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+A 36-yr-old previously healthy Sri Lankan male who takes care of a horse presented to the medical casualty ward with fever, arthralgia and myalgia for one day.
+He complained of mild dysuria but had normal urine output.
+He did not have chest pain or shortness of breath.
+Further inquiry revealed that he was treated for leptospirosis during a febrile illness in the past.
+On examination, patient was afebrile, anicteric.
+His blood pressure was 90/60 mmHg and pulse rate 76 bpm.
+Rest of the examination was unremarkable.
+Initial investigations performed on the day of admission revealed neutrophil leukocytosis, mild thrombocytopaenia and microscopic haematuria (Table 1).
+Renal function and liver enzymes were within normal limits.
+Urine analysis revealed pus cells 05 – 06 /hpf, red cells 30 – 35 /hpf.
+CRP (C-reactive protein) was 75 mg/dl.
+A clinical diagnosis of leptospirosis was made and he was started on intravenous penicillin in addition to adequate hydration.
+On the second day of illness, he developed hypotension with tachycardia and dyspnoea.
+ECG revealed sinus tachycardia with ST depression in leads V4 – V6 [Figure 1].
+His CXR (chest x ray) showed gross cardiomegaly and bilateral pulmonary shadows [Figure 2].
+CVP (central venous pressure) was 16 cmH2O and 2D echocardiogram revealed dilatation of all four chambers, severe global hypokinesia and ejection fraction of 20%.
+Troponin I was 12.77 ng/ml (normal range < 0.40).
+He was diagnosed to have early and severe myocarditis.
+Patient was transferred to ICU (intensive care unit) as he needed inotropic support.
+Intravenous antibiotics including penicillin, meropenem and levofloxacin were continued.
+Patient was electively ventilated on the 3rd day of illness due to severe respiratory distress.
+On the same day, he developed rapid atrial fibrillation [Figure 3] unresponsive to digoxin and intravenous amiodarone.
+Platelet count dropped to 10 × 103 μ/L and he was given platelet transfusions to prevent bleeding [Table 1].
+We started intravenous methylprednisolone based on previous studies showing a mortality benefit in severe leptospirosis complicated with myocarditis [11].
+His serum creatinine increased to 362 μ mol/L by the 5th day of illness and ALT (alanine transaminase) and AST (aspartate transaminase) were markedly elevated up to 2726 U/l and 7438 U/l respectively.
+Dengue and Mycoplasma infections were excluded.
+Blood cultures were negative.
+Leptospira IgM antibody performed on the 5th day of illness was positive (IgG negative).
+Patient developed refractory shock and died of persistent ventricular tachycardia despite optimal treatment in the ICU.