Review
Problem pathogens: paediatric legionellosis—implications for improved diagnosis

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Summary

Legionnaires' disease is an established and frequent cause of pneumonia in adults but is thought to be a rare cause in children. We reviewed the medical literature for cases of Legionnaires' disease in children and analysed the epidemiology, clinical characteristics, and treatment. 76 cases of legionella infection in children were identified. In 56%, diagnosis was made with culture methodology. 46% were community-acquired infections. 51·5% were under 2 years of age. 78% of the patients had an underlying condition such as malignancy. Fever, cough, and tachypnoea were the most common symptoms. The overall mortality rate was 33% and was higher in immunosuppressed children and in children younger than the age of 1 year. Patients who were treated empirically with anti-legionella therapy had a notably lower mortality rate compared with patients on inappropriate therapy (23% vs 70%). In 88% of hospital-acquired cases, an environmental link to potable water colonised with legionella was identified. We found no clinical features unique to Legionnaires' disease in children that would allow differentiation from pneumonia due to other respiratory pathogens. Awareness of legionella as a potential cause of paediatric pneumonia is particularly important because infection can be severe and life threatening and antimicrobial therapy often used for empirical therapy in children is not effective against legionella. In any case of pneumonia unresponsive to antibiotics, Legionnaires' disease should be considered and specific diagnostic tests to verify this diagnosis should be done. As legionella diagnostic tests become more widely applied, we predict that legionellosis may appear as an emerging infectious disease in children.

Introduction

Legionnaires' disease is considered a rare cause of community-acquired pneumonia in children. Seroepidemiological studies in children have shown variable results with raised titres of legionella antibody ranging from 2% to 52%.1, 2 A prospective study found raised titres for Legionella pneumophila in 52% of children without clinical signs for infection.3 The authors concluded that “L pneumophila is not a common cause of acute respiratory disease in early childhood in the study area but that children are frequently exposed to the organism.”3 Diagnosis based only on serological tests for which the sensitivity and specificity is uncertain is a major drawback for these earlier studies in children. We reviewed the literature of paediatric legionellosis. However, we adopted rigorous criteria for the diagnosis of legionellosis in the cases to be included in this review. The evolutionary course of discovery of Legionnaires' disease in children seems to parallel that of adults. We suggest an approach that might uncover occult cases of Legionnaires' disease in children to allow earlier treatment and, possibly, prevention.

Section snippets

Paediatric cases of legionella infection

We identified 76 cases of legionella infection in children that fulfilled our inclusion criteria.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56 Diagnosis was made with legionella culture methodology in 45 (59%) of these cases; culture was the only diagnostic method that was positive in 23 (30%) cases. Seroconversion and direct

Discussion

Legionnaires' disease in adults is now an established and frequent cause of both community-acquired and hospital-acquired pneumonia.57, 58 However, from the 1980s to the early 1990s, Legionnaires' disease was considered a rare and exotic disease usually identified with sporadic outbreaks. As diagnostic methods improved and were more commonly used, cases of Legionnaires' disease increased.59

Pneumonia is a common infection in children, but few reliable clinical or radiological features exist that

Search strategy and selection criteria

We searched Medline with the following keywords: “Legionella”, “children”, “infant”, “neonates”, “infection”, and “Legionnaires' disease”. All case reports and case series were reviewed to identify other reports of paediatric legionellosis. Inclusion criteria were based on diagnostic tests for Legionnaires' disease. A case was included if at least one of the following diagnostic methods was positive: culture of respiratory secretions, direct fluorescent antibody assay, urine antigen, or

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