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.