Unusual Presentation of Multi-organ Failure Leptospirosis without Fever


Dr Swamikannu Murugan, Dr Muhammed Zohaib Ghatala, Dr Anand Sankar S, Dr Jothi Krishnan    27 November 2017

Abstract Leptospirosis is a zoonotic disease of sporadic occurrence caused by bacteria that belongs to the genus Leptospira . Here we report a case of rare form of leptospirosis with multi organ failure called Weil s disease. This patient did not have a fever which is the most common presentation of leptospirosis. Introduction Leptospirosis is a zoonotic disease caused by bacteria that belongs to the genus Leptospira. Leptospira interrogans is pathogenic for humans. The genus can be separated into more than 200 serovars belonging to 23 serogroups 1 . The median global incidence of endemic human lept ospirosis excluding cases due to outbreaks was 5 cases per 100 000 population but in some areas the inci dence was as high as 975 cases per 100 000. The mean annual global incidence of epidemic leptospirosis as reported in outbreak reports was 14 cases per 100 000 population. Some concern was expressed at the signifi cant lack of data especially from Africa and the Eastern Mediterranean Region and at the substantial hetero geneity in the data 2 . Case Report A 68 year old male was brought to our hospital with chief complaints of decreased level of consciousness breathing difficulty and decreased urine output. The patient had a past medical history of asthma and hypertension. He was a non smoker and non alcoholic. Two weeks prior to presentation at our hospital he had an episode of vomiting while running his daily errands and subsequently developed breathing difficulty. He was taken to a nearby hospital where his chest X Ray Figure 1a showed right upper zone patch. During his stay there he was treated with bronchodilators and antibiotics. He progressively became drowsy and his urine output decreased and further evaluation showed a deranged liver and renal functions. He was then referred to our hospital for higher level of care. Vitals in the emergency room at our hospital were notable for a normal temperature pulse rate of 93 min and a blood pressure of 150 100 mmHg. The patient was drowsy but obeying commands with a GCS of 10 15 E4 V2 M4 . He did not have neck stiffness. He did not have a history of fever headache body pain abdominal pain hematuria or melena Ocular examination was notable for scleral icterus. The chest on auscultation revealed crepitation which were greater on the right side and the abdomen was soft and non tender. Initial laboratory study revealed a white blood count of 23 000 ul which was polymorphonuclear predominant poly 78.4 hemoglobin of 11.3 gm platelet of 17 000 ul creatinine of 8.2 mg dl BUN of 194 mg dl total bilirubin of 8.4 mg dl direct bilirubin of 5.7 mg dl AST of 60 U L ALT of 84 U L alkaline phosphatase of 67 U L serum cortisol level was 39.88 ug dl and LDH was 1053 U L. CT scan of his chest showed patchy diffuse bilateral ground glass attenuation with minimal right side pleural effusion Figure 2 . Ultrasound of his abdomen showed bulky and hypoechoic kidneys. The patient was admitted to intensive care unit because of multi organ dysfunction. The possibility of sepsis was considered for which the patient was started meropenem and fluid resuscitation. As the patient was afebrile leptospirosis was an unlikely diagnosis but given his clinical presentation doxycycline was also added to the treatment regimen. The following day the patient s urine output and level consciousness decreased further and he was in uremic encephalopathy with a serum creatinine of 9.2 mg dl and a BUN of 229mg dl. CT brain showed diffuse age related cerebral and cerebellar atrophy and small vessel ischemic disease. The patient was started on dialysis considering his poor renal function. By then his leptospirosis serology test returned positive dengue serology was negative blood culture and urine culture were sterile. The patient was dialysed thrice during this period and there was gradual improvement in his urine output along with improvement in his renal function liver function and platelet counts Figure 3a 3b 3c respectively . Patient was also transfused 2 units of PRBC. Repeat chest X Ray was taken which showed good resolution. Patient was transferred to the wards on the 7th day with improving urine output a progressively improving renal function and a GCS of 15 15. In wards the same line of management was continued with no further need of dialysis. At discharge patient was symptomatically better with a hemoglobin of 8.0 gm platelet count of 181 000 ul serum creatinine of 2.2 mg dl AST of 41 U L ALT of 56 U L total bilirubin of 2.2 mg dl indirect bilirubin or 1.0 mg dl direct bilirubin of 1.2 mg dl and normal Chest X ray Figure 1b . One week after discharge from the hospital the patient s serum creatinine was 1.8 mg dl and hemoglobin was 9.3 gm on follow up visit. Discussion Leptospirosis is the most widespread zoonosis in the world. Tropical countries and low socioeconomic conditions with poor sanitation have particularly been identified as favorable for disease transmission. Human leptospiral infections result primarily from direct or indirect exposure to the urine of infected animals. Rats are the most common reservoir in India. Human infections can occur either by direct contact with infected urine of the infected animal 4 . A retrospective study reported that in patients with leptospirosis the common clinical features included fever 100 headache 75 myalgia 55 arthralgia 45 and vomiting 39 5 .Leptospirosis is usually biphasic. The first phase is the septicemic phase that usually lasts a week. The patient presents with fever headache conjunctival congestion nausea vomiting joint pain and myopathy. This phase is followed by a brief afebrile period of variable duration that in turn is followed by the immune phase of illness. During this phase the patient has multi organ involvement. This severe form of leptospirosis is called Weil s disease. The common organs involved during this phase are the liver kidneys and lungs. Liver involvement leads to elevated liver enzymes and a high total bilirubin. Kidney involvement can give rise to azotemia hematuria uremia and pyuria The patients with lung involvement can present with cough hemoptysis chest pain and shortness of breath pulmonary haemorrhage or ARDS 6 7 . Leptospirosis can present atypically with predominant pulmonary manifestation which normally results in misdiagnosis and hence delayed appropriate treatment 8 . Some of the common differential diagnosis of leptospirosis include dengue malaria encephalitis and scrub typhus. Diagnosis of leptospirosis is based on clinical suspicion and laboratory investigations. The commonly ordered laboratory investigation in a suspected case of leptospirosis at our hospital is detection of leptospirosis IgM antibody by ELISA test. A confirmatory test is microscopic agglutination test MAT although this is not commonly done when there is high suspicion of leptospirosis based on clinical presentation and a positive leptospirosis IgM by ELISA. Leptospirosis can be treated with antibiotics like penicillin doxycycline and ceftriaxone. A Jarisch Herxheimer reaction can occur during the treatment but it is usually mild 1 . It is important to start the treatment early to shorten the hospital stay. A retrospective case control study identified predictors of mortality as age 40 years development of oliguria platelet count 70 000 956 L creatinine 3 mg dl and pulmonary involvement 9 . Mortality rate of Weil s disease is 5 15 . Conclusion Our patient did not present with fever and he did not have the classic symptoms of the septicemic phase of leptospirosis either but because of pulmonary hepatic and renal involvement we had leptospirosis as one of our main differential diagnosis. We wish to emphasize that leptospirosis should be considered as a differential diagnosis in tropical countries when a patient presents with multi organ failure or fever of greater than 3 days duration without an obvious cause. Reference 1. 20th Edition of Davidson s Principles and Practise of Medicine Page no. 321 2. WHO Report of the Second Meeting of the Leptospirosis Burden Epidemiology Reference group Page no. 12 3. Elizabeth F. Daher Rafael S.A. Lima Geraldo B. Silva J nior Eveline C. Silva Nahme N.N. Karbage Raquel S. Kataoka Paulo C. Carvalho J nior Max M. Magalh es R osa M.S. Mota Alexandre B. Lib rio The Brazilian Journal of Infectious Diseases Volume 14 Issue 1 Pages 3 10 4. Indian J Crit Care Med. 2013 Jan Feb 17 1 43 45 Multivisceral organ failure related to leptospirosis in pregnant patient Sbai Hicham Mellouki ihsane 1 El Bouazzaoui Abderahim Boukatta Brahim Smail Labib Harrandou Mustapha Khatouf Mohamed Ibrahimi Adil 1 Melhouf Abdelilah 2 and Kanjaa Nabil 5. Postgrad Med 2005 51 179 83 Unusual Clinical Manifestations of Leptospirosis Bal AM 6. J Postgrad Med 2005 51 179 83 Unusual Clinical Manifestations of Leptospirosis by Bal AM 7. Journal of Medical Case Reports 2011 5 7 Fulminant Leptospirosis Weil s disease in an urban setting as an overlooked cause of multiorgan failure a case report Elias Maroun Anurag Kushawaha Elie El Charabaty Neville Mobarakai and Suzanne El Sayegh 8. Gulati S Gulati A. Pulmonary manifestations of leptospirosis. Lung India 2012 29 347 53 9. Marotto PC Nascimento CM Eluf Neto J Marotto MS Andrade L Sztajnbok J et al. Acute lung injury in leptospirosis Clinical and laboratory features outcome and factors associated with mortality. Clin Infect Dis 1999 29 1561 3

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