Case Presentation: A 69 year old woman presented to our hospital with 5 days of fever, diarrhea, abdominal pain & debilitating leg pain. Her only known medical problem was hyperlipidemia, for which she had recently increased her statin dose. 6 weeks prior to admission, she visited her hometown in Jiangxi, China. There, she drank tap water, ate home-cooked food, and was exposed to dogs, chickens, mice, and mosquitoes. On presentation, patient was febrile to 38.7°C, tachycardic and normotensive. She had profuse diarrhea. Her abdomen and thighs were tender and she was unable to walk due to the severity of her leg pain. Labs showed anemia (Hb 10.9), thrombocytopenia (Plts 134), and elevated creatinine kinase (412 U/L). Following admission, the rhabdomyolysis (CK 412→ 2805) and thrombocytopenia (platelet 105 → 49) worsened. Abdominal CT revealed severe mesenteric inflammation and enlarged mesenteric lymph nodes. She developed elevated transaminases and progressive renal failure (Cr 0.5→2.4). Peripheral smear showed no hemolysis. Urine studies were consistent with acute tubulointerstitial inflammation. Initial differential was broad and important consideration was given to patient’s travel history. Leptospirosis, which is endemic to China’s Juangxi Province, fit our patient’s clinical picture. Myalgia, mild rhabdomyolysis, thrombocytopenia & renal failure are common in severe disease. Our patient’s GI symptoms, mesenteric inflammation, and long incubation period, however, were highly atypical. Testing for malaria, rickettsia, dengue, salmonella, viral hepatitis, HIV, TB, CMV, and EBV was negative. Despite atypical features, due to suspicion for Leptospirosis, IV Ceftriaxone and oral doxycycline were started on hospital day 3. Over the next 5 days, her fever resolved, and labs improved renal function normalized. She was discharged to complete 7 days of doxycycline for presumed leptospirosis. The diagnosis was later confirmed when a Leptospira IgM returned positive.

Discussion: Although rare in the U.S., Leptospirosis is a globally widespread zoonosis. Transmission takes place via the urine or feces of infected animals, and humans become infected by ingesting contaminated food or water. Common features include fever, myalgia, rhabdomyolysis, thrombocytopenia and renal failure in severe disease. The typical incubation period is 1-3 weeks, but incubations up to 1 month have been reported. GI manifestations are rare, but pancreatitis and cholecystitis have been described. We report an atypical case of Leptospirosis presenting with diarrhea, mesenteric inflammation, and renal failure 6 weeks following travel to an endemic region. In this case, antibiotics were initially deferred while infectious diarrhea causing hemolytic uremic syndrome was excluded. We also considered statin-induced myopathy and other cosmopolitan infections endemic to Jiangxi, where the WHO reports sporadic malaria, typhoid, and recent outbreaks of scrub typhus. Ultimately, Leptospirosis was felt to be the unifying diagnosis, despite atypical features, due to relevant exposure, fever with multiorgan involvement, renal failure and thrombocytopenia.

Conclusions: Our patient presented with typical findings of severe Leptospirosis but with several uncommon features including a long incubation period and prominent diarrhea. In an increasingly interconnected world, it is imperative that clinicians develop illness scripts for global infectious diseases, especially those that carry a high mortality if untreated.