A FATAL CASE OF PULMONARY HEMORRHAGE: RARE MANIFESTATION OF LEPTOSPIROSIS

Abstract

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Leptospirosis can cause multi-organ failure and adult respiratory distress syndrome. Clinical suspicion is the key to diagnosis. A detailed social history is superior to serum and radiological investigation to prevent mortality. CASE PRESENTATION: A 41-year-old man presented to the hospital with diffuse muscle pain and chills for 3-weeks. He worked as a waste-water worker in New York City. On arrival, he had a temperature of 100.8 F, heart rate 94/min, blood pressure 102/67 mmHg, respiratory rate 21/min. Initial blood tests showed platelet count of 90,000 k/ul, serum creatinine 3.7 mg/dl, BUN 67 mg/dl, ALT 78 u/l, AST 101 u/l and total bilirubin of 6.9 mg/dl. Chest X-ray showed mild diffuse interstitial infiltrates. He was admitted to the medical floor for management of presumed bacterial pneumonia. Broad-spectrum antimicrobials therapy with intravenous vancomycin and cefepime was initiated. One week into inpatient stay, his clinical condition deteriorated with worsening hypoxemia along with worsening renal and liver function tests. Blood cultures, sputum cultures, and COVID-19 PCR tests were negative. CT Chest was performed which showed extensive ground-glass opacities with interstitial thickening in both lungs. He had worsening hypoxemia requiring mechanical ventilation and septic shock requiring vasopressors. Bronchoscopy was performed that showed diffuse endobronchial and alveolar hemorrhage. Based on his social history, empiric treatment with doxycycline was begun and serology for leptospirosis was ordered which resulted in positive. After 9-days of mechanical ventilation and renal replacement therapy, he recovered and was discharged home. DISCUSSION: Leptospirosis disease is caused by Leptospira interrogans which is transmitted from the urine of wild animals and it can cause multi-organ involvement by initiating a cytokine storm.(1) Severe pulmonary hemorrhage syndrome (SPHS) can present as cough, massive hemoptysis, and is associated with circulatory collapse.(2) Chest radiography can show a wide variety of nodular infiltrates, ground glass opacifications, or multifocal consolidations which make the diagnosis difficult.(3) In non-endemic areas, clinical suspicion and social history play a pivotal role in the diagnosis. Suspected cases should be confirmed with serology (microscopic agglutination test). Mild disease is treated with tetracycline, while IV penicillin or ceftriaxone are preferred for severe disease, however beneficial effects are limited once organ dysfunction is progressed.(1) CONCLUSIONS: Due to the severity of Leptospirosis, the diagnosis should be made based on social history and a disproportionate rise of bilirubin. The mortality rate is significantly high in cases of pulmonary hemorrhage. Early treatment with antimicrobials is needed while serology testing is being performed. REFERENCE #1: Haake DA, Levett PN. Leptospirosis in humans. Curr Top Microbiol Immunol. 2015;387:65-97. doi:10.1007/978-3-662-45059-8_5 REFERENCE #2: Gouveia EL, Metcalfe J, De Carvalho ALF, et al. Leptospirosis-associated severe pulmonary hemorrhagic syndrome, Salvador, Brazil. Emerg Infect Dis. 2008;14(3):505-508. doi:10.3201/eid1403.071064 REFERENCE #3: Marchiori E, Lourenço S, Setúbal S, Zanetti G, Gasparetto TD, Hochhegger B. Clinical and imaging manifestations of hemorrhagic pulmonary leptospirosis: A state-of-the-art review. Lung. 2011;189(1):1-9. doi:10.1007/s00408-010-9273-0 DISCLOSURES: No relevant relationships by Ahad Azeem, source=Web Response No relevant relationships by Manasa Velagapudi, source=Web Response