Fulminant Leptospirosis as a Cause of Multiorgan Failure
Fulminant Leptospirosis as a Cause of Multiorgan Failure
A 49 year-old man of Chinese descent with no medical history presented in mid-January to our hospital for a history of fever (102.5°F), myalgias, and severe bilateral calf pain that began six days prior.
He had a 30 pack-year history of cigarette smoking, drank four to six beers almost every day for two years and smoked marijuana occasionally. He denied recent travel, owned two healthy pets and worked as a construction worker. The patient denied any recent travel outside the USA. He denied recent antibiotic exposure or sick contacts.
Vital signs in the emergency department were notable for a temperature of 101°F, pulse of 120 beats/min and blood pressure of 156/63 mm Hg. The patient was alert and oriented. The ocular examination was notable for scleral icterus. The skin appeared jaundiced, the lungs were clear to auscultation, the abdomen was soft, bilateral lower extremity tenderness was noted and dorsal pedal pulses were present bilaterally.
Initial laboratory study results were notable for a creatinine of 2.3 mg/dL, platelets of 58,000 cells/mm, hemoglobin of 12.8 G/dL, white blood cell count of 8.9 × 10 cells/mm with lymphopenia of 2.4%, total bilirubin of 4.3 mg/dL, direct bilirubin of 2.6 mg/dL, alkaline phosphatase (ALP) of 143 U/L, aspartate aminotransferase (AST) of 201 U/L, alanine aminotransferase (ALT) of 246 U/L, and creatine kinase of 1219 U/L. The urine analysis showed moderate hematuria but no proteinuria. Results of lower extremity Doppler ultrasonography and chest radiography were negative, and electrocardiography showed normal sinus rhythm at 76 beats/min.
The patient was admitted to the intensive care unit for sepsis and multiorgan dysfunction. Intravenous (IV) ceftriaxone and vancomycin were initiated with aggressive fluid resuscitation.
The following day, the patient's acute renal failure, hyperbilirubinemia, anemia and thrombocytopenia worsened. Serologic test results for acute hepatitis A, B and C infections were negative. A peripheral smear showed no schistocytes. Levels of C3, C4, antinuclear antibodies, anti-dsDNA, antineutrophil cytoplasmic antibodies, and anti-glomerular basement membrane antibodies were within normal limits. Renal ultrasonography results were normal. Computed tomography of the abdomen showed pancolitis, cholelithiasis and nephromegaly.
On the third day, the patient had worsening oxygenation with slight hemoptysis and developed new inferior bilateral infiltrates. Physical examination revealed the development of fine crackles at the bases of his lungs. Arterial blood gas on 2 L of oxygen revealed a pH of 7.45, PCO2 (partial pressure of carbon dioxide) of 28, PO2 (partial pressure of oxygen) of 55, oxygen saturation of 90% and bicarbonate of 19.5. The antibiotic regimen was broadened to IV cefepime, and vancomycin was continued. The right upper quadrant sonogram showed thickening of the gallbladder wall. Urine legionella antigen and serum HIV antibody results were negative. Initial blood cultures and sputum culture results were negative. The patient's acute renal failure, hyperbilirubinemia, anemia and thrombocytopenia continued to deteriorate. The patient was started on 125 mg of methylprednisone every six hours for five days and desmopressin for suspicion of alveolar hemorrhage in the presence of renal failure.
On the fourth hospital day, a nasopharyngeal swab for influenza A was conducted, and results were positive. All antibiotics were stopped, and the patient received one dose of oseltamivir. The patient's clinical status and renal failure started to improve, but the cholestatic picture was worsening, with a total bilirubin of 64.7 mg/dL, direct bilirubin of 44.8 mg/dL, AST of 87 U/L and ALT of 121 U/L.
On the fifth day, the patient developed a maculopapular, nonpruritic rash on the face, torso, abdomen and upper extremities involving the palms. Biopsy was done and showed lichenoid dermatitis (drug reaction). Serum leptospira antibodies were sent to the NYC Board of Health for specialized testing. While the patient was taking corticosteroids, the hyperbilirubinemia, thrombocytopenia, hemoptysis and renal failure resolved over the next few days. The final laboratory study results were notable for a creatinine of 0.8 mg/dL, total bilirubin of 1.8 mg/dL and platelets of 165 cells/mm. There was a near complete resolution of the chest radiography findings. Furthermore, the rash and the patient's calf pain gradually improved, and the patient was subsequently discharged.
Two weeks later, the NYC Board of Health reported the antibodies for leptospira as positive. A microagglutination test (MAT) confirmed the serovar Leptospira icterohaemorrhagiae, with the titers 1:6400. The patient was recalled for insertion of an indwelling catheter for a 14-day course of IV ceftriaxone after which he improved. Retrospectively, after having been asked about any epidemiologic factors that placed him at risk for contracting leptospirosis, the patient admitted to having been in contact with rat urine with his bare hands at a construction site in NYC.
Case Presentation
A 49 year-old man of Chinese descent with no medical history presented in mid-January to our hospital for a history of fever (102.5°F), myalgias, and severe bilateral calf pain that began six days prior.
He had a 30 pack-year history of cigarette smoking, drank four to six beers almost every day for two years and smoked marijuana occasionally. He denied recent travel, owned two healthy pets and worked as a construction worker. The patient denied any recent travel outside the USA. He denied recent antibiotic exposure or sick contacts.
Vital signs in the emergency department were notable for a temperature of 101°F, pulse of 120 beats/min and blood pressure of 156/63 mm Hg. The patient was alert and oriented. The ocular examination was notable for scleral icterus. The skin appeared jaundiced, the lungs were clear to auscultation, the abdomen was soft, bilateral lower extremity tenderness was noted and dorsal pedal pulses were present bilaterally.
Initial laboratory study results were notable for a creatinine of 2.3 mg/dL, platelets of 58,000 cells/mm, hemoglobin of 12.8 G/dL, white blood cell count of 8.9 × 10 cells/mm with lymphopenia of 2.4%, total bilirubin of 4.3 mg/dL, direct bilirubin of 2.6 mg/dL, alkaline phosphatase (ALP) of 143 U/L, aspartate aminotransferase (AST) of 201 U/L, alanine aminotransferase (ALT) of 246 U/L, and creatine kinase of 1219 U/L. The urine analysis showed moderate hematuria but no proteinuria. Results of lower extremity Doppler ultrasonography and chest radiography were negative, and electrocardiography showed normal sinus rhythm at 76 beats/min.
The patient was admitted to the intensive care unit for sepsis and multiorgan dysfunction. Intravenous (IV) ceftriaxone and vancomycin were initiated with aggressive fluid resuscitation.
The following day, the patient's acute renal failure, hyperbilirubinemia, anemia and thrombocytopenia worsened. Serologic test results for acute hepatitis A, B and C infections were negative. A peripheral smear showed no schistocytes. Levels of C3, C4, antinuclear antibodies, anti-dsDNA, antineutrophil cytoplasmic antibodies, and anti-glomerular basement membrane antibodies were within normal limits. Renal ultrasonography results were normal. Computed tomography of the abdomen showed pancolitis, cholelithiasis and nephromegaly.
On the third day, the patient had worsening oxygenation with slight hemoptysis and developed new inferior bilateral infiltrates. Physical examination revealed the development of fine crackles at the bases of his lungs. Arterial blood gas on 2 L of oxygen revealed a pH of 7.45, PCO2 (partial pressure of carbon dioxide) of 28, PO2 (partial pressure of oxygen) of 55, oxygen saturation of 90% and bicarbonate of 19.5. The antibiotic regimen was broadened to IV cefepime, and vancomycin was continued. The right upper quadrant sonogram showed thickening of the gallbladder wall. Urine legionella antigen and serum HIV antibody results were negative. Initial blood cultures and sputum culture results were negative. The patient's acute renal failure, hyperbilirubinemia, anemia and thrombocytopenia continued to deteriorate. The patient was started on 125 mg of methylprednisone every six hours for five days and desmopressin for suspicion of alveolar hemorrhage in the presence of renal failure.
On the fourth hospital day, a nasopharyngeal swab for influenza A was conducted, and results were positive. All antibiotics were stopped, and the patient received one dose of oseltamivir. The patient's clinical status and renal failure started to improve, but the cholestatic picture was worsening, with a total bilirubin of 64.7 mg/dL, direct bilirubin of 44.8 mg/dL, AST of 87 U/L and ALT of 121 U/L.
On the fifth day, the patient developed a maculopapular, nonpruritic rash on the face, torso, abdomen and upper extremities involving the palms. Biopsy was done and showed lichenoid dermatitis (drug reaction). Serum leptospira antibodies were sent to the NYC Board of Health for specialized testing. While the patient was taking corticosteroids, the hyperbilirubinemia, thrombocytopenia, hemoptysis and renal failure resolved over the next few days. The final laboratory study results were notable for a creatinine of 0.8 mg/dL, total bilirubin of 1.8 mg/dL and platelets of 165 cells/mm. There was a near complete resolution of the chest radiography findings. Furthermore, the rash and the patient's calf pain gradually improved, and the patient was subsequently discharged.
Two weeks later, the NYC Board of Health reported the antibodies for leptospira as positive. A microagglutination test (MAT) confirmed the serovar Leptospira icterohaemorrhagiae, with the titers 1:6400. The patient was recalled for insertion of an indwelling catheter for a 14-day course of IV ceftriaxone after which he improved. Retrospectively, after having been asked about any epidemiologic factors that placed him at risk for contracting leptospirosis, the patient admitted to having been in contact with rat urine with his bare hands at a construction site in NYC.
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