A seasonal disease out of season

Abstract

Objective: The description of this clinical case aims to raise awareness among internists to the fact that the typically known seasonal disease may rarely present it outside the “regular époque”. Methods: Clinical case of a febrile syndrome with bright liquor meningitis, epidemiology, pathophysiology and differential diagnosis. Results: Woman aged 54 years old who is a farmer with a pathological history of gastric ulcer. The patient recurs to the Emergency Service on 9/12/12 by severe myalgias, high fever, vomiting and diarrhea with 7 days of evolution. Objectively, at the entry, the patient was feverish, with a positive meningeal signs (Kernig and Brudzinski), a dried mucousis, a sub-jaundice and an abdominal pain. Analytically, she presented an anemia (10.3 g/dL), 19,000 platelets, creatinine of 1.0 mg/dL, urea 33 mg/dL, direct bilirubine, LDH 626 IU/L, liver citocolestase (increase of GOT/GPT and GGT/AP) and 12.6 mg/dL PCR. Urine 2 with proteinuria was 20 mg/dL. Abdominal ultrasound: the spleen dimensions were around the upper limit of normal. At admission, a lumbar puncture was performed (cytology — 247 cells per mm3, 60% mononuclear cells; biochemistry — limpid aspect with no other changes; microbiology — negative) and an empirical doxycycline was started. On the persistence of symptoms, by the 4th day of doxycycline a vancomycin, acyclovir, ceftriaxone, and dexamethasone was associated which resulted on a symptom and a laboratorial improvement. Immunology: Leptospira Ab. IgM 79 and IgG > 100 U/mL. The patient was asymptomatically discharged with guidance for consultation. Conclusions: Leptospirosis is an infectious fever, whose spectrum can vary from an unapparent process to severe forms (S. Weil). It is a zoonosis with an especially manifestation in late summer and early autumn, but for our “wonder” it occurred in winter. A patient with febrile syndrome may present headache. However, the positivity of meningeal signs (excluding “meningism” fever) imposes us to perform a lumbar puncture.