AB022. A case of severe leptospirosis with acute respiratory distress syndrome

Abstract: Leptospirosis is a microbial infection which occurs in humans and animals and is caused by Leptospira (Leptospira spp.). In Greece, it occurs at a frequency of 0.22:100,000, and 24 severe cases have been reported in 2013. It manifests in three forms: anicteric (90%), icteric (5–10%) and severe. Severe leptospirosis can be a rare cause of acute respiratory distress syndrome (ARDS), leading to intubation, jaundice, alveolar bleeding and multi-organ failure. A 71-year-old male patient presented at the emergency department with dyspnea on exertion, fever, gastrointestinal disorders, muscle aches and fatigue, that started four days ago. Occupation with pigeons was also reported. Blood gas analysis revealed severe type I respiratory failure, and a chest CT was performed, revealing ARDS. The patient was intubated. Acute renal failure (urea: 238, creatinine: 4.81) that required renal replacement therapy developed along with increased bilirubin (max value of total: 8.2 with direct: 7.42), and positive direct and indirect Coombs test. Moreover, hemorrhage through the tracheal tube complicated the clinical condition, resulting to obstruction of tracheal tube. Furthermore, anemia, thrombocytopenia and severe leycocytosis were also observed (white blood cells: 42,620). Diffuse alveolar hemorrhage due to vasculitis and connective tissue disease was suspected, and a complete immunological control was ordered. Infectious pathogens, such as Str. Pneumoniae, Legionella, Mycoplasma, Leptospira spp., Chlamidia, HBV, HCV, influenza were also suspected and all the necessary samples were tested. He received levofloxacin, piperacillin/tazobactam, vibramycin, and oseltamivir, but after receiving the positive results for leptospira, antibiotic treatment was revised with the final choice of levofloxacin and piperacillin/tazobactam. Despite improvement of renal and liver function, leycocytosis, CRP and PCT values, high fever begun that was attributed at first to the Jarisch-Herxheimer syndrome. Some days after, pneumonia due to Acinetobacter baumannii was diagnosed and treated with colimyxin resulting to further improvement. The patient underwent tracheostomy but finally weaned from mechanical ventilation after 23 days and was discharged from the respiratory failure unit on the 26th day.

Keywords: Leptospirosis; acute respiratory distress syndrome (ARDS); occupation with pigeons