Leptospirosis is a zoonotic disease usually found in developing nations, but infrequently encountered in the U.S. We report the case of a returning traveler with multi-organ dysfunction found to have Weil’s disease, the most severe form of leptospirosis.
A 38 year-old healthy male presented to a local emergency department complaining of a five day history of fevers, chills, malaise, frontal headaches, and dark-colored urine. The patient had previously been vacationing in northern Jamaica about 4 weeks prior to presentation, where he had spent time swimming in local lakes. CXR was notable for an infiltrate and he was started on ceftriaxone and azithromycin. He was subsequently transferred to UAB, where initial oxygen saturation on room air was 85% and physical exam was notable for jaundiced skin and icteric sclera. Labs on transfer were notable for WBC of 2.82 (differential 86% neutrophils, 10% lymphocytes), Hgb/HCT 10/29, Platelets of 14. Chemistry revealed BUN/Creatinine 28/3.1, and liver panel showed T bili 6.6 (direct 4.4, indirect 2.2), and ALT/AST 103/144 respectively. Initial antimicrobials included ceftriaxone and doxycycline. The patient had an increasing oxygen requirement, and subsequent CT chest revealed diffuse peribronchovascular nodular alveolar opacities with small bilateral pleural effusions. Abelcet was started at that time to include coverage for histoplasmosis. Intubation for hypoxic respiratory failure was soon required, and BAL from bronchoscopy showed progressively bloodier aliquots. Empiric Solumedrol at 125 mg every 6 hours was begun. Transbronchial biopsy revealed only intra-alveolar hemorrhage, with negative AFB and GMS stains. He slowly improved over the next few days, and was able to be extubated with return of normal kidney and liver function. After discharge from the hospital he returned to his normal state of health. Although initial leptospirosis serology was negative on admission, a repeat specimen sent to the CDC at hospital day 10 was positive, with a positive confirmatory microscopic agglutination test.
Leptospirosis is caused by the spirochete Leptospira interrogans, which is distributed world-wide. The highest incidence occurs in tropical and sub-tropical regions. Animals, particularly rodents, can become colonized with Leptospira and shed the organism in urine which can contaminate soil or water leading to human infection. Clinical presentation includes the non-specific symptoms of fevers, headaches, and chills. Weil’s disease is the most severe manifestation of the disease, characterized by jaundice (with elevation of serum bilirubin elevated out of proportion to ALT/AST), acute renal failure, and thrombocytopenia. Pulmonary manifestations range from cough and dyspnea to hemoptysis. Imaging of the chest frequently reveals patchy infiltrates or consolidation, with occasional pleural effusions.
Although infrequently encountered in the U.S., leptospirosis should be considered in patients with multi-organ dysfunction who have a travel history to endemic areas.
Paul Perry, No Financial Disclosure Information; No Product/Research Disclosure Information