A 59-year-old man presented to the accident and emergency department with a 6-day history of ‘flu-like symptoms’—hot/cold sweats and high fever. For 3 days prior to admission, he also complained of breathlessness, productive cough, palpitations and diarrhoea. He gave a history of foreign travel to Portugal approximately 12 week previously.
Initial observations showed a pyrexia of 40.2, Sp02 93% on room air, respiratory rate 25/min, heart rate 170 bpm, blood pressure 110/70 mm Hg. Bibasal crepitations were present on chest auscultation with dullness to percussion at the right base. An ECG confirmed atrial flutter with a rapid ventricular response. The chest x-ray showed widespread pulmonary infiltrates ().
The patient was given a stat dose of metoprolol intravenously and subsequently reverted to sinus rhythm. Oral beta blocker was maintained thereafter.
Swine flu was diagnosed on the basis of symptoms and a positive RIDT. Initial treatment was with oseltamivir 75 mg twice daily and the patient moved to an isolated side room as per hospital infection policy.
On review 24 h later, a diagnosis of probable atypical pneumonia was made and treated with rifampicin and clarithromycin initially pending the result of a urinary legionella antigen (subsequently positive). A real time PCR test for swine flu was negative at 72 h. Oseltamivir was discontinued. His antibiotics were subsequently changed to ciprofloxacin when his liver function tests became abnormal. On further questioning, the patient gave a history of recently cycling to work for 3 weeks prior to his presentation. On arriving, he would shower in the work's changing rooms—a facility that was not widely used. Suspecting this as the source of his infection, Public Health and the occupational health at the patient's work were informed. Culture of the shower heads at his work revealed growth of Legionella pneumophila serogroup 1, monoclonal antibody subgroup ‘Benidorm’, identical to the serogroup isolated from the patient. The patient continued to spike a high pyrexia intermittently, but this gradually resolved and he made a full but slow recovery and was discharged at 14 days.