Thanks to Hengameh and Max for presenting a very interesting case of a 66M with CLL, cutaneous eosinophilic syndrome who presented with dyspnea, cough and diarrhea found to have hyponatremia, hypophosphatemia and an elevated CK concerning for legionella!
1. Gerald Hsu taught use a lot about CLL. It is a disorder of mature lymphocytes [CD 5 positive, smudge cells] and has a wide clinical spectrum ranging from an asymptomatic benign disease to an aggressive lymphoma with potential for transformation to a diffuse large B cell lymphoma.
2. In patients who truly have sudden onset of symptoms, consider  rupture of blood vessel/hollow viscus  Perforation of blood vessel/hollow viscus or  electrical [arrhythmia/seizure]
3. Legionella is a mutlisystem disorder that frequently causes pneumonia. High fever, relative bradycardia, CNS sx, GI sx, hyponatremia, hypophosphatemia and an elevated CK are also clues to the presence of legionella.
4. In a febrile patient, for each degree fahrenheit increase in temperature an increase of 10 beats/min in the HR is expected. Relative bradycardia refers to a less than expected pulse in a febrile patient. Beta-blockers are the most common cause. In the absence of these medications, infection by intracellular organisms [including Legionella!] or non-infectious fever are possible.
Here’s a short evernote about CLL.
Evernote about legionella:
Sudden onset of Symptoms
- Physiologically, for each degree fahrenheit increase in temperature, there should be a 10 beat/min increase in HR.
- However, this only applies for temperatures >102F
- Patients with conduction system disease or AV block blockade are excluded.
Official criteria + expected values
Note the propensity for intracellular organisms.