25884600 Visualization

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