A case report of cruise-related leptospirosis, requiring a high level of suspicion for diagnosis.
Dueweke J, Maki G, Vahia A, and Brar I. A case report of cruise-related leptospirosis, requiring a high level of suspicion for diagnosis. J Gen Intern Med 2018; 33(2):417.
J Gen Intern Med
Learning Objective #1: Recognize the clinical features of leptospirosis Learning Objective #2: Maintain high clinical suspicion for rare pathogens not endemic to area CASE: A 32 year-old male with no significant past medical history presented with 1 week of muscle weakness, lower extremity pain, nausea and vomiting. Patient reported being on a Caribbean cruise 1 week prior. On presentation, patient was hemodynamically stable. Labs were significant for AKI with creatinine 7 mg/dL (baseline ~1 mg/dL), CPK 1500 IU/L, total bilirubin 11 mg/dL, AST 137 IU/L, ALT 86 IU/L, and alkaline phosphatase 75 IU/L, LDH of 262 IU/L and Fibrinogen > 700 mg/dL. Abdominal US, CTAbdomen, and HIDA scan were positive only for nonobstructive cholelithiasis. CBC revealed leukocytosis and thrombocytopenia. Patient started on broad spectrum antibiotics and given IV fluids, but kidney function and hyperbilirubinemia continued to worsen. Viral hepatitis panel, autoimmune panel, urine toxicity screen, HIV, EBV, CMV, and ANAwere negative. Patient was tested for Leptospirosis and started on empiric Ceftriaxone therapy, which was switched to Doxycy-cline after he developed a drug rash secondary to ceftriaxone. Symptoms began to resolve, hyperbilirubinemia improved and creatinine returned to baseline. He was discharged, to complete a 14 day course of Doxycycline. Subsequently, Leptospirosis PCR in the urine was reported positive and negative PCR in blood. IMPACT: Cruise ship travel presents a unique combination of health con-cerns. Infectious diseases unique to persons who cruise are rare. Leptospirosis has emerged as a globally important infectious disease. Our case represents the importance of keeping a broad differential and maintaining a high index of suspicion for less common pathogens. DISCUSSION: Leptospira is a zoonotic pathogen with protean clinical manifestations caused by spirochetes. Typically, the disease runs a biphasic course with an initial acute or septicemic phase lasting roughly 1 week followed by an immune phase characterized by antibody production and clearance of organism from the urine. Most cases are self-limited, but some have severe and potentially fatal presentations. The illness generally presents as abrupt onset of fever, rigors, myalgias and headache followed by an incubation period of 2-26 days. Conjunctival suffusion is a frequently overlooked sign. Weil's Disease is a complication of leptospirosis characterized by liver and renal failure, which can lead to hypokalemia, hyperbilirubinemia, transaminitis, and thrombocyto-penia. A severe potential complication is pulmonary hemorrhage. A high index of suspicion is needed. Diagnosis is made most frequently by serologic testing, though molecular diagnostics have demonstrated increasing utility. Treatment depends on severity. Doxycycline, azithromycin, or amoxicillin (in children) is preferred in mild cases. For hospitalized patients or more severe presentations, doxycycline, ceftriaxone, or cefotaxime are the preferred agents withaduration of treatment usually 7-14 days.