INTRODUCTION: Leptospirosis and Hepatitis E are zoonotic diseases of global distribution. It is endemic in tropical and sub-tropical climates. In non-endemic areas it is associated with occupational and recreational activities. The presentation is highly variable with progression to multiple organ failure (MOF) and acute respiratory distress syndrome (ARDS) in some cases. In non-endemic areas, Hepatitis E accounts for < 1 percent of all cases. We report a rare non-endemic co-infection of Leptospira with Hepatitis E.
CASE PRESENTATION: 30 years old male construction worker and smoker with no prior medical history, presented to ER with fever of 101 F, chills, body aches, headache, weakness, nausea, vomiting, abdominal cramps and diarrhea of 2 days duration, diaphoresis, myalgias, joint pain. Exam was remarkable for: normal vitals signs, conjunctival erythema, mild jaundice, dry pale mucosas, purpural over both lower extremities, abdominal tenderness and hepatomegaly. Abnormal laboratory findings included mild transaminitis, total Bilirubin 1.8 mg/dl, thrombocytopenia 74k, WBC 16.8, BUN/Creatinine 42/1.4. CXR was normal. He was admitted with a presumptive diagnosis of hepatitis. Clinical course deteriorated with worsening of liver, renal and hematological function (Table 1). There was a disproportionate increase in bilibubin, 26.9 with marginal increase in transaminitis. Hematocrit decreased from 36.5 to 22.1 and platelets from 74 to 29. INR was unchanged. Work up for DIC and hemolysis was negative. Renal function worsened (BUN/Creat 96/6.9). Serological markers for Rickettsia, Babesia, Dengue, Malaria, Leptospira and Hepatitis E were requested. He was transferred to ICU on day 4 and course was remarkable for septic shock, ARDS and MOF. He was started on Penicillin and Doxycycline for suspected Leptospirosis. CXR showed extensive bilateral infiltrates, bronchoscopy revealed mucus plugs and was negative for an infectious process or alveolar hemorrhage. He was transfused with blood products. His condition improved and by the 19th day, he was off pressors and was subsequently weaned and extubated. He did not require RRT. Antibodies for Leptospira and Hepatitis E IgM were positive and Rickettsia, Babesia, Dengue, Malaria, was negative. On follow up two weeks later he is asymptomatic with improving biochemical parameters and normal CXR.
DISCUSSIONS: Acute fever in an urban, multiethnic city may be a diagnostic challenge especially in the setting of MOF. Malaria, Dengue (with travel history), viral hepatitis, and noninfectious disorders form the differential diagnosis. Leptospirosis can present as an anicteric febrile disease or as a more serious Weil's disease, with hepato-renal involvement and MOF. Infected rodent urine is the usual source. ARDS in Leptospirosis is seen more commonly with spontaneous pulmonary hemorrhage syndrome and is managed with NIH protocol. Hepatitis E is uncommon in US and is mainly associated with travel history. However rodent populations as a source of contamination for Hepatitis E in urban areas is documented with prevalence of antibodies demonstrated among rodents in US. Our patient is unique because he had two rare concurrent infections and developed septic shock and ARDS, very rare complications of Leptospirosis. His renal function recovered completely without dialysis. Our patient, a construction worker probably had an occupational exposure to both Leptospira and Hepatitis E from the same contaminated source, as he had no history of travel.
CONCLUSION: Awareness of this febrile illness in non-endemic areas is important for clinicians since clinical presentation may vary and its association with others infectious diseases is possible. Obtaining complete history that includes occupational, recreational and travel information is fundamental in the evaluation of febrile illness. Early recognition and therapy are important in order to decrease morbidity and mortality of these cases.
DISCLOSURE: Jorge Cos, No Financial Disclosure Information; No Product/Research Disclosure Information