Brief history of the Present Illness:
A 64-year-old male presented to the emergency department complaining of fever, chills, nausea, vomit, non-bloody watery diarrhea, mild headache, generalized malaise, weakness, and low blood pressure for 3 days duration. His wife had catarrhal symptoms. However, he denied sore throat, cough, rhinorrhea, chest pain, abdominal discomfort, bleeding, neck pain/stiffness, photophobia, dysuria, skin rash, arthralgia, myalgia or any other symptoms.
Past Medical History including allergies:
The patient reported a previous adverse drug reaction to Doxycycline which caused headache, nausea, and vomit. He denied pruritus, rash, swelling, or respiratory compromise.
The patient and his wife had just returned from an eleven day Southern Caribbean cruise when his symptoms began. He traveled to Aruba, Curacao, Bonaire, Jamaica, Dominican Republic, and Costa Rica. He participated in numerous outdoor activities including river rafting/tubing, zip lining, and snorkeling. He mostly drank bottled water, avoided street food, and denied any animal exposures. However, they did not seek pre-travel advice.
Vital signs revealed high fever of 104 degrees Fahrenheit, tachycardia, and refractory hypotension that required vasopressors. Physical examination disclosed hepatomegaly, jaundice, scleral icterus, conjunctival suffusion, and subconjunctival hemorrhages.
Complete blood count (CBC) unveiled new anemia, leukocytosis, and severe thrombocytopenia. Comprehensive metabolic panel (CMP) showed elevated liver enzymes, hyperbilirubinemia with direct predominance, and acute kidney injury (creatinine increased 7 times above baseline). There was evidence of multi-organ damage. His previous baseline laboratories were completely normal. Disseminated intravascular coagulopathy (DIC) and hemolysis was ruled out. No schistocytes or parasites were seen on the peripheral smear. Abdominal imaging divulged hepatomegaly but no evidence of obstruction. Amylase and lipase levels were normal.
Clinical Course Prior to Diagnosis:
Cultures were collected and he was started empirically on intravenous Vancomycin, Piperacillin-Tazobactam, and Doxycycline. He was subsequently admitted to the intensive care unit due to septic shock. Initially chest film was clear, but then bilateral patchy infiltrates became apparent. An echocardiogram showed preserved ejection fraction and no vegetations. Hospital course was complicated by respiratory failure requiring endotracheal intubation and mechanical ventilation due to acute respiratory distress syndrome (ARDS). Hemoptysis later ensued. However, autoimmune and vasculitis workup was non-revealing. He also required continuous renal replacement therapy and blood products.
- Dengue Fever
- Chikungunya Virus Infection
- Zika Virus Infection
Diagnostic Procedure(s) and Result(s):
Blood, sputum, urine, and stool cultures exhibited no growth. Stool ova/parasites, Clostridium difficile toxin, as well as antigens for Cryptosporidium, Campylobacter, and Norovirus were not detected. Zika, Dengue, and Chikungunya viruses were ruled out via polymerase chain reaction (PCR) and serology. Malaria, Influenza, and pneumococcus was also discarded. Leptospira IgM collected on admission was negative. However, Leptospira DNA was detected in urine. Serology obtained during the convalescent period confirmed presence of Leptospira interrogans canicola canicola ruebish (titer 1:3200).
The patient completed a course of intravenous Ceftriaxone and Doxycycline with marked improvement. He was successfully weaned off mechanical ventilation after tracheostomy. He participated in inpatient rehabilitation and was subsequently discharged home after a prolonged hospitalization.
Brief Discussion of Differential/Major Teaching points of case:
Fever in the returning traveler is a common but challenging clinical scenario that can easily become a diagnostic dilemma. It often leads to hospitalization and may represent a life threatening disease. The evaluation should focus on clinical presentation, detailed travel history, potential exposures, incubation period, malaria chemoprophylaxis, and vaccine administration.
Leptospirosis is an under reported zoonosis worldwide occurring mainly in the tropics. Weil’s disease, its severe form, is potentially fatal. A high index of suspicion is required to make the diagnosis due to non-specific clinical findings and the biphasic nature of the illness. Conjunctival suffusion is an important sign. It is not a common finding in other infectious diseases and its presence should raise suspicion for leptospirosis.
- Thwaites, G. E. and N. P. J. Day (2017). "Approach to Fever in the Returning Traveler." New England Journal of Medicine 376(6): 548-560.
- Karnad, D. R., et al. (2018). "Tropical diseases in the ICU: A syndromic approach to diagnosis and treatment." J Crit Care.
- Singh, J., Singh, G., Khaliq, F., Ferguson, R., & Haile, C. (2017). Multi-organ failure, weeks after being exposed to murky water – rule out leptospirosis. Journal of Community Hospital Internal Medicine Perspectives, 7(3), 173–174.
- Haake, D. A. and P. N. Levett (2015). "Leptospirosis in humans." Curr Top Microbiol Immunol 387: 65-97.
- McGrowder, D., et al. (2010). "Clinical and laboratory findings in patients with leptospirosis at a tertiary teaching hospital in Jamaica." Research and Reports in Tropical Medicine: 59.
- Keenan, J., Ervin, G., Aung, M., McGwin, G., & Jolly, P. (2010). Risk Factors for Clinical Leptospirosis from Western Jamaica. The American Journal of Tropical Medicine and Hygiene, 83(3), 633–636.
- Levett, P. N. (2001). Leptospirosis. Clinical Microbiology Reviews, 14(2), 296-326.
Figure #, location of image, type of image, legend
- Conjunctival suffusion, subconjunctival hemorrhages, and scleral icterus on physical examination.
- Initial chest x-ray on admission was negative for acute cardiopulmonary abnormalities.
- Repeat chest x-ray with diffuse patchy infiltrates concerning for acute respiratory distress syndrome (ARDS).
- Leptospira interrogans canicola canicola ruebish was the serovar identified.
Please indicate which photo or figure you think is most representative of the case.
The figure most representative of the case is Figure #1 depicting conjunctival suffusion which was an important diagnostic clue.
S. M. Moore-Pardo,
S. Aslam, None
R. Oehler, None