View source for Unexplained transient loss of consciousness after legionella pneumonia

''Nynke van Dijk, C.T. Paul  Krediet and Wouter Wieling, Department of Medicine, Academic Medical Centre. University of Amsterdam, Amsterdam (The Netherlands)
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[[File:TLOC_legionella_pneumonia_fig1.jpg | thumb | 500px | left | Figure 1. Blood pressure and heart rate response of the patient to exercise. Note the progressive fall in blood pressure]]
[[File:TLOC_legionella_pneumonia_fig2.jpg | thumb | 500px | left | Figure 2. Blood pressure and heart rate response during the Valsalva maneouvre. Note the fall in pressure during straining and the lack of blood pressure overshoot after release of the strain]]
A 58 year-old male was referred by a cardiologist to our syncope unit for evaluation of an unexplained episode of transient loss of consciousness. Four years prior to this visit he had been admitted to an intensive care unit for a Legionella pneumonia. On recovery urinary bladder dysfunction and erectile dysfunction were evident. An urologist diagnosed prostate hypertrophy and a Trans Urethral Resection of the Prostate (TURP) was performed. The  problems of the sensation of a full bladder and frequent voiding (6 to 8 times at night) remained. Urinary incontinence was not present. 
Urodynamic evaluation showed an atonic areflexic bladder. Self-catheterisation was started. Prior to the Legionella pneumonia his general health and sexual and bladder functions had been normal. In the years following this episode the patient experienced progressive problems of fatigue and dyspnea during stair climbing. These symptoms were attributed to diminished pulmonary function after the Legionella pneumonia. He also complained of light-headedness during prolonged standing and near-syncope during toilet visits at night. A few months prior to the visit to our unit he lost consciousness on a very hot day shortly after standing up from a chair. He fell into a swimming pool and almost drowned. After this episode cardiological assessment was performed An EKG and echocardiogram both were normal. During tilt-table testing a large drop in blood pressure was observed after administration of nitroglycerin (from 150/80 mm Hg prior to the tilt test to 60 mmHg systolic during the test), but the patient did not faint and the test result was interpreted as negative. During bicycle exercise testing  the patient had to stop at a load of 120 Watt only, because of fatigue and light-headedness. Blood pressure dropped from 150/60  mmHg sitting on the bicycle to 60/40 mmHg directly post-exercise. No EKG-changes were noted. Because the fall in blood pressure during exercise was unexplained, cardiac catheterisation including ventricular and coronary angiography was performed to exclude cardiac disease. No abnormalities could be found.  



On examination in our syncope unit he was in good general health. His finger arterial pressure was 190/93 mmHg supine with an asymptomatic fall to 175/93 after 3 min standing. During an exercise test (step-test) blood pressure decreased in 1 minute from values around 175/95 mmHg to levels of 114/64 (Figure 1). 

During a Valsalva test there was a large fall in blood pressure with hardly any recovery in pressure during straining  and no overshoot of blood pressure after release of the strain (Figure 2). Heart rate followed the changes in blood pressure suggesting intact afferent, central and efferent cardiac arterial baroreflex pathways. The lesion therefore appeared to be located in the efferent sympathetic vasoconstrictor pathways.

Based on the symptoms of orthostatic hypotension and abnormalities in urinary bladder and sexual function autonomic neuropathy was diagnosed clinically and confirmed by autonomic testing. Autonomic neuropathy has been described as a complication of a Legionella infection earlier <cite>Bernardi</cite>. The patient received explanation and instructions about his condition (see case 5 in this section). 


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