Woodhull Medical Center/NYC Health + Hospitals Brooklyn, NY
Introduction: Weil’s disease (Leptospirosis) is a relatively common worldwide zoonotic infection due to Leptospira spp. However, leptospirosis is underreported due to its low incidence in the United States and its variable presentation. Furthermore, leptospirosis-induced acute hepatic injury is extremely rare. The purpose of this case report to enlighten urban practitioners to consider testing for leptospirosis in patients with acute liver injury. We are reporting a rare case of leptospirosis induced acute liver injury.
Case Description/Methods: A 38 year-old-male with no past medical history presented with 6-day history of fever, abdominal pain, N/V, fatigue and myalgia. On presentation patient was vitally stable, physical exam, ill appearing man with icterus sclera, mild tenderness in RUQ abdomen. Labs: WBC 14.16, ALT 181, AST 232, Bilirubin 7.5 (direct bilirubin 6.2), platelets 41, INR 1.13, aPTT 19.7, BUN 33, Cr 3.41, GFR 21.6, CT abdomen revealed hepatic steatosis and hepatomegaly. Extensive hepatic and sepsis work up sent and patient was started on vancomycin, piperacillin/tazobactam. For next 4 days, WBC 25.22, Bilirubin 18, (direct bilirubin >10.0) with more yellow skin, however, ALT 68, AST 54, platelets 93 improved. Renal function worsened to BUN 58, Cr 4.05, GFR 17.5. All the extensive work up came back unremarkable, Leptospira IgM antibody was sent on day 5. The patient was transferred to the intensive care unit on day 6 for multi-organ failure. On day 8 leptospira IgM antibody came back positive and antibiotics were de-escalated to IV penicillin G. On day 12, patient had significant clinical and labs improvement, WBC 10.16, Platelets 347, ALT 59, AST 44, Bilirubin 4.2, (direct bilirubin 2.6), BUN 20, Cr 1.22, GFR >60. 2 weeks after hospital discharge, patient was feeling much better and his hepatic and renal function returned to baseline.
Discussion: Leptospirosis-induced acute liver injury is exceedingly rare in United States; hence, a high index of suspicion is required to make the diagnosis due to its variable clinical course. Most cases are mild, while some are severe and potentially fatal. In urban areas, the disease is mainly transmitted via rodent urine contamination of water and soil. With the increase use of various types of cycles, riders of these devices, as well as sewer workers and joggers, risk greater exposure to the disease. Providers, especially in urban settings, should have a high index of suspicion, and evaluate patients with acute liver injury for leptospirosis.
