CURRICULUM VITAE

Dr. Hj.Noormartany, dr., SpPK(K), MSi

Konsultan Alergi dan Imunologi

RIWAYAT PENDIDIKAN :
• Dokter Umum FK UNPAD 1979
• Dokter Spesialis Patologi Klinik FK UNPAD 1992
• Magister Genetika & Biomolekuler ITB, 2000
• Doktor Imunologi Patologi Klinik UNPAD 2009

RIWAYAT PEKERJAAN :
• Ka. Puskesmas Buahdua Sumedang 1980-1983
• Ka. Puskesmas Conggeang Sumedang 1983-1984
• Ka. Puskesmas Cimalaka Sumedang 1984-1986
• Ka. Sie. P3M Dinkes DT II Sumedang 1986-1988
• Ka. Instalasi Patologi Klinik RS Majalengka 1993-1994
• SMF. Patologi Klinik RSHS 1994-1996
• Ka. Instalasi Patologi Klinik RSHS 1996-2001
• Direktur Penunjang dan Pendidikan RSHS 2001-2006
• Direktur Umum dan Operasional RSHS 2006- 2008
• Ketua Bidang Organisasi Pengurus Pusat PDS Patklin 2005-2010
• Dosen S1, S2 dan S3 F.K- UNPAD 1996-sekarang
• Ka. Divisi Imunologi Bagian Pat. Klinik RSHS 1996-sekarang
• Ka. Unit Pelayanan Teknik Kesehatan UNPAD 2008- sekarang
• Ketua Program Studi Patologi Klinik FK UNPAD 2010 - sekarang
• Wakil Ketua IV IDI Wilayah Jabar 2010 - sekarang
• Sekretaris Jendral Kolegium PDS-Patklin 2011- sekarang
• Bendahara Perhimpunan Alergi Imunologi Bandung 2006- sekarang
• Komite Internship Dokter Indonesia Prov. Jawa Barat 2011-sekarang
 Legionella
and
Legionnaire's Disease
Dr. Hj. Noormartany, dr., SpPK, M Si
Konsultan Alergi dan Imunologi
What is Legionella?
 A naturally occurring
bacterium
 Found in most water
systems
 Often present in mains
water
 Easily colonises most
domestic water systems –
hot and cold
What Is Legionella ?
 It is a gram-negative bacteria.

 42 known species, and 70

serogroups.

 Enjoys warm water environments.

 Requires protozoa and other gram

negative bacteria to proliferate.

 Requires special media in order to

be cultured.
 Legionella sp.
Species isolated Species isolated from
from humans environment only
L. pneumophila, serotypes 1-15 L. cherrii
L. micdadei L. erythra
L. bozemanii L. gratiana
L. dumoffii L. jamestowniensis
L. feelei L. brunensis
L. gormanii L. brunensis
L. hackeliae L. fairfieldensis
L. longbeachae L. santicrusis
L. oakridgensis
L. wadsworthii

• Over 40 species in the genus

• L. pneumophila is the predominant pathogen
•Legionella pneumophila – 23 sub types
Legionella pneumophila
• Aerobic, slender, pleomorphic bacteria
• Universal inhabitants of water
• Humans acquire the disease by inhaling the bacteria
in aerosols from various water sources
• Intracellular parasites
• Causes Legionnaires’ disease
– Results in pneumonia
– Immunocompromised individuals are more susceptible
• Elimination of the bacteria is not feasible but reducing
their number is a successful control measure
Requirements for Growth?

 Optimum temperature of 20 - 45 ⁰C
 Food source (other bacteria & sediments)
 Prefers stagnant conditions
 Route of Infection?
 Primarily through inhalation
of aerosols, fine droplets &
mists
 Can be minimized by choking
on contaminated water
 Statistically most susceptible
- 50 to 70 year olds
- Males
- Smokers
 Legionella and Human Disease
 Initially discovered in 1976 after an outbreak in a Philadelphia
hotel that hosted a July 4th American Legion celebration
 221 attendees ill  34 died
 Legionella bacteria discovered in lung tissue and cooling tower.

 Today:
 ~ 2,000 cases of Legionella pneumonia in the US each year
 An estimated 8,000 – 18,000 are thought to occur .

 Estimated to cause 2-15% of community acquired pneumonias.

 In New York State 200 – 300 cases have been reported yearly the
past two years.
 200-300 cases of infection in England & Wales annually
 Indonesia ?
 Sources of Legionella Infection
 Any stagnant warm water can be a reservoir for
Legionella.
 Ideal breeding temperature is between 77oF and
115oF.
 Historically, two main sources of published
outbreaks have been:

1) Cooling Towers

2) Domestic Hot Water Systems.

Sources of Legionella Infection: Cooling Towers
Sources of Legionella Infection
Trouble with cooling towers:
►Require careful maintenance.

►Large volumes of water and high powered fans

enable wide dispersal.
►The largest outbreaks of legionellosis on record
have been due to contaminated cooling towers.
Sources of Legionella Infection
Trouble with Hot Water Systems:
 Showering, drinking, or anything creating an aerosol
can be an exposure source
 Hot water “dead legs”, and water tanks can provide
ideal refuge for breeding.
.
Sources of Legionella Infection:
Hot Water Systems

Dead Leg
Legionella Problems in Healthcare Facilities
 Why?
 Compromised patients are easy targets for Legionella

 Old buildings, old water systems, modern medicine.

 Nosocomial Legionella in MARO 2003-2005:

 20 different Hospitals reported cases.
 10 nursing homes reported cases.
Legionnaire's Disease
 Legionellosis
DEFINITION
Legionellosis: an infection with Legionella.
Two manifestations predominate:
1. Legionella Pneumonia (“Legionnaires’ Disease”).
2. Pontiac Fever .
Extra pulmonary and wound infections have been reported too
but are very rare.
 Potentially fatal form of pneumonia
 Incubation period 2-10 days-typically 3-6 days
Pontiac Fever
Pontiac Fever
Is a self limited illness due to Legionella exposure in immune competent
host
So named after an outbreak in Pontiac Michigan 1968
 It can occur in any individual.
 Symptoms begin a few hours to a few days after exposure.
 Symptoms include fever, malaise, myalgia, and headache.
 Illness is self limited, and lasts 2-5 days.
Diagnosis:
• Primarily by serology and symptoms.
• Pontiac Fever patients may not have detectable levels of urinary
antigen.
Legionella pneumonia
Legionella pneumonia:
Onset 2-10 days after exposure.
►Symptoms include:
 Moderate to severe pneumonia with infiltrates.
 Fever
 Non- productive cough
 Hyponatremia (low sodium)
►Occurs primarily in immune compromised hosts.
 Elderly, immune suppressed, chronically ill (COPD, diabetic).
 Immune suppression and hematological malignancy seem
to be the highest risks.
►Mortality 5-20%
Confirmed:
1) Culture of any Legionella organism from respiratory
secretions, lung tissue, pleural fluid, or other sterile
fluid

2) Detection of Legionella pneumophila serogroup 1

antigen by urinary antigen using valid reagents.

3) Seroconversion with fourfold or greater rise in specific

serum antibody titer to Legionella pneumophila
serogroup 1 using validated reagents.
Case Definitions
Suspect:
1) Seroconversion with fourfold or greater rise in antibody titer to
specific species of Legionella other than Legionella pneumophila
serogroup 1 using validated reagents.
2) Seroconversion with fourfold or greater rise in antibody titer to
multiple Legionella species using pooled antigen and validated
reagents.
3) Detection of specific Legionella antigen or staining if the
organism in respiratory secretions, lung tissue, or pleural fluid by
direct fluorescent antibody DFA staining, immunohistochemistry,
or similar method using validated reagents.
4) Detection of Legionella species by validated nucleic assay.
 Laboratory Diagnosis

Specimen collection
• Respiratory tract specimens
- sputum, BAL, pleural fluid

• Blood, tissue, biopsy material

Specimen processing
• Standard precautions (BSC)

• Concentration of dilute specimens

Culture
 Good Points
 Gold Standard – leaves no doubt for diagnosis.
 Recovery allows you to match for sources

 Draw backs
 Requires special media: BCYE agar
 Requires time 5-7 days to grow.
 Infection intracellular, patients do not often produce sputum.
Culture
• Include Buffered Charcoal Yeast Extract (BCYE) Agar
Charcoal to detoxify specimen
Cysteine
Inhibitors (polymixin B, anisomycin, cefamandole)
• Incubate 35 – 37°C, room air, for 7-10 days

Colonies on BCYE
Colonies Identification
• Small, gray-white to blue-green colonies, wet,
ground-glass speckling

• Gram stain yields thin, gram-negative rods

• ID of colony using FA reagents

• Report as Legionella sp.

Direct detection
• DFA for organism in respiratory specimens

• Urine antigen test

Immunochromatographic commercial test
Only detects L. pneumophila, serogroup 1
Legionella DFA Legionella Urine Ag
 LEGIONELLA PNEUMOPHILA
This smear is from a case of
Legionella pneumophila
pneumonia. Notice that these
thin irregular bacilli are
rather similar to some of the
other organisms we have seen
previously. Filamentous
forms occur occasionally in
clinical specimens and
frequently when grown on
suboptimal media. Detection
of pale staining organisms
such as Legionella and many
anaerobes is facilitated by
addition of 0.05% basic
fuchsin to the safranin
counterstain in Gram’s stain.
 The Gram Stain

Gram's
Crystal
iodine
violet

Decolorise with
acetone

Gram-positives
appear
purple
Counterstain
with Gram-negatives
e.g. methyl red appear pink
Gram stain
Urine Antigen
 Good Points
 High sensitivity (80-90%) High specificity (~100%)
 Rapid – only takes a few hours

 Draw backs
 Antigen can be shed for months after infection which can distort
source and timing.
 Only detects L. pneumophila 1. (Although some assays can cross-
reacts with serogroup 3).
 Some patients can’t produce urine (e.g. ESRD patients)
Legionella Serology
 Good Points
 Allows for retrospective studies
 Some IFAs detect IgM
 Most Kits detect L. pneumophila serogroups
1-6

 Draw backs
 Requires months to make a diagnosis.
 IFA has lower specificity
 Single positive titers can be meaningless!
 Won’t detect other than serogroups 1-6
PCR and DFA
 DFA:
 Low sensitivity and specificity.
 Should only be used as additional evidence

 PCR:
 Not widely available.
 Theoretically it could be clinically valuable.
 Be careful if using for environmental testing
Treatment of Legionella
 Effective Agents:
 Macrolides
 Fluoroquinalones
 Tetracyclines

 Non-Effective Agents:
 Glycopeptides
 Penicillins
 Carbapenems
 Cephalosporins
 Aminoglycosides

 Agents of Uncertain Efficacy:

 Trimethoprim sulfamethoxazol
Typical Systems at Risk
 Cooling Towers
 Domestic hot & cold water systems
 Water features incl. ornamental fountains
 Equipment producing aerosols, mists or
droplets from stored water sources including
showers & humidifiers
 Equipment holding / circulating
water at 20 - 45⁰ C
 Examples of lab & workshop equipment
 Water tanks & baths
 Spray taps
 Water recirculation systems for cooling
 Rarely used taps & showers (even at home)
 Misting equipment
 Dentistry tools
 Oil / water emulsions for
lubricating lathes
 Mobile AC equipment with water
We hope you found this
information useful!
Thank You