Case Presentation: A 48 year-old man presented with one day of headache and pain in his low back, buttocks, calves, thighs and arms after days of strenuous yardwork, including digging in soil to move pipes. He took infrequent breaks, felt overheated, and had inadequate fluid intake. He had bilateral subconjunctival hemorrhage, tachycardia, tachypnea with accessory muscle use, and tenderness to palpation of large muscle groups. Creatinine was 3.9 mg/dL, white blood cells were 14.5 K/µL, platelets were 111 K/µL, total bilirubin was 8.4 mg/dL, and creatine kinase (CK) was 8500 U/L. He was admitted for rhabdomyolysis and acute kidney injury. Within one day, he had worsening cough and new hypoxia. Chest x-ray demonstrated progression of bilateral pulmonary infiltrates. Labs revealed a rising creatinine, worsening hyperbilirubinemia, troponin of 1.1 ng/mL, platelets of 46 K/µL, and CK of 6895 U/L. The patient developed multiorgan failure and was transferred to the intensive care unit requiring vasopressors and continuous renal replacement therapy. Subsequently, his organ dysfunction improved. Infectious work-up was notable for a positive Leptospira IgM. He was diagnosed with Leptospirosis and the associated Weil syndrome. He was discharged to complete a 10-day course of doxycycline.
Discussion: Leptospirosis is an infection caused by the spirochete Leptospira and is transmitted via direct exposure to urine of infected animals or contaminated soil or water, as was suspected in this case. More common in tropical climates, only 100-200 cases are documented in the United States annually. Leptospira invade nonintact skin and mucous membranes. Once inoculated, the bacteria travel into the lymphatics and can cross into the bloodstream, spreading systemically.
Two distinct clinical syndromes occur with leptospirosis. An anicteric syndrome is typically self-limited and presents as a flu-like illness. However, the icteric syndrome (Weil syndrome) is severe and often fatal. It is associated with fever, renal failure, liver failure, coagulopathy, and respiratory failure. It can involve muscles, cardiac tissue, and the central nervous system. Severe uveitis and conjunctival hemorrhage are possible. A definitive diagnosis of leptospirosis is only made with a specialized culture or microscopic agglutination test. However, in the setting of a redolent clinical syndrome and negative infectious and immunologic evaluation, a positive Leptospira IgM is strongly suggestive. Patients often require admission to the intensive care unit due to respiratory and multiorgan failure. Mild cases can be treated with oral antibiotics including doxycycline or amoxicillin; severe cases often require intravenous penicillin G or third-generation cephalosporins.
Conclusions: Hospitalists frequently care for patients with multiorgan failure of unclear etiology. When an initial diagnosis fails to explain a constellation of symptoms, a thorough history and an expanded differential can sometimes elucidate alternative diagnoses.