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Potentially life-threatening emergency
Other Resources UpToDate PubMed
Potentially life-threatening emergency


Contributors: Neil Mendoza MD, Paritosh Prasad MD
Other Resources UpToDate PubMed


Legionellosis is caused by Legionella pneumophila, a small gram-negative bacillus found in aqueous environments.

Almost all cases of legionellosis are a result of inhalation of aerosolized bacteria residing in warm man-made water bodies, such as water heaters, air conditioning equipment, cooling towers, warm-water baths, warm-water plumbing systems, and recirculating water systems. Contamination of such water systems in hospitals has led to nosocomial outbreaks of disease. Person-to-person transmission does not occur.

Legionellosis is believed to occur throughout the world; 8 000-18 000 cases occur each year in the United States. About a quarter of these cases originate in a hospital environment and are associated with a higher proportion of fatalities. Most cases are sporadic. Less than one-fifth of all cases are associated with an outbreak.

Cigarette smoking, chronic heart and lung disease, male sex, diabetes mellitus, end-stage renal disease, cancer, and advanced age (older than 50 years) are some of the host factors that increase the risk for contracting legionellosis. Patients who are immunosuppressed are at a higher risk for infection with L pneumophila. Occupational exposures increase risk, such as hospital employment, work as a heating and air-conditioning technician, and building maintenance work. Social exposures include hot tub use.

The incubation period is generally between 2-10 days, but cases with incubation periods as long as one month have been reported. A prodromal illness consisting of headaches, myalgias, weakness, diarrhea, and abdominal pain may occur. These symptoms may suggest a viral illness and lead to a misdiagnosis. Cough, shortness of breath, pleuritic chest pain, and fever, often very high (40°C [104°F] or higher), will eventually predominate. Mental confusion may be present. Clinical examination findings are nonspecific and may include focal rales or signs of lung consolidation. The viral-like prodrome that does not progress to pneumonia is also referred to as Pontiac fever and is self-limited. Pontiac fever has been recognized only during outbreaks of legionellosis.

A number of nonspecific findings such as pulse-temperature dissociation, hyponatremia, abnormal liver enzymes, lymphocytopenia, thrombocytopenia, disseminated intravascular coagulation, elevated creatine kinase (CK), and elevated serum lactate dehydrogenase (LDH) have been described with legionellosis. These findings are insufficiently specific and sensitive to be of diagnostic value.

Rare cases of extrapulmonary disease with manifestations such as brain abscess, intra-abdominal abscess, infection of surgical wounds, cellulitis, and myocarditis have been described.


A48.1 – Legionnaires' disease

26726000 – Legionellosis

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Differential Diagnosis & Pitfalls

Agents causing community-acquired pneumonia such as Streptococcus pneumoniae pneumonia, Haemophilus influenzae pneumonia, and Moraxella catarrhalis can present with a similar picture. Legionellosis accounts for 2%-5% of cases of community-acquired pneumonias.

Other diagnoses within the differential include:
  • Viral infections (eg, Influenza, Respiratory syncytial virus infection, or Adenovirus infection)
  • COVID-19
  • Endemic fungal infection (Coccidioidomycosis, Histoplasmosis, Blastomycosis)
  • Cryptococcosis
  • Psittacosis
  • Hantavirus pulmonary syndrome
  • Leptospirosis
  • Pneumonic plague
  • Q fever
  • Tularemia
  • Melioidosis – with a compatible travel history
  • Invasive fungal infection (Aspergillosis, Mucormycosis) – in immunosuppressed patients
  • Malignancy (eg, Lung cancer)

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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Last Reviewed:06/26/2017
Last Updated:12/19/2021
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Potentially life-threatening emergency
Patient Information for Legionellosis
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Potentially life-threatening emergency
A medical illustration showing key findings of Legionellosis : Cough, Diarrhea, Fever, Headache, Nausea, Pleuritic chest pain, Dyspnea, Myalgia
Imaging Studies image of Legionellosis - imageId=2954652. Click to open in gallery.  caption: 'Frontal chest x-ray with opacities in the bilateral lower lobes in this patient with Legionnaires' disease.'
Frontal chest x-ray with opacities in the bilateral lower lobes in this patient with Legionnaires' disease.
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