular disease 4 Alcoholism 4 Ischemic heart disease 3 Postgastrectomy 3 Congestive heart failure 2 Cardiomyopathy 2 Rheumatoid arthritis 1 HTLV-1 1 Severity by JRS classification Mild 19 Moderate 37 Severe 13 Very severe 5 COPD, chronic obstructive pulmonary disease; HTLV-I, human T-cell lymphoma virus type 1; JRS, Japan Respiratory Society 4 5 BALF4 4 1 BALF3 23 7 1 4 56 BALF BALF Legionella pneumophila 1 4 2) 50 67.6 29 7 10 5 BALF 15 11 Vol. 22 No. 1 2012. 29
30 Fig. 1. Number of Legionella pneumonia cases Number of Legionella pneumonia cases dramatically increases in 1999, but decreased in 2004 and 1 to 6 person was diagnosed at our hospital as having Legionella pneumonia per year. 49 5. 1) a) Table 2. Positivity of various tests Positive No. performed Positivity Sputum Culture 7 42 16.7% Gimenez stain 2 11 18.2% Bronchial washing Culture 10 19 52.6% Gimenez stain 1 10 10.0% BALF Culture 14 20 70.0% Gimenez stain 6 15 40.0% Urinary antigen test 20 46 43.5% Paired sera 60 68 88.2% BALF, bronchoalveolar lavage fluid 50 46 20 (43.5 ) 6 14 14 14 2, 3 2 10) 1 12 10 (83.3 ) b) 257 18.2 2/11 10.0 1/10 BALF 40.0 6/15 2 BALF 4 1 BALF 1 BALF 5 1 BALF 2 BALF3 7 7 6 c) 15 9 4 BALF3 BALF 1 5 3 1 BALF1 6 2 BALF1 BALF 1 4 30 Vol. 22 No. 1 2012.
31 1 BALF 1 BALF 1 BALF 1 6 1 Legionella pneumophila 2 ATS/IDSA JRS BALF BALF 2) 5822 (38.0 ) 24 1 22 2 1 3 1 7 2 1 1 BALF 13 3 BALF 7 BALF 7 4 BALF 0 1 BALF3 3) 68 60 74 40 40 22 24 7 BALF 4 6. 1) (Table 3) 53 18 4 4 2 1 4 3 2) (Table 4) 42 12 4 4 2 3 4 1 Table 3. Number of patients undergoing both culture and measurement of antibody titers Paired sera (significant change of antibody titers) Positive (n=46) Negative (n=7) Culture Positive 18 4 Negative 28 3 Table 4. Results of urinary antigen test and antibody titers Urinary antigen test Positive (n=16) Negative (n=26) Paired sera (significant change of antibody titers) Positive (n=35) 12 23 Negative (n=7) 4 3 Table 5. Number of patients undergoing both urinary antigen test and culture Urinary antigen test Positive (n=17) Negative (n=21) Culture Positive (n=14) 10 4 Negative (n=24) 7 17 Table 6. Polymicrobial infection in Legionella pneumonia (n=20) Mycoplasma pneumoniae 4 Influenza virus 4 Streptococcus pneumoniae 3 Pseudomonas aeruginosa 2 Klebsiella pneumoniae 2 Chlamydia pneumoniae 2 Chlamydia psittaci 1 Influenza virus and Streptococcus pneumoniae 1 Influenza virus and respiratory syncytial virus 1 3) (Table 5) 38 10 4 7. (Table 6) 20 (27.0 ) 6 4 Vol. 22 No. 1 2012. 31
32 III. 12) 2009 96 6 2 (33.3 ) BALF 1 2002 13, 14) 12) Legionella pneumophila 1 60 95 99 7) Legionella pneumophila 183.3 10) Legionella pneumophila 1 10, 13, 14) 43.5 20/46 15, 16) BALF BALF 1/7 BALF 1 BALF 17) 18) 22.2 2/9 25.7 9/35 17) 74 40 2 6 6 12 7) Lieberman 19) 56 35 (62.5 ) 41 27 21 5Bates 20) 19 5 (26.3 ) 4 2 (10.5 ) 1 (5.3 ) 1 (5.3 ) 74 20 (27.0 ) 8) 43 IV. 74 32 Vol. 22 No. 1 2012.
33 Legionella pneumophila 1 BALF BALF 59 2010 1) 2006. 44: 875 883. 2) 2009. 65 47: 558 568. 3) 2004. 132: 176 179. 4) IASR. 1999.4 2002.12. 24: 27 28. http://idsc.nih.go.jp/iasr/24/276/tpc276-j.html 5) IASR. 2003.1 2008.9. 29: 27 28. http://idsc.nih.go.jp/iasr/29/346/tpc346-j.html 6) BAL BALp. 38 41, 00. 7) Edelstein, P. H. 2005. Legionella. p. 2711 2724 In: Mandell, Douglas, and Bennett s Principles and Practice of Infectious Diseases, 6th ed. (G. L. Mandell, J. E. Bennett, R. Dolin, eds.), Churchill, Livingstone, Philadelphia, Pennsylvania. 8) 2004. 42: 62 67. 9) 2011. 1: 00 00. 10) 2011. BALF 1 1 6: 00 00 [in press]. 11) 2006. HTLV-I 1 44: 885 891. 12) McDade, J. E. 1981. p. 55 60 G. L. Jones, G. A. Hebert 13) Helbig, J. H., S. A. Uldum, P. C. Luck, et al. 2001. Detection of Legionella pneumophila antigen in urine samples by the Binax NOW immuno-chromatographic assay and comparison with both Binax Legionella Urinary Enzyme Immunoassay (EIA) and Biotest Legionella Urine Antigen EIA. J. Med. Microbiol. 50: 509 516. 14) Shimada, T., Y. Noguchi, J. L. Jackson, et al. 2009. Systematic review and metaanalysis urinary antigen tests for Legionellosis. Chest 136: 1576 1585. 15) 2002. 25 40: 875 883. 16) Miyamoto, H., S. Jitsurong, R. Shiota, et al. 1997. Molecular determination of infection source of a sporadic Legionella pneumonia case associated with a hot spring bath. Microbiol. Immunol. 41: 197 202. 17) 2008. [BAL]p. 96 98, 18) Gomes, J. C. R., W. L. Pedreira, Jr., E. Araujo, et al. 2000. Impact of BAL in the management of pneumonia with treatment failure. Chest 118: 1739 1746. 19) Lieberman, D., A. Porath, F. Schlaeffer, et al. 1996. Legionella species community-acquired pneumonia, a review of 56 hospitalized adult patients. Chest 109: 1243 1249. 20) Bates, J. H., G. D. Campbell, A. L. Barron. 1992. Microbial etiology of acute pneumonia in hospitalized patients. Chest 101: 1005 1012. Vol. 22 No. 1 2012. 33
34 Investigation of Diagnostic Method in 74 Legionella pneumonia Cases Hiroaki Yoshioka, 1) Noboru Takayanagi, 2) Takashi Ishiguro, 2) Mitsumasa Konishi, 1) Masae Itoi, 1) Shigeki Maruyama, 1) Yutaka Sugita 2) 1) Department of Laboratory Medicine, Saitama Cardiovascular and Respiratory Center 2) Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center Results of Gimenz staining, cultures, urinary antigen tests, and antibody titers in 74 cases of Legionella pneumonia were reviewed. Positivity of Gimenez staining used for rapid diagnosis of Legionella pneumonia was 18.2 (2/11 cases), 10 (1/10 cases) for bronchial washings (including bronchial sputum samples), and 40.0 (6/15 cases) for bronchoalveolar lavage fluid, indicating the usefulness of bronchoalveolar fluid samples. Gimenez stain was useful in establishing rapid diagnosis of Legionella pneumonia in cases of pneumonia due to Legionella pneumophila serogroup 2. Urinary antigen test was positive in 43.5 (20/46) of cases of Legionella pneumonia. Culture positivity was 16.7 (7/42 cases) for sputum, 52.6 (10/19 cases) for bronchial washings, and 70.0 (14/20) for bronchoalveolar lavage fluid. Increase or decrease in antibody titers in paired sera was found in 88.2 (60/68) of cases. Urinary antigen test can be useful for rapid diagnosis, but its sensitivity is not high enough. Gimenez stain is useful for rapid diagnosis even when the urinary antigen test is generally used. 34 Vol. 22 No. 1 2012.