Correspondence.

(Letters to the Editor are welcomed. They may report new clinical or laboratory observations and new developments in medical care or may contain comments on recent contents of the Journal. They will be published, if found suitable, as space permits. Like other material submitted for publication, letters must be typewritten, double-spaced, and submitted in duplicate. They must not exceed two typewritten pages in length. No more than five references and one figure or table may be used. See "Information for Authors" for format of references, tables, and figures. Editing, possible abridgment, and acceptance remain the prerogative of the Editors.)

Legionella Pneumonia: An Unusual Cause of Rhabdomyolysis and Acute Renal Failure 

To the Editor: Rhabdomyolysis with subsequent renal failure due to Legionella pneumonia is an infrequently recognized entity with high morbidity and mortality rates. Prompt recognition and treatment of this extrapulmonary manifestation is critical. We report such a case to highlight the existence of this clinical entity.

A 56-year-old man with a medical history of type 2 diabetes mellitus presented to our emergency department with a chief complaint of generalized weakness. The patient described a several day history of progressive cough productive of dark gray sputum, shortness of breath, nausea, vomiting, watery diarrhea, subjective fevers, chills, rigors, and anorexia. He reported a history of occasional alcohol use and smoking, but no illicit drug use. He worked as a building maintenance engineer, with responsibility for air conditioner maintenance.

Physical examination revealed a temperature of 103[degrees]F, pulse rate 120/min, respiratory rate 30/min, and blood pressure 148/83 mm Hg. Significant laboratory values at admission included: sodium, 130 mEq/L; potassium, 3.7 mEq/L; chloride, 87 mEq/L, bicarbonate, 16 mEq/L, blood urea nitrogen (BUN), 21 mg/dL; creatinine, 2.8 mg/dL; white blood cell (WBC) count, 12,100/[micro]L; hematocrit, 35%; platelet count, 160,000/[micro]L; and calculated serum osmolarity, 293 mOsm/kg. Results of a serum toxicology screen were negative, and chest radiography disclosed a patchy left lower lobe infiltrate.

The patient was admitted, and intravenous levofloxacin was started empirically for community-acquired pneumonia. Within 12 hours, urine output had decreased significantly, despite intravenous fluid administration. Repeat laboratory evaluation revealed the following values: BUN, 41 mg/dL; creatinine, 5.8 mg/dL; glucose, 86 mg/dL; and creatinine phosphokinase, 115,880 U/L. Urine obtained on admission had a measured myoglobin of 53.30 UG/mL (normal, 0 to 2 UG/mL), and was positive for Legionella pneumophila serogroup 1 antigen. All blood, sputum, and urine culture results remained negative, and renal ultrasonography was unremarkable.

The most common precipitating etiologies for rhabdomyolysis are trauma/compressive injury, alcohol ingestion, seizures, and illicit drug use. (1-5) Legionella pneumophila infection, however, is a recognized but rare cause of rhabdomyolysis. While the mechanism of rhabdomyolysis associated with Legionella infection is unknown, theories include direct invasion of Legionella into the muscle itself, or the release of its endotoxin into the circulation with subsequent muscle injury. (23)

Legionnaires' disease is a multisystemic illness. Fifteen percent of patients with Legionnaires' disease have acute renal failure, with shock and hypotension implicated as the causes in most cases. In this case, rhabdomyolysis induced by Legionella pneumophila was the cause of renal failure. The source of the infection was presumed to be potable water exposure at work. Clinicians should remain alert to the existence of this complication of Legionella infection, since prompt recognition may be lifesaving.

David Kaufman, DO

Karen Weber, DO

Jeremy D. Gradon, MD

Department of Medicine

Sinai Hospital of Baltimore

2401 W Belvedere Ave

Baltimore, MD 21215

References

(1.) Hall SL, Wasserman M, Dall L, et al: Acute renal failure secondary to myoglobinuria with Legionnaires' disease. Chest 1983; 84:633-635

(2.) Johnson DA, Etter HS: Legionnaires' disease with rhabdomyolysis and acute reversible myoglobinuric renal failure. South Med J 1984; 77:777-779

(3.) Smeal WE, Schenfeld LA, Hauger W: Legionella causing rhabdomyolysis and renal failure. Postgrad Med 1985; 78:42,44

(4.) Monteforte R, Marcq F, Struch R, et al: Multiple organ involvement by Legionella pneumophila in a fatal case of Legionnaires' disease. J Infect Dis 1989; 59:809

(5.) Gartenberg G, Weinstein MP, Fernando NK, et al: Rhabdomyolysis with acute renal failure in Legionnaires' disease. J Med Soc N J 1981; 78:119-120

Unfiltered Coffee Raises Cholesterol

To the Editor: In 1989, Bak and Grobbee (1) published a study that indicated that persons who drank boiled coffee had a higher blood cholesterol concentration than those who drank filtered coffee. This has been confirmed since then, and the mechanism has at least partially been elucidated. (24) Coffee contains two terpenes, cafestol and kahweol, that are responsible for the elevated cholesterol. These terpenes are removed when coffee is filtered through paper. I read the article by Bak and Grobbee in 1989, but did not think that it applied to me, since I always drank filtered, decaffeinated coffee. Furthermore, I made it a point to have my cholesterol levels checked regularly, and they were always fine.

As shown in the Table, in September 1996, my cholesterol level rose to 240 mg/dL, the first time it had risen above the safe level of 200 mg/dL. At first, I did not believe this and had the assay repeated. Initially, I could not think of a reason for this rapid rise in cholesterol (it had been 190 mg/dL in 1995); then I remembered the paper by Bak and Grobbee and the fact that my spouse had bought a cappuccino machine several months earlier.

In August 1997, I suggested to my wife that we should change the procedure for making cappuccino coffee by adding a small paper filter to the metal filter of the coffee maker. As a result, my cholesterol level returned to normal over a period of about 1 year (220 mg/dL in January 1998; 190 mg/dL in October 1998). I drink 1 cup of coffee on weekdays and 2 cups on Sundays.

Cappuccino can be added to the observations in the literature of boiled and perked coffee leading to higher cholesterol levels. Meanwhile, in an informal study, I have asked people who take statin drugs to lower their cholesterol if a health professional had ever warned them against drinking unfiltered coffee. I have yet to find anyone who has been warned. I hope that this message will convince physicians, pharmacists, and other health professionals to warn their patients about the effects of unfiltered coffee on cholesterol level. I suggest that pharmacists prepare a warning label to stick on the containers for statin drugs. Maybe the pharmaceutical companies that produce statin drugs and other medications designed to lower blood cholesterol levels can be persuaded to add a warning against unfiletered coffee to their product descriptions.

I wonder how many people worry about their cholesterol levels and may be taking medication needlessly, when a simple change in the preparation of their coffee might bring their cholesterol level into the normal range.

Frans Huijing, PhD

Department of Biochemistry and Molecular Biology

University of Miami School of Medicine

PO Box 016129

Miami, FL 33101-6129

TABLE. Cholesterol Levels, 1971-2000

                 Total Serum
Month  Year  Cholesterol (mg/dL)  Comments

       1971          150
       1981          170          Total cholesterol/HDL cholesterol
                                   always in the desirable range (<4)
       1995          190          Normal progression related to age
Sept   1996          240          Unexplained increase
Oct    1996          240          Repeat assay
March  1997          245          In August 1997, I switched to
                                   paper-filtered cappuccino
Oct    1997          228
Jan    1998          220
Aug    1998          196          HDL cholesterol 51 (desirable>39);
                                   total cholesterol/HDL cholesterol
                                   3.8
Oct    1998          190
Oct    1999          180
Oct    2000          180

References

(1.) Bak AA, Grobbee DE: The effect on serum cholesterol levels of coffee brewed by filtering or boiling. N Engl J Med 1989; 321:1432-1437

(2.) de Roos B, Gaslake MJ, Stalenhoef AF, et al: The coffee diterpene cafestol increases plasma triacyiglycerol by increasing the production rate of large VLDL apolipoprotein B in healthy normolipidemic subjects. Am J Clin Nutr 2001; 73:45-52

(3.) de Roos B, Van Tol A, Urgert R, et al: Consumption of French-press coffee raises cholesteryl ester transfer protein activity levels before LDL cholesterol in normolipedaemic subjects: J Intern Med 2000; 248:211-216

(4.) Post SM, de Roos, B, Vermeulen M, et al: Cafestol increases serum cholesterol levels in apolipoprotein E*3-Leiden transgenic mice by suppression of bile acid synthesis. Art erioscler Thromb Vase Bio 2000; 20:1551-1556