Background: Legionnaires’ disease (LD) is one of the leading causes of severe community acquired pneumonia (CAP) and shows a high mortality rate. Its incidence has exhibited a steady rise globally, with the highest rates being notified in EU region. Antimicrobial therapy is the mainstay of treatment, with hospitalization and intensive care being frequently required.
Case presentation: We present a case of a 42 year old Swiss man diagnosed with LD who benefited from individualized cl***ical homeopathy adjunct to conventional therapy at the hospital.
Results: The patient showed resolution of clinical signs and symptoms within a brief period with the aid of the homeopathic remedy Tuberculinum.
Conclusion: This case report suggests that individualised cl***ical homeopathy may have a role in managing cases of LD. However, further research with well-designed studies are essential to prove the effectiveness of this therapeutic approach.
Keywords: Legionnaires’ disease, pneumonia, homeopathy
Background
Legionellosis is a water-borne infection caused by the gram-negative bacteria Legionella1,2. Legionnaires’ disease (LD) and Pontiac fever are the two disease entities that comprise legionellosis, the former presenting as a severe pneumonic illness and the latter as a non-pneumonic, self-limiting febrile illness3.
Despite advances in recent decades in the diagnosis and reporting of legionellosis, the exact global incidence of LD remains unknown but estimates suggest a steady rise1,4. It is a notifiable disease and EU/EEA had the highest annual notification rate of Legionnaires’ illness to date in 2021, with 2.4 cases per 100,000 people5.
LD accounts for 1 to 10% of community acquired pneumonia (CAP) and is the second most frequent cause of severe CAP4. Risk factors include male block, advanced age, immunosuppression, chronic lung disease, alcoholism, history of smoking, malignancies, and diabetes1,6.
It shows a seasonal variation with high prevalence in warmer seasons and increased incidence in spring7. The most common ways that humans contract Legionella are via inhaling aerosols from contaminated water sources (such as drain pipes, and air conditioning systems) or by inhaling contaminated water directly during specific events, like water births4.
After inhalation, Legionella invades lung alveolar macrophages through phagocytosis, blocks their bactericidal action and converts them into an ideal environment for its proliferation8,9. The average incubation period for LD is 2 to 10 days10.
Most common symptoms of LD are fatigue, high fever, cough, myalgias, headache, pleuritic chest pain, abdominal pain, and diarrhoea9,10. Immunocompromised patients may exhibit extrapulmonary symptoms such as cellulitis, septic arthritis, myocarditis, endocarditis, peritonitis, and skin abscess11.
Diagnosis of LD is based on the presence of a combination of laboratory tests, medical and exposure history and the presence of clinical and radiological signs1. Certain laboratory findings like hyponatremia, hypophosphatemia, elevated creatine kinase levels, impaired renal function, microscopic haematuria, hyperleukocytosis with lymphopenia, elevation of serum ferritin and C-reactive (CRP) protein have been seen to be ***ociated with LD8.
Urinary antigen test is the most used diagnostic tool but the gold standard for diagnosing legionellosis is sputum and respiratory secretion culture2,10. There are no pathognomic imaging features of LD but progressing patchy pulmonary opacities are seen in chest radiographs4.
For treatment, antimicrobial cl***es such as macrolides and fluoroquinolones are preferred12. Most patients require hospitalization with half of them requiring intensive care9. We present a case of LD, where along with conservative management, administration of cl***ical homeopathy was done. We did not find any other case like this in the literature where LD benefitted from homeopathy.
Case Presentation
On 26th July 2023, the patient, a previously healthy 44-year-old man started experiencing severe fatigue along with fever and stabbing, burning headache. He was a resident of Switzerland and had a history of travel to Germany, from where he returned 5 days ago.
On 29th July 2023, the headaches worsened with retro-orbital radiation, nausea, slight photophobia and phonophobia. His temperature was between 37.2-37.5ºC and he was hospitalized for further investigations. The diagnosis was made using findings of thoraco-abdomino-pelvic CT and urinary antigen test for L. pneumophilia post which conservative infusion therapy was started at the hospital.
Past medical history: The patient suffered from chickenpox and measles during childhood. He also had a sino-nasal papilloma of the left nasal fossa of oncocytic type, KRAS-mutated which was treated by surgical resection in October 2022.
History of excessive alcohol consumption with depressive and suicidal thought since his divorce in 2021.
Family history: His mother and father had Hypertension.
Diagnosis: Legionnaires’ disease (ICD10: A48.1)13
Hospital Discharge Summary of 10 August 2023: Left Lobar Pneumonia due to Legionella pneumoniae. Upon arrival in emergency room, patient was feverish and had unusual non-disabling transient headache with haemoptoic sputum but no other abnormality of vitals.
Bacteriological and viral blockyses carried out were negative, except for Legionella pneumoniae with positive urinary antigens. Thoraco-abdomino-pelvic CT of 01.08.2023 showed a focus of lobar pneumonia in left lung with a positive urinary antigen test for L.pneumophilia.
Comorbidities include probable bicuspid aortic valve with degenerative valve rearrangement and moderate stenosis. Antibiotic therapy with Ceftriaxone and Doxycycline was relayed with Levofloxacin for 7 days until 08.08.2023.
The patient was transferred to our internal medicine department for follow up care on 02.08.2023. Radiology of 03.08.2023 showed no signs of intracranial hypertension or cavernous sinus thrombosis. A relay by Clarithromycin was carried out from 07.08.2023. The clinical evolution was favourable with amendment of haemoptoic sputum and headaches. Given a favourable evolution, the patient returns home on 08.08.2023.
Differential diagnosis: LD may be confused with pneumococcal pneumonia which does not cause extrapulmonary manifestations like gastrointestinal and neurological symptoms and electrolyte abnormalities as seen in LD14. It must also be differentiated from other causes of atypical CAP like Chlamydophila pneumoniae and Mycoplasma pneumoniae9. Bacterial culture usually clinches the diagnosis.
Homeopathic consultation: The patient sought online homeopathic consultation over the phone on 4th August 2023, when he felt no change in his condition despite 4 days of conventional treatment at the hospital. Cl***ical homeopathy involves individualized prescription of a single homeopathic remedy based on the totality of symptoms on all levels – physical, mental and emotional.
A detailed history revealed that his temperature would rise to 40ºC, every night around midnight, accompanied by profuse sweating and chilliness. His attendant observed that the patient would begin to talk a lot, often incoherently with rise of temperature at night.
Antipyretic drugs would reduce the temperature by only 1-1.5 ºC and he was even treated with external ice applications. But the temperature would drop to 37.2-37.5ºC every morning, remain the same throughout the day, and rise again around midnight.
The patient still experienced excessive weakness and he was also bothered by muscular pains, temporal headaches and dry cough. He also had a thirst for cold water and drank often, in large quantities. The peculiar fever pattern coupled with loquacity during fever, headache, thirst and dry cough indicated the homeopathic remedy Tuberculinum 15. (Fig 1)
Prescription:
Tuberculinum 200 CH, 5 globules in 200 ml water, which the patient sipped throughout the day.
Follow up: The Follow-up is given in Table 1.
Table 1
| Date | Symptoms | Analysis | Prescription |
| 05 Aug 2023 | The night after taking the remedy, the temperature rose up only to 38.5 ºC and at 7am it came down to 37 ºC.
At about 5am teeth grinding appeared. |
Appearance of grinding of teeth which was a symptom belonging to the pathogenesis of the remedy, confirmed the correctness of the remedy choice. | Tuberculinum 200CH in solution
|
| 06 Aug 2023 | At night the temperature rose to 37.5 ºC and came down to 37 ºC in the morning. Weakness reduced by 20-30%. Appetite improved. Cough relieved. | Patient is showing some improvement, hence we must wait. | Nil |
| 07 Aug 2023 | The temperature was normal at night. Weakness decreased by 35-40%.
|
Considerable improvement in the condition with no appearance of fever, hence we must wait until any new symptoms appear | Nil |
| 08 Aug 2023 | Patient was discharged from hospital. | The remedy continued to act. There is overall improvement. | Nil |
| 02 Sept
2023
|
No complaints.
Patient noted a significant improvement in his mental state, the disappearance of depression and suicidal thoughts. |
Discussion
LD poses as a serious public health concern owing to its propensity to spread, high mortality rate in untreated cases, and difficulty in detection and control1,9. Though antibiotic resistance is not a problem yet for LD, antibiotics usually take longer to work on infections caused by intracellular microorganisms.
Hence, clinical improvement is not seen until 5-7 days despite early therapy8. The same scenario was evident in the above case, where the patient did not improve in the first few days. Hence, the patient sought homeopathic help as a complementary therapy together with conventional treatment.
After initiation of homeopathy, improvement was seen in clinical symptoms like fever, weakness, pains and cough on the same day. Patient was discharged from the hospital on 5th day from the commencement of adjunct homeopathy, 9 days from initiation of conventional treatment.
There were no adverse events. Cl***ical homeopathy has previously shown favourable results in infectious diseases16,17, however authors are not aware of any prior publications of treating LD with adjunct homeopathy thus far.
The Modified Naranjo Criteria for Homeopathy (MONARCH) causality ***essment provided a score of 8 /13, suggesting (Table 2) a potential benefit from cl***ical homeopathy, the score being low due to the adjunct nature of the therapy in this case. Further studies are needed to determine its effect on the intensity of symptoms, duration of hospital stay and recovery time.
Table.2
| Domains | Yes | No | Not sure or N/A | Case |
| 1. Was there an improvement in the main symptom or condition for which the homeopathic medicine was prescribed? | +2 | -1 | 0 | 2 |
| 2. Did the clinical improvement occur within a plausible timeframe relative to the drug intake? | +1 | -2 | 0 | 1 |
| 3. Was there an initial aggravation of symptoms? | +1 | 0 | 0 | 0 |
| 4. Did the effect encomp*** more than the main symptom or condition (i.e., were other symptoms ultimately improved or changed)? | +1 | 0 | 0 | 1 |
| 5. Did overall well-being improve? | +1 | 0 | 0 | 1 |
| 6A Direction of cure: did some symptoms improve in the opposite order of the development of symptoms of the disease? | +1 | 0 | 0 | 0 |
| 6B Direction of cure: did at least two of the following aspects apply to the order of improvement of symptoms:
–from organs of more importance to those of less importance? –from deeper to more superficial aspects of the individual? –from the top downwards? |
+1 | 0 | 0 | 0 |
| 7. Did “old symptoms” (defined as non-seasonal and non-cyclical symptoms that were previously thought to have resolved) reappear temporarily during the course of improvement? | +1 | 0 | 0 | 0 |
| 8. Are there alternate causes (other than the medicine) that—with a high probability—could have caused the improvement? (Consider known course of disease, other forms of treatment, and other clinically relevant interventions) | -3 | +1 | 0 | 0 |
| 9. Was the health improvement confirmed by any objective evidence?
(e.g., laboratory test, clinical observation, etc.) |
+2 | 0 | 0 | 2 |
| 10. Did repeat dosing, if conducted, create similar clinical improvement? | +1 | 0 | 0 | 1 |
| Total | 8 |
The limitation in this case was the unavailability of records of all laboratory parameters. Also, a confounding effect could be present as a result of the use of conventional medicines along with homeopathy, making it difficult to attribute the effect entirely to adjunct therapy.
Conclusion
This case of LD showed significant improvement under adjunct cl***ical homeopathic treatment. Though there are some limitations, it provides a basis for further scientific investigation to determine the extent of benefit from cl***ical homeopathy in cases of LD.
References
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- 2024 ICD-10-CM Diagnosis Code A48.1: Legionnaires’ disease. Icd10data.com. Published 2024. Accessed September 30, 2024. https://www.icd10data.com/ICD10CM/Codes/A00-B99/A30-A49/A48-/A48.1#:~:text=Billable%2FSpecific%20Code-,A48.,ICD%2D10%2DCM%20A48.
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