Severe leptospirosis after rat bite: A case report

Abstract

A 43-year-old woman presented to an emergency department in Salvador, Brazil, with a twoday history of fever (39.5 o to 40.0˚C), chills, headache, arthralgia, myalgia, and loss of appetite in the setting of a recent rat bite. She had no previous relevant medical history but reported a street-rat bite on her right ankle 13 days prior to presentation (Fig 1). The rat bite occurred while she was walking to a drugstore in the early evening in December 2014 in a mediumincome neighborhood of Salvador, a coastal city in the northeast of Brazil. Shortly after the incident, she went to an urgent care unit where she received tetanus and rabies vaccines and wound care. She denied exposure to other potentially leptospires-contaminated environments, such as water or mud. When the symptoms began, she was seen at the hospital where she received medical examination and laboratory evaluation. Her complete blood count (Day 1) showed discrete anemia, leukocytosis with neutrophilia, and thrombocytopenia (Table 1). Her urinalysis showed hematuria. The erythrocyte sedimentation rate was 24 mm 3 /hr, creatine phosphokinase was 1,182 U/L, and no other pertinent findings were reported. Blood culture showed no growth, and a rapid dengue test was nonreactive. She received intravenous fluids, muscle relaxants, and analgesics and was discharged without a clear diagnosis. Persistent symptoms brought the patient back to the hospital the next day (Day 2) complaining of shortness of breath, diffused myalgia, arthralgia, odynophagia, dry mouth, and hemoptysis as well as cutaneous rashes. Clinical examination recorded a temperature of 38.0˚C, blood pressure of 117/72 mmHg, heart rate of 100 beats per minute, respiratory rate of 16 breaths per minute, and oxygen saturation of 99% breathing room air, in addition to dehydration. She was admitted to the hospital that same day-antibiotics (ceftriaxone) and supportive measures were initiated. On Day-3, she developed shortness of breath and crepitus on thorax auscultation at the base of her right lung and had 82% of oxygen saturation at room air. The patient was admitted to the intensive care unit (ICU) for noninvasive respiratory support. Thorax computed tomography and X-ray revealed bilateral diffused consolidation with air bronchogram and a posterior basal laminar stroke of her left lung (Fig 2). The antibiotics were changed to moxifloxacin and cefepime. Oseltamivir and corticosteroids were introduced. Additionally, during Day 3 in the ICU, the patient presented with hemoptysis and pulmonary congestion, likely associated to hypervolemia, which were resolved by the Day 4. The patient was discharged on Day 6 with complete resolution of fever and respiratory symptoms. A definitive diagnosis of leptospirosis was made based on the epidemiological history of rat bite, compatible clinical symptoms, and laboratory tests. A positive immunoglobulin M (IgM) ELISA (Bio-Manguinhos, Rio de

A Rare Manifestation of Leptospirosis: Long-Term Elevation in Liver Enzymes

“…Studies investigating clinical manifestation and laboratory test abnormalities in patients who had severe leptospirosis and case reports reported in the literature confirm that elevated liver enzymes in leptospirosis usually resolve without long-lasting effects (8). In our case, high liver enzyme elevation for a long time is remarkable.…”

Case report: Leptospirosis with multi-organ failure complicated by massive upper gastrointestinal bleeding in a non-epidemic setting with successful management

“…Rat bite is an unusual mode of transmission that results in a direct infection, as in our patient. Even though it's a rare mode of transmission, some cases have been reported ( 9 , 10 ).…”