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Legionella pneumonia with severe rhabdomyolysis

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A 41-year-old man presented with a 5-day history of fever, non-productive cough and shortness of breath associated with copious watery diarrhoea and excessive fatigue. Apart from heavy smoking and alcohol misuse, there was no significant past medical history including no recent travel.

On examination, we found the patient to be diaphoretic, tachycardic (144 beats/min) and tachypnoeic (42 breaths/min), with a temperature of 39.7°C and blood pressure of 155/105 mmHg. He had an oxygen saturation of 98% after 8 L/min of supplemental oxygen. Auscultation of the chest elicited coarse crepitations over the right lung base and normal heart sounds. He had generalised weakness but no focal neurological deficit.

Laboratory results on admission showed a sodium level of 126 mmol/L (reference interval [RI], 137–145 mmol/L); chloride level, 96 mmol/L (RI, 100–109 mmol/L); potassium level, 3.3 mmol/L (RI, 3.5–4.9 mmol/L); urea level, 10.7 mmol/L (RI, 2.7–8.0 mmol/L), rising to a peak of 46.5 mmol/L; and creatinine concentration 310 μmol/L (RI, 50–120 μmol/L), rising to a peak of 908 μmol/L. Liver function test results were moderately abnormal: aspartate transaminase, 471 U/L (RI, < 45 U/L; peak, 860 U/L); alanine transaminase, 200 U/L (RI, < 55 U/L; peak, 1309 U/L); and lactate dehydrogenase, 4379 U/L (RI, 110–230 U/L). There was leucocytosis, with a white blood cell count of 13.6…