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Multiorgan Failure Secondary to Hemorrhagic Pulmonary Leptospirosis and Treatment With Methylprednisolone Bolus and Open Lung Ventilation FREE TO VIEW

Erick Rendón Ramírez, MD; Jasel Tapia-Orozco, MD; Sergio Sanchez-Salazar, MD; Alexis Herrera-Guerra, MD; Diego Hernandez-Velazquez, MD; Roberto Mercado-Longoria, MD; Perla Colunga-Pedraza, MD; Miguel Flores-Caballero, MD; Hector Ibarra-Sifuentes, MD
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Pulmonary and Critical Care Hospital Universitario UANL, Monterrey, Nuevo León, Mexico; Internal Medicine, Hospital Universitario UANL, Monterrey, Nuevo León, Mexico

Chest. 2015;148(4_MeetingAbstracts):874A. doi:10.1378/chest.2270184
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SESSION TITLE: Pulmonary Manifestations of Systemic Disease Student/Resident Case Report Posters I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Leptospirosis is a zoonosis that can be transmitted from animals to humans. This illness generally presents with an abrupt onset of fever, rigors, myalgias and headache in 75 to 100% of patients, Pulmonary involvement has been reported in 20-70%.

CASE PRESENTATION: We report the case of a 19-year-old man with severe sepsis and respiratory failure. Leptospirosis was suspected because of conjuntival suffusion. Refractary septic shock requiring three vasopressors and intra-alveolar hemorrhage was present. Pulmonary artery catheter (PAC) was placed. Bi-Level Open lung (OL) ventilation was provided with a high PEEP of 35 cm H2O and a low PEEP of 8 cm H2O, a RR of 14 breaths/min, and a time high of 4 seconds. This maneuver was attempted after trying protective lung strategies. Renal, cor pulmonale and hepatic function worsened. Continuous venovenous hemodiafiltration (CVVHDF) and methylprednisolone (MP) was initiated at 1 g/day for five days. Forty-hours after the first dose, ventilatory and multiorgan failure improved with subsequent extubation and discharge from the ICU. The indirect hemaglutination test for qualitative detection of IgM and IgG antibodies for leptospirosis was positive.

DISCUSSION: Alveolar hemorrhage is the leading cause of death in patients with severe disease. The pathogenesis of the pulmonary manifestations is poorly understood, infectious vasculitis is believed to be the cause. Antimicrobial therapy does not improve prognosis or survival after the onset of severe pulmonary symptoms; On this basis, high-dose methylprednisolone have been used in patients with severe pulmonary involvement and no consensus exists about a preferred scheme. Shenoy et al. describe 30 patients with pulmonary leptospirosis, 13 patients did not receive corticosteroids and the remaining 17 received bolus MP, overall mortality was 18% (3/17) in patients who received MP compared with 62% (8/13) in those who did not (p = 0.02). We chose to treat our patient with MP 1 gr/day for 5 days, then tapered to 0.5 mg/kg/day of prednisone five days, and discontinued it in a 10-day period.

CONCLUSIONS: Corticosteroids on the other hand seem to reduce mortality for severe pulmonary manifestation of leptospirosis, and although no randomized trials have been designed to prove its benefit, its use should be considered in alveolar hemorrhage.

Reference #1: Shenoy VV, Nagar VS, Chowdhury AA, Bhalgat PS, Juvale NI. Pulmonary leptospirosis: an excellent response to bolus methylprednisolone. Postgrad Med J. 2006;82(971):602-6.

Reference #2: Kularatne SA, Budagoda BD, de Alwis VK, Wickramasinghe WM, Bandara JM, Pathirage LP, et al. High efficacy of bolus methylprednisolone in severe leptospirosis: a descriptive study in Sri Lanka. Postgrad Med J. 2011;87(1023):13-7.

Reference #3: Trivedi SV, Chavda RK, Wadia PZ, Sheth V, Bhagade PN, Trivedi SP, et al. The role of glucocorticoid pulse therapy in pulmonary involvement in leptospirosis. J Assoc Physicians India. 2001;49:901-3.

DISCLOSURE: The following authors have nothing to disclose: Erick Rendón Ramírez, Perla Colunga-Pedraza, Miguel Flores-Caballero, Jasel Tapia-Orozco, Sergio Sanchez-Salazar, Alexis Herrera-Guerra, Diego Hernandez-Velazquez, Hector Ibarra-Sifuentes, Roberto Mercado-Longoria

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