Severe Leptospirosis With Pulmonary Hemorrhage

Introduction: The clinical course of Leptospirosis infection can range from a mild, self-limited febrile illness to a severe disease with multiorgan failure. Mortality in severe disease is 5-15%, but over 50% in the presence of pulmonary hemorrhage. For patients with risk factors or travel history presenting with severe febrile illness and associated characteristic findings of jaundice, renal failure, conjunctival suffusion and hemorrhage, early testing and empiric antimicrobial therapy for Leptospirosis should be considered.


Description: A 15 year-old male with no significant past medical history presented with fluid refractory shock and multiorgan dysfunction in the setting of four days of fever, headache, myalgias, cough, conjunctivitis, abdominal pain, diarrhea and hematemesis. He recently immigrated from Mexico and had worked on a pig farm. Laboratory studies were notable for severe AKI, lactic acidosis, a normal white blood cell count with 23% bands, anemia, thrombocytopenia, mildly elevated transaminases and progressive hyperbilirubinemia. Chest X-ray revealed diffuse bilateral nodular opacities. Fluid resuscitation and empiric antibiotics were started. Shortly after admission, he required intubation and multiple vasoactive infusions. Frank blood was noted from the endotracheal tube. A high PEEP strategy was employed and inhaled tranexamic acid was administered. Chest CT revealed diffuse ground glass opacities. Bronchoscopy was performed on hospital day 4, and bronchoalveolar lavage confirmed diffuse alveolar hemorrhage. Initial differential diagnosis included both rheumatologic and infectious etiologies, such as tuberculosis, coccidioides, hantavirus, dengue and malaria. His multiorgan dysfunction gradually improved and he was extubated on hospital day 7. Leptospirosis IgM antibodies ultimately returned positive and serum Karius pathogen detection testing later identified Leptospirosis DNA, confirming acute infection. He completed a 7-day course of ceftriaxone.


Discussion: It is critical to maintain a high index of suspicion for leptospirosis in patients with compatible clinical features and epidemiologic risk factors. Early recognition is crucial in severe cases, with multi-organ involvement and high risk of mortality, prompting appropriate antibiotic therapy and aggressive supportive care.