Case Presentation: A 25-year-old woman with no significant past medical history presented for a three-day history of fevers to 39.9 Celsius, frontotemporal headaches, and diffuse myalgias. She reported working outdoors for a summer camp without known insect or tick bites. Physical exam was notable for tenderness with neck flexion, nuchal rigidity, and abdominal tenderness to palpation in the right upper quadrant. Labs with a creatinine 1.0 mg/dL, AST 117 units/L, ALT 121 units/L, direct bilirubin 1.9 mg/dL, white blood cell 2,500/cubic mm, hemoglobin 9.6 g/dL, and platelets 101,000/cubic mm. Lumbar puncture cell count and cultures were normal. Imaging showed mild diffuse periportal edema. In the emergency department, her blood pressure nadired to 68/33. She was started on empiric vancomycin, cefepime, and metronidazole due to concern for sepsis and norepinephrine for blood pressure support. Bacterial blood cultures were negative. After 12 hours without improvement on broad spectrum antibiotics, doxycycline was empirically initiated for tick-borne or zoonotic illness. She was weaned off from norepinephrine the following day and antibiotics narrowed to doxycycline. After discharge, her urine Leptospira qualitative RT-PCR returned positive.
Discussion: Empiric antibiotic coverage in sepsis should be geared toward the most likely cause of infection to improve patient outcomes. Patients with sepsis of unclear etiology are often started on “broad spectrum” antibiotics with vancomycin, cefepime, and metronidazole. However, in a patient with generalized malaise, hepatitis, and pancytopenia, zoonotic organisms should be considered with the recognition that these infections are not covered by empiric antibiotics. Although leptospirosis is classically considered a tropical disease, it has been implicated as a source of severe infection ranging from fulminant pneumonitis to pancreatitis in urbanized cities in the United States. On further history, our patient reported that her apartment contains rats, which could be a potential source of exposure to Leptospira. Classically, anicteric leptospirosis presents with sudden-onset flu-like illness and fever. The disease can be biphasic, with the flu-like illness followed by a delayed “immune” phase, presenting with aseptic meningitis, uveitis, and systemic symptoms of fever, headache, and abdominal pain. Icteric leptospirosis (Weil’s disease) presents with fever, jaundice, and renal failure and can progress to pulmonary hemorrhage and cardiac complications. Diagnostically, although serum RT-PCR is sensitive early in the disease course, urine RT-PCR is more sensitive during later stages. Treatment of leptospirosis is with seven days of doxycycline or amoxicillin.
Conclusions: Leptospirosis can cause acute septic shock physiology in previously healthy patients. Hospitalists should be aware of the presentation for leptospirosis as it can occur in urban areas with a significant rodent burden. Initiating a seven-day course of doxycycline may be warranted in septic patients who are not responding to empiric antibiotics and have appropriate risk factors.