Anicteric leptospirosis presenting as acute respiratory distress syndrome

SESSION TITLE: Bugs and Drugs in the ICU SESSION TYPE: Case Reports PRESENTED ON: 10/10/2023 08:30 am - 09:30 am INTRODUCTION: Leptospirosis is a spirochetal zoonotic disease. Less than 150 cases are reported in the US annually (1). Clinical presentation of leptospirosis is often divided into two syndromes (depending on liver involvement), icteric and anicteric. The anicteric form usually presents as a mild flu-like illness. Icteric is the severe form, characterized by multiorgan failure. CASE PRESENTATION: A 50-year-old female with hyperlipidemia presented to the emergency department for abdominal pain and poor oral intake for three days. Review of symptoms otherwise negative. Initial vital signs were remarkable for a blood pressure of 70/40 mmHg, a pulse rate of 98 beats per minute, and SpO2 of 95% on room air. The patient was administered intravenous fluids. Laboratory findings were significant for leukocytosis (12,000/mm3), thrombocytopenia (57,000/mm3), and lactic acidosis (5.1 mmol/L). CT scan of chest/abdomen/pelvis revealed bilateral patchy ground glass opacities, without any intra-abdominal pathology. Respiratory viral PCR positive for Rhinovirus. She started getting short of breath in the ED, ultimately requiring intubation for acute hypoxic respiratory failure. Post-intubation chest radiograph was notable for left pneumothorax, which warranted pigtail placement. Blood cultures were collected and the patient was started on broad-spectrum antibiotics with vancomycin, cefepime, and doxycycline. Intravenous vasopressors were started and she was admitted to the medical intensive care unit. Steroids were initiated, and lung protective ventilation strategies for ARDS were employed. Respiratory cultures were collected. Her course was complicated by acute kidney injury. The patient was proned for refractory hypoxemia (P:F of 110). Subsequently, her gas exchange improved. Blood cultures grew Staphylococcus epidermidis. Without a clear cause of ARDS and high local prevalence of leptospirosis, leptospira serology was sent and doxycycline was continued. Additionally, a bedside diagnostic bronchoscopy was performed, which revealed diffuse alveolar hemorrhage. An autoimmune work-up was initiated and she received a three-day course of pulse dose steroids. Subsequently, respiratory cultures and bronchoalveolar lavage grew methicillin-resistant Staphylococcus aureus. BAL cytology negative for malignant cells. Leptospira serology revealed positive IgM. Her renal function improved and was extubated to a high-flow nasal cannula. Pigtail was removed. She completed a 7-day course of vancomycin/ceftriaxone and a 10-day course of doxycycline. She was persistently hypomagnesemic. She was transferred to the medical floor, where was weaned to room air from high flow and discharged to home. DISCUSSION: Pulmonary manifestation is uncommon (<5%) in the icteric form and not typically described in the anicteric form (2). To the best of our knowledge, this is the first reported case of ARDS in the anicteric form in the United States. Patients with pulmonary involvement have high mortality rates (30-60%) (3). She had a complete recovery. Of note, she also had hypomagnesemia, which is a classic finding in leptospirosis. CONCLUSIONS: Leptospirosis is an emerging cause of ARDS in high-risk populations (e.g. overcrowded urban areas with poor sanitation). One should have a high index of suspicion even in the absence of hepatic involvement or classic signs such as conjunctival suffusion. Early detection and timely antibiotic administration are imperative for a good prognosis of leptospira-mediated ARDS. REFERENCE #1: https://www.cdc.gov/leptospirosis/pdf/fs-leptospirosis-clinicians-eng-508.pdf (Accessed on March 20, 2023) REFERENCE #2: Segura ER, Ganoza CA, Campos K, et al. Clinical spectrum of pulmonary involvement in leptospirosis in a region of endemicity, with quantification of leptospiral burden. Clin Infect Dis. 2005;40(3):343-351. doi:10.1086/427110 REFERENCE #3: Marotto PC, Nascimento CM, Eluf-Neto J, et al. Acute lung injury in leptospirosis: clinical and laboratory features, outcome, and factors associated with mortality. Clin Infect Dis. 1999;29(6):1561-1563. doi:10.1086/313501 DISCLOSURES: No relevant relationships by Fernando Enrique Amador Fiallos No relevant relationships by David Chong No relevant relationships by Anant Jain No relevant relationships by Elffy Munoz No relevant relationships by Dishant Shah No relevant relationships by Khushee Shah