Case history

Case history #1

A 17-year-old boy was admitted to a hospital in Brazil with 4 days of fevers, headaches, and myalgias and 2 days of diarrhea, abdominal pain, and prostration. Two weeks prior to admission, he reported falling into an open sewer during a flood and suffering lacerations. On hospital admission, the patient had a fever of 102.6°F (39.2ºC) and on physical examination, was found to be anicteric and have conjunctival suffusion, scant rales, hepatomegaly, and severe abdominal wall and calf tenderness. Laboratory examination showed leukocytosis, mildly elevated liver aminotransferases, an elevated creatinine of an elevated creatinine of 2.5 mg/dL (221 micromol/L), and hypokalemia. Within the next 24 hours, despite intravenous antibiotic and supportive therapy, the patient developed hypoxemic respiratory failure and oliguric renal insufficiency. On day 2 of the hospital admission he developed respiratory distress; he was noted to have a pH of 7.34, became oliguric with a rising creatine, and required intraperitoneal dialysis. On day 3 of hospital admission, he was intubated for severe respiratory distress, with a pH of 7.3, PaO₂ 55, and PaCO₂ 62 on FiO₂ 100%; following endotracheal intubation, he developed massive bleeding and hypotensive shock, and died. Blood and urine cultures were unrevealing and microscopic agglutination test (MAT) was negative; however, the diagnosis of leptospirosis was confirmed by polymerase chain reaction.

Case history #2

A 42-year-old man presented to the emergency department complaining of anorexia, fever, malaise, headaches, retro-orbital pain, and myalgia of 4 days' evolution. He denied recent travel or contact with animals; he works harvesting fruit on a local farm. The patient stated that, during the preceding 14 days, he was working after heavy rainfall. Physical exam disclosed a nonpruritic morbilliform rash on the trunk, bilateral conjunctival suffusion, and lacerations in the upper extremities. Laboratory examination showed leukocytosis, anemia, and elevated liver aminotransferases. During his hospital admission, the patient developed pancreatitis as a complication, manifesting with intractable vomiting and abdominal pain. Amylase and lipase were significantly elevated. Diagnosis was made using MAT, which confirmed suspicion of leptospirosis.

Other presentations

Aseptic meningitis is a common manifestation during the immune phase of the disease; its incidence is approximately 25%.[6][7] Symptoms invariably include headache, mental status changes, and fever. However, in a minority of patients, neurologic involvement can present with a spectrum of unusual manifestations, such as coma, meningoencephalitis, transverse myelitis, hemiplegia, and Guillain-Barre syndrome.[1] Symptoms include restlessness, confusion, hallucinations, delirium, and psychotic behavior. A small proportion of patients develop acute pancreatitis as a complication, which can be fatal.[8] One case of leptospirosis with clinical features of nephrotic syndrome with massive proteinuria has been reported.[9]

Certain patient populations, such as older adults and pregnant women, have a higher risk of developing severe disease as a result of leptospiral infection. During pregnancy, fetuses can acquire infection during the acute/initial phase through placental transmission, which can lead to fetal death.[10] Women are more likely to have a spontaneous abortion if leptospirosis occurs early in pregnancy.[11] Fetuses are at risk of morbidity and mortality if the mother has high fever or marked hemodynamic disturbances.[12] Older adults may be at increased risk for more severe infection, and patients in this age group who develop Weil disease have a high mortality.[5] Infection in immunocompromised individuals can be more severe and lead to cardiovascular complications, including heart block, although this is a very rare presentation.[13]

Coinfections can occur with leptospirosis, including dengue, malaria, rickettsia, scrub typhus, and HIV.[14][15][16][17][18] Patients with leptospirosis and malaria coinfection can have a severe illness and develop hepatorenal dysfunction.[19] The clinical diagnosis of leptospirosis in tropical areas is often challenging, given that the clinical manifestations of leptospirosis are often indistinguishable from other endemic infections.[20]

Use of this content is subject to our disclaimer