Abstract Leptospirosis is a zoonotic infection with a clinical spectrum ranging from mild febrile illness to severe multiorgan dysfunction. Pulmonary complications, including diffuse alveolar hemorrhage and acute respiratory distress syndrome (ARDS), are uncommon but associated with high mortality.An 84-year-old male with chronic kidney disease stage 3a, hypertension, type 2 diabetes mellitus, and coronary artery disease status post-CABG (2006) presented with three days of watery diarrhea, malaise, fever, and lower back pain. He denied cough, dyspnea, dysuria, abdominal pain, or vomiting. Social history was notable for chronic alcohol use, a 40-pack-year smoking history, and residence in a rural area with exposure to chickens and goats.On examination, he appeared acutely ill but alert, without jaundice, petechiae, or orthostatic changes. Laboratory studies revealed leukocytosis (9,100/mm³ with 4% bands), thrombocytopenia (90,000/mm³), and acute kidney injury (BUN 67.2 mg/dL, creatinine 4.91 mg/dL) with normal bilirubin (0.33 mg/dL). Procalcitonin was elevated at 1.96 ng/mL, and proBNP markedly increased at 29,379 pg/mL. Chest radiograph showed diffuse interstitial markings. Given the febrile illness with thrombocytopenia and rural exposure, dengue was initially suspected. Differential diagnoses included leptospirosis, viral infections, and systemic vasculitis. During the first hospital night, he developed acute respiratory distress with hypoxia requiring BiPAP and was transferred to the ICU for septic shock management with vasopressors. Chest CT revealed bilateral pleural effusions and patchy infiltrates. His course was complicated by progressive thrombocytopenia (21,000/mm³), rising bilirubin (3.8 mg/dL), worsening renal function (BUN 106.4 mg/dL, creatinine 6.96 mg/dL), and leukocytosis. He required intubation, and bronchoscopy confirmed diffuse alveolar hemorrhage; no organisms were identified on Gram stain or multiplex PCR.Empiric doxycycline and meropenem were initiated, later complemented by intravenous corticosteroids for severe ARDS and alveolar hemorrhage. On day 3, he developed hemodynamically unstable atrial flutter and underwent successful electrical cardioversion. Leptospira DNA testing on day 6 returned positive, confirming Leptospirosis-associated Severe Pulmonary Hemorrhagic Syndrome (SPHS). Antibiotics were de-escalated to ceftriaxone.The patient’s renal function and platelet count gradually improved; vasopressors were discontinued, and he was extubated on day 9. He achieved full recovery and was discharged in stable condition.This case underscores the need for early recognition of severe leptospirosis in endemic regions. Although the role of corticosteroids in SPHS remains debated, their timely use alongside antimicrobial therapy and intensive supportive care likely contributed to this patient’s survival. Given the typically poor prognosis associated with SPHS, this patient’s full recovery represents an exceptional and uncommon clinical outcome. This abstract is funded by: None
Sierra et al. (Fri,) studied this question.