Travel-associated infections caused by unusual serogroups of Legionella pneumophila identified using Legionella BIOCHIP slides in Turkey and Iraq

Background Although Legionella pneumophila serogroup 1 is the common disease causing serogroup, rare serogroups can also may cause legionellosis. A 54-year-old male patient (index case) reported that he had been on a religious trip (for visiting, tomb of Ali, which is important for Shias) to Iraq with a large group (50 shia pilgrims from Kars city of Turkey) two weeks prior to admission. Due to civil war, the hotel where the patient stayed in Iraq lacked proper hygiene. A large number of people in the travel group were experiencing the same symptoms. Other five cases were 2 males (ages; 50, 45) and 3 females including the wife of the index case (ages; 50, 28, 27). Method The detection of L. pneumophila IgG and IgM was performed by anti-L. pneumophila Indirect Immunofluorescent IgM, IgG kit. Legionella 1 biochip/verification BIOCHIP slides were used for serogrouping in Euroimmun AG, Leubeck, Germany. Results In index case, L. pneumophila IgM was positive with a titer of 1/32 titer. IgG was negative with a 1/100 titer. Another case (28 year old female), had clinical symptoms identical to the index case. L. pneumophila IgM and IgG were positive with titers of 1/64 and 1/100, respectively. These two cases were diagnosed with Legionnaires' disease caused by L. pneumophila serogroup 12 (index case) and female (28-year-old) by serogroup 11. The other 4 cases were diagnosed with possible Pontiac fever caused by L. pneumophila serogroups 14 (wife of the index case), 4, and 6 whereas the serogroup of L. pneumophila detected in 27 years old female case could not be identified. Conclusion A major limitation of this work is the absence of genotyping and the serogroup difference between index case and his wife who shared the same hotel. We suggest that this serogroup difference may be caused by (for men and women) sitting separately in Islamic rules. On the other hand, the movement of people in the context of mutual visits between countries or neighboring countries for tourism-related (i.e., for religious events or visits to holy sites) or immigration-related reasons, may cause some epidemic diseases. This study reemphasized that not only L. pneumophila serogroup 1, but other rare serogroups might cause also legionellosis which may increase in frequency and cause regional epidemics. We propose that increased financial resources for improving the hygiene conditions and performing routine legionella surveillance studies in touristic hotels would be useful measures for legionellosis prevention and control.