An outbreak of leptospirosis with predominant cardiac involvement: a case series

Abstract

BackgroundSevere leptospirosis is known to cause multi organ dysfunction including cardiac involvement. In the clinical setting with limited resources, high degree of suspicion is needed to diagnose cardiac involvement including myocarditis. Although myocarditis is not reported as a common complication due to lack of diagnostic facilities, there are evidence to support myocarditis is more prevalent in post mortem studies of patients died due to leptospirosis. We present a case series of severe leptospirosis with cardiac involvement observed during a period of one month at Colombo-North Teaching Hospital, Sri Lanka.Case presentationWe report here five patients with severe leptospirosis complicated with cardiac involvement, admitted to a single medical ward, Colombo-North Teaching Hospital, Sri Lanka during a one-month period. Out of six suspected leptospirosis patients admitted during that period, five in a raw developed severe leptospirosis with cardiac involvement. In this case series, four patients were confirmed serologically or quantitative PCR and one patient had possible leptospirosis. All patients developed shock during their course of illness. Two patients developed rapid atrial fibrillation. One patient had dynamic T wave changes in ECG and the other two had sinus tachycardia. Two patients had evidence of myocarditis in 2D echocardiogram, whereas other two patients had nonspecific findings and one patient had normal 2D echocardiogram. All five patients had elevated cardiac troponin I titre and it was normalized with the recovery. All five patients developed acute kidney injury. Four patients needed inotropic/vasopressor support to maintain mean arterial pressure and one patient recovered from shock with fluid resuscitation. All patients were recovered from their illness and repeat 2D echocardiograms after recovery did not show residual complications. One patient had serologically proven dengue co-infection with leptospirosis.ConclusionsMyocarditis and cardiac involvement in leptospirosis may be overlooked due to non-specific clinical findings and co-existing multi-organ dysfunction. Atypical presentation of this case series may be due to micro-geographic variation and unusual outbreak of leptospirosis. Co-infection of dengue with leptospirosis should be considered in managing patients especially in endemic areas.

Sequel and therapeutic modalities of leptospirosis associated severe pulmonary haemorrhagic syndrome (SPHS); a Sri Lankan experience

“…Though the increasing awareness is contributing to increase detection, the large number of patients reported in this study with SPHS could not be attributed totally to increased awareness. Several recent reports from Sri Lanka showed that the different outbreaks of leptospirosis are associated with different clinical presentations such as pancreatitis [28] and cardiac involvement [29]. Further, regional differences of leptospirosis in Sri Lanka are partly explained with infecting Leptospira [30].…”

A Patient with Severe Leptospirosis Treated with Cytokine Removal and High-Dose Corticosteroids

“…Endocardial inflammation with vasculitic changes has been reported as one of the pathogenic mechanisms of disease in a report of the pathological examination of hearts from patients who died from leptospirosis. Due to associated multiorgan involvement, the cardiac manifestations may possibly be underdiagnosed [ 11 , 12 ].…”

Immunohistochemical detection of Lp25 and LipL32 proteins in skeletal and cardiac muscles of fatal human leptospirosis

“…Leptospira antigens were easily demonstrated in myocytes, interstitium and endothelial cells. From a clinical point of view, myocarditis has important consequences in severe leptospirosis 27,28 . It seems that the cardiac muscle was involved in the course of septicemia, through hematogenous dissemination 29,30 .…”