2012 Legionellosis ABCs Case Report

20

23. UNDERLYING CAUSES OR PRIOR ILLNESSES: (Check all that apply OR if NONE or CHART UNAVAILABLE, check appropriate box) 1
1
1
1
1
1
1
1
1
1
1
1

AIDS or CD4 count <200
Alcohol Abuse
Asthma
Atherosclerotic Cardiovascular Disease (ASCVD)/CAD
Bone Marrow Transplant (BMT)
Cerebral Vascular Accident (CVA)/Stroke
Chronic Renal Insufficiency
Cirrhosis/Liver Failure
Complement Deficiency
Current Smoker
Dementia
Legionella Test

Was this test ordered?
1
2
9

24. Urine Antigen, EIA

1
2
9

25. Culture

26. Paired Serology, IFA
or ELISA

27. PCR
(direct specimen only)

28. DFA
(direct fluorescence
assay, direct
specimen only)

Diabetes Mellitus
Dysphagia
Emphysema/COPD
Former Smoker
Heart Failure/CHF
HIV Infection
Hodgkin’s Disease/Lymphoma
Immunoglobulin Deficiency
Immunosuppressive Therapy
(Steroids, Chemotherapy, Radiation)
IVDU

1

Date Collected

Yes
No
Unknown

/

Yes
No
Unknown

/

/

Acute

Convalescent
1 Yes
2 No
9 Unknown

Convalescent

1
2
9

1
2
9

/

/

Yes
No
Unknown

/

Yes
No
Unknown

/

Yes
No
Unknown

/

1
1
1
1
1
1
1
1
1
1

1

Unknown
Renal Failure/Dialysis
Seizure/Seizure Disorder
Sickle Cell Anemia
Solid Organ Malignancy
Solid Organ Transplant
Splenectomy/Asplenia
Systemic Lupus Erythematosus (SLE)
Other (specify) __________________

Result
1
2
9

1 Sputum
2 BAL/bronchial washing
3 Lung tissue
4 Pleural fluid
5 Blood
8 Other (specify)
________________________

/

/

/

1 Sputum
2 BAL/bronchial washing
3 Lung tissue
4 Pleural fluid
5 Blood
8 Other (specify)
________________________

/

1 Sputum
2 BAL/bronchial washing
3 Lung tissue
4 Pleural fluid
5 Blood
8 Other (specify)
________________________

/

None

Leukemia
1
Multiple Myeloma
1
Multiple Sclerosis
1
Nephrotic Syndrome
1
Neuromuscular Disorder
1
Obesity
1
Parkinson’s Disease
1
Peripheral Neuropathy
1
Plegias/Paralysis
Premature Birth (specify gestational age
at birth)
(wks)

Site

/

Acute
1 Yes
2 No
9 Unknown

1
2
9

29. IHC
(immunohistochemistry)

1
1
1
1
1
1
1
1
1

1 Sputum
2 BAL/bronchial washing
3 Lung tissue
4 Pleural fluid
5 Blood
8 Other (specify)
________________________

Species

Positive
Negative
Unknown or Indeterminate
1

1
2
9

Positive
Negative
Unknown or Indeterminate

2
8
9

L. pneumophila
If yes, list serogroup:
1 serogroup 1
8 Other (specify) _________________
9 Unknown
L. species (non-pneumophila)
Other (specify)____________________
Unknown or not specified

Acute
1 Positive
If yes, titer: ____________
2 Negative
9 Unknown or Indeterminate

Acute
Species: _____________________________

Convalescent
1 Positive
If yes, titer: ____________
2 Negative
9 Unknown or Indeterminate

Convalescent
Species: _____________________________

1
2
9

1
2
9

Positive
Negative
Unknown or Indeterminate

Positive
Negative
Unknown or Indeterminate

Serogroup(s): ________________________

Serogroup(s): ________________________

1
2
8
9

L. pneumophila
L. species (non-pneumophila)
Other (specify) ____________________
Unknown or not specified

1

L. pneumophila
If yes, list serogroup:
1 serogroup 1
8 Other (specify) _________________
9 Unknown
L. species (non-pneumophila)
Other (specify)____________________
Unknown or not specified

2
8
9
1

1
2
9

Positive
Negative
Unknown or Indeterminate

2
8
9

L. pneumophila
If yes, list serogroup:
1 serogroup 1
8 Other (specify) _________________
9 Unknown
L. species (non-pneumophila)
Other (specify)____________________
Unknown or not specified

30. COMMENTS:

– SURVEILLANCE OFFICE USE ONLY –
32. Was this case also identified
31. Was case first
through routine passive notifiable
identified through
disease surveillance?
audit?
1

Yes 2

9

Unknown

No

1

Yes 2

No 9

Unknown

33. CRF Status:
1
2
3
4

34. Does this case have
recurrent disease?
Complete
Incomplete
1 Yes 2
No 9
Unknown
Edited & Correct
If yes, previous (1st) state ID:
Chart unavailable
after 3 requests

35. Case status:
1 Confirmed
2

Mo.

Day

37. Initials of
S.O.:

Suspect
Year

Submitted By:

Phone No. : (

)

Physician’s Name:

Phone No. : (

)

CDC 52.15C REV. 01-2012

36. Date reported to EIP site:

– LEGIONELLOSIS ACTIVE BACTERIAL CORE SURVEILLANCE CASE REPORT –

Date:

/

/

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