Legionnaires' Disease outbreak linked to Shropshire hotel.

A woman has died and another has been treated in hospital after apparently contracting Legionnaires' Disease at a hotel in Shropshire, England. The woman who died is described as having been in her 60s, stayed in the historic Feathers Hotel in Ludlow in July this year, and subsequently fell ill and died in August. The surviving woman, in her 70s, received treatment in a Mersyside hospital after falling ill in April following a stay at the hotel, and is now understood to have recovered. Due to the long gestation of the illness it can take time to uncover the origin of the infection, but tests carried out by Public Health England's West Midlands Health Protection Team isolated the Bacterium that causes the disease in water samples from the hotel on Monday 11 September 2017. The hotel has closed voluntarily and is contacting recent guests urging them to seek medical advice. 

 

 The historic Feathers Hotel in Ludlow, England, temporarily closed due to an outbreak of Legionnaire's Disease. Grand Tour of the Middling Sort.

Legionnaire's Disease is caused by Bacteria of the genus Legionella. Symptoms typically include shortness of breath, muscle pains, headaches, fever, nausea, vomiting, and diarrhoea. It can also lead to pneumonia, which is the main cause of fatalities. The Bacteria are naturally occurring in soil and freshwater systems, but infection in humans generally comes from standing water within plumbing systems, such as water storage systems, air conditioning units, or pipes to taps which have been disconnected or are seldom used and which remain attached to the main water system, which provide an ideal breeding ground for the Bacteria. Since gestation of the disease is typically between 10 and 20 days, and most victims only suffer mild flu-like symptoms, tracing the cause of infection can be notoriously difficult.

Colony of Legionella pneumophila, one of the main causes of Legionnaire's Disease. Centers for Disease Control and Prevention/Wikipedia.

Legionella Bacteria are Gram-negative, aerobic, flagellated Gammaproteobacteria, related to other pathogenic Bacteria such as Yersina pestis (Bubonic Plague), Vibrio cholerae (Cholera), and Esherchia coli (food poisoning). They naturally occur within biofilms made by freshwater Amoeba, particularly at warmer temperatures (above about 25°C) rather than by being obligate pathogens, but can become problematic when these films form within Human-made water systems. Since the first known outbreak of Legionnaire's Disease occurred in 1976, and the disease was not understood for some time after this, many older buildings have plumbing systems that were not designed with this problem in mind.

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Neovahlkampfia nana: A new species of Heterolobosean Amoeba from the Czech Republic.

Heteroloboseans are flagellated Amoebas closely related to Slime Molds, and generally though to be the most primitive group of flagellated Eukaryotes (i.e. the group closest to the first such organisms to have appeared. They typically have a life-cycle which includes both flagellated and non-flagellated stages, as well as an inert cyst stage that can survive periods of hostile conditions, such as a cold, or dry season.

In a paper published in The Journal of Eukaryotic Microbiology on 13 July 2017, Tomáš Tyml of the Faculty of Science at the University of South Bohemia and the Faculty of Science at Masaryk University, Luis Lares-Jim énez, also of the Faculty of Science at Masaryk University, Martin Kostka, also of the Faculty of Science at the University of South Bohemia, and Iva Dykov á, again of the Faculty of Science at Masaryk University, describe a new species of Heterolobosean Amoeba from the gills of Rainbow Trout, Oncorhynchus mykiss, infected with an unknown nodular gill disease in the Czech Republic.

The new species is place in the genus Neovahlkampfia, which currently only contains a single species, Neovahlkampfia damariscottae, a marine Amoeba from an estuary in Maine, which was formerly placed in the genus Vahlkampfia until a genetic analysis sugested that it should be excluded from this group. It is given the specific name Neovahlkampfia nana, in reference to the small size of this species, which reached 8–15 μm in length.

Globular form of Neovahlkampfia nanawith nucleus (n), mitochondria (m), electron-dense structure (es), and dense bodies (db) in cytoplasm. Tymel et al. (2017).

Neovahlkampfia nana was identified as a a member of the Heterolobosea and a close relative of Neovahlkampfia damariscottae by genetic analysis (morphological comparisons of Amoebae are close to worthless). The species adopted a number of forms in response to changes in conditions, but these were essentially behavioural, rather than true metamorphoses, and the Amoebas were not observed to produce a flagellated or cyst stage (though this does not necessarily mean that they cannot do this).

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Free-living Amoebae in the water system of a South African hospital.

Free-living Amoebae are unicellular protozoan’s common in aquatic ecosystems, which are also known to colonize Human created water systems such as water supply systems and swimming pools. Whilst in some ways these organisms can be helpful, consuming a range of Bacterial, Viral and Fungal pathogens, they have also been shown to cause a range of infections themselves, and can themselves be infected by a variety of pathogenic Bacteria, such as Legionella pneumophila, Mycobacteria, Pseudomonas aerugionosa and Acinetobacter baumannii. Whilst most Bacteria are consumed and digested by the Amoebae, these pathogenic species have been shown to be able to resist digestion, instead surviving within the Amoebae, where they receive protection from biocides and antibiotics, later emerging to cause infections in Humans.

In a paper published in the South African Journal of Science in January 2015, Petros Muchesa and Tobias Barnard of the Water and HealthResearch Centre at the Department of Biomedical Technology at the University of Johannesburg and Catheleen Bartie of Immunology and Microbiology at the National Institute for Occupational Health, describe the results of a series of tests in which water samples and swab samples from taps and showers were collected from a number of locations at a hospital in Johannesburg and cultured to determine the presence of free-living Amoebae.

Muchesa et al. were able to culture Amoebae belonging to three identified genera, Acanthamoeba, Hartmanella and Balamuthia, as well as a number of unidentified species, from 43.7% of the water samples and 45.1% of the swab samples.

Balamuthia cysts (indicated by arrows) in water and biofilm samples from ahospital water system. Muchesa et al. (2015).

There have been relatively few published studies on free-living Amoebae in hospital water supplies, but these results are higher than a study of water in a Swiss hospital in 2006 which found Amoebae in 5.7% of samples and a study from American hspitals in 2014, which found Amoebae in 14.8% of samples.

While there have not been any reported instances of Amoeba-related invfections at the hospital, Acanthamoeba and Balamuthia have previously been implicated in infections of the eyes, skin and nervous system, and the presence of these organisms in the water supply system is of concern, particularly as the hospital has a high proportion of immunocompromised patients.

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