Icahn School of Medicine at Mount Sinai New York, NY, United States
Samarth Dhawan, MD Icahn School of Medicine at Mount Sinai, New York, NY
Introduction: Leptospirosis is one of the most common Zoonotic infections in the world caused by a spirochete that infects rodents whose urine contaminating water becomes the source of infection. It is presumed to be relatively uncommon in the US and therefore often goes missed. The increasing burden of rodents in bigger cities like NYC prompts us to check for the infection in patients with similar/atypical presentations of Liver injury. Here we present an unusual presentation of acute liver failure due to a not so uncommon disease.
Case Description/Methods: A 75-year-old homeless male with Diabetes Mellitus (DM) and chronic alcohol use presented to the ER for fatigue and somnolence for 1 week. 3 weeks prior, at PCP: platelets (PLT) 210, BUN 12, Cr 0.8, Bilirubin of 0.3; AST 32/ALT 20, INR 1.1, asymptomatic except uncontrolled DM. Day 1, vital signs stable, physical exam, frail man with yellow skin, alert and oriented. Reported headaches and decreased oral intake for 1 month; no fever or photophobia. Labs: PLT 15,000. Bilirubin 4.5 (direct 3), AST 340, ALT 300, INR 1.6, BUN 52, Cr 2.6, WBC 9. Head CT with no acute changes; peripheral blood smear: no signs of hemolysis seen. For the next 4 days, the PLT remained < 20,000; bone marrow biopsy unremarkable. 1 unit PLT improved count to 46, ITP was ruled out and steroids not used. Developed acute liver failure with INR of 2.5, bilirubin progressively increasing to 10.5 over 7 days, severe transaminitis with AST 1100 and ALT 1350. Pan CT and MRCP showed no obstructive mass. Renal function worsened to BUN of 117 and Cr 5.8. He became increasingly altered and underwent hemodialysis. All infectious panel was sent. On day 7, WBC 12.3, empirically Ceftriaxone IV started with a dramatic overall improvement in the next 36hrs. On day 10, Leptospira IgM was reported reactive. Ceftriaxone was continued for 7 days. 3 weeks after hospital discharge, Hepatic function returned to baseline, Thrombocytopenia, renal function, and mentation all normalized.
Discussion: In 1886 Dr. A. Weil described a fulminant form of Leptospira in sewer workers with Renal failure, Thrombocytopenia, jaundice which was later known to be Weil's disease. There are 8 million rats/mice in NYC alone. All the population in these metropolitan cities when present with acute hepatic failure, especially those with poor living conditions should be tested for Leptospirosis as a part of infectious etiology and empirically treated with Ceftriaxone if suspicion is high and if drug-induced liver injury is ruled out.
Samarth Dhawan indicated no relevant financial relationships.
Samarth Dhawan, MD. P2890 - Leptospirosis as a Cause of Acute Liver Failure, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.