An Infectious Cause of Liver Dysfunction and Rhabdomyolysis

Abstract

Introduction: Leptospirosis is a widespread zoonotic disease. Human infection occurs from exposure to environmental sources, such as animal urine, contaminated water or soil, or infected animal tissue. Most cases of leptospirosis are mild to moderate but when severe, case fatality rate can be as high as 50%. We present a case of leptospirosis which presented as nonspecific symptoms, elevated liver enzymes, hyperbilirubinemia and rhabdomyolysis. Case presentation: A 40 year old male, referred to our hepatologist for further workup of transaminitis and hyperbilirubinemia. His symptoms started 5 days prior to presentation as arthralgias, fevers, chills, night sweats, generalized weakness and coffee colored urine which progressively got worse. He denied exposure to sick contacts, recent medication changes, illegal substance abuse or high risk sexual behavior. He denied any animal bites including ticks or exposure to animal waste.Vital signs were stable. Laboratory testing demonstrated an indirect and direct hyperbilirubinemia, elevated liver enzymes (ALT 247 and AST 721), normal alkaline phosphatase, INR of 1.2 suggesting a hepatocellular injury. Urine analysis showed large blood. His CK was elevated at 17,911 suggesting rhabdomyolysis. Acute hepatitis panel, HIV, CMV, HSV type 1 and 2, FANA were negative. A respiratory viral panel including Influenza A and B was negative. EBV serology suggested past infection. Acetaminophen level and ammonia level were checked and were normal, urine drug screen was normal. CT abdomen and pelvis showed a few prominent lymph nodes in the retroperitoneum and inguinal region. RUQ US was normal other than mild fatty changes in the liver. On further questioning into other etiologies of liver dysfunction, he reported that he swam frequently at a nearby lake. Leptospira IgM was ordered, which came back positive. Patient was started on doxycycline. Discussion: As clinical and laboratory findings are nonspecific a high index of suspicion is required to make the diagnosis of leptospirosis based on epidemiologic exposure and clinical manifestations. Transaminitis can occur in up to 40% cases, usually < 200. In our case liver enzymes were much higher secondary to rhabdomyolysis which was caused by leptospirosis. Oral doxycycline is used for mild illness and intravenous penicillin or ceftriaxone are used for severe illness. Prevention measures include avoiding potential sources of infection and animal vaccination.