case_images: PMC8232522_01
case_images: Timeline with relevant data from the episode of care; body temperature curves, leukocyte counts, and CRP. Major events are indicated with arrows. Yellow line shows the leukocyte counts in peripheral blood. Blue line on the top shows body-temperature values. Blue line on the bottom shows CRP values. Horizontal thick gray lines show the medications administered: IMP/CS, Imipenem and cilastatin sodium; AMK, Amikacin; LZD, Linezolid; AMB, Amphotericin B; ATM, Azithromycin; SCF, Sulbactam and cefoperazone sodium; PCZ, Posaconazole; CDZM, Cefodizime.
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case_images: PMC8232522_01_fmed-08-643473-g0001.jpg
case_images: F1
case_images: Thirty-nine days after transplantation, the patient developed a high fever, and her blood neutrophil count and inflammation indicators increased (Figure 1). The anti-infection regimen was changed to azithromycin combined with cefoperazone, sulbactam, and posaconazole on May 10, 2019 (Figure 1). The patient's body temperature returned to normal after 1 day of treatment with azithromycin and remained normal for 1 week (Figure 1), but 10 days after initiating azithromycin treatment, a CT scan still showed inflammation in both lungs (Figure 2B).
case_images: (A) Chest CT scan showing double pneumonia: the upper lobe of the left lung was consolidated; (B) Chest CT scan showing inflammation in both lungs after 10 days of treatment with azithromycin; (C) Chest CT scan revealed that multiple lung lesions were absorbed 18 days later.
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case_images: PMC8232522_01_fmed-08-643473-g0002.jpg
case_images: F2
case_images: After 1 week of treatment, the patient's body temperature had not returned to normal, and CT showed double pneumonia, in which the upper lobe of the left lung was consolidated (Figure 2A). The patient's body temperature returned to normal after 1 day of treatment with azithromycin and remained normal for 1 week (Figure 1), but 10 days after initiating azithromycin treatment, a CT scan still showed inflammation in both lungs (Figure 2B). A CT scan revealed that multiple lung lesions were absorbed 18 days later (Figure 2C).
case_images: Diagnosis of Legionella pneumophila infection using mNGS. (A) The majority of reads mapped to the L. pneumophila genome with coverage of 28.12%. (B) The majority of reads mapped to the L. pneumophila genome with coverage of 13.35%.
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case_images: PMC8232522_01_fmed-08-643473-g0003.jpg
case_images: F3
case_images: We sent the patient's blood samples for mNGS, and 8,112 raw reads belonged to L. pneumophila (Figure 3A). The number of raw reads of L. pneumophila in BALF was 1,960 (Figure 3B).
case_images: (A,B) Gram stain of bronchoalveolar lavage fluid (BALF) with arrows indicating Legionella pneumophila, magnification x1,000. (C)
  L. pneumophila colonies on MWY selective agar (red arrows) from BALF. (D) Gram stain of L. pneumophila colonies (magnification x1,000).
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case_images: PMC8232522_01_fmed-08-643473-g0004.jpg
case_images: F4
case_images: The phagocytosis of gram-negative bacilli by leukocytes in BALF was observed under a microscope (Figures 4A,B). Six days later, several off-white colonies were visible on the MWY medium (Figure 4C). After Gram staining of the colonies, a large number of gram-negative bacilli were observed under microscopy (Figure 4D).