Leptospirosis
Patient Presentation:
D.S., a 25 year old male, presented to the ER with chills, muscle pain mostly in the calves and lower back, dry cough, headache with neck pain, nausea, vomiting, conjunctival redness, and a blotchy skin rash. He thought he was just feeling under the weather after his recent trip to Hawaii, which he returned from one week ago. However, the onset of nausea, vomiting, and the appearance of the skin rash prompted him to go to the ER. His vital signs taken in the ER were: BP 115/82, HR 90, RR 16, Temp 39.2, SpO2 99%. He reports that he recently went to Hawaii where he swam in water at the base of a waterfall at the top of a mountain. He has no significant past medical history. D.S. was admitted to the hospital for further work up.
Differential List:
Based on the clinical presentation, these symptoms could possibly be caused by bacterial, viral, or fungal infection. The infection could be linked to diseases involving hemorrhagic fever or meningitis. Initially these symptoms could have been attributed to influenza, but the appearance of the blotchy skin rash caused that to be ruled out.
Diagnosis:
Upon admission, labs were drawn including a CBC, BMP, LFT, ESR, ELISA, blood cultures x2, and a UA/UC was collected. An EKG was done as well as a LP and a chest x-ray. Lab results showed increased WBCs, decreased platelets, increased BUN, increased creatinine, decreased K+, increased liver enzymes, increased ESR, and +ELISA. The EKG showed sinus arrhythmia. The chest x-ray was normal. The blood, urine, and CSF were positive for Leptospira bacteria. Based on this finding along with the fact that D.S. recently spent time in the water in Hawaii where this infection is prevalent, the microscopic agglutination test (MAT) was ordered. This test was positive, which is definitive of the diagnosis of leptospirosis.
Treatment:
D.S. was started on a course of IV Penicillin G, the treatment of choice. He was monitored on telemetry and his renal function was closely monitored. As D.S. improved and he was nearing discharge from the hospital, a ten day course of oral doxycycline was started.
Outcome:
D.S. improved after treatment with antibiotics. His vital signs were stable and he was no longer experiencing the flu-like symptoms that initially brought him into the hospital. His skin rash cleared. His kidney function returned to normal as evidenced by his BUN, creatinine, and urine production. His EKG now showed NSR. D.S. reported that he felt much better. He was discharged from the hospital with education regarding leptospirosis and how to prevent it. He was instructed to continue to take the oral doxycycline to complete the ten day course and to call his primary health care provider if he developed nausea, vomiting, a high fever, rash, or if he had any other concerns.