Abstract Leptospirosis is a zoonotic infection caused by Leptospira spirochetes, with the highest incidence in tropical regions. Approximately 100 to 150 cases are reported annually in the United States. While most infections are asymptomatic or mild, severe leptospirosis (Weil’s disease) develops in 5 to 10% of symptomatic cases and is characterized by fever, jaundice, and renal failure. Complications may include pulmonary hemorrhage with acute respiratory distress syndrome (ARDS), myocarditis, and rhabdomyolysis. Pulmonary involvement carries a mortality rate of 50 to 70%. We present a 75-year-old woman with rheumatoid arthritis on methotrexate and etanercept who presented with malaise and jaundice. She developed acute hypoxic respiratory failure requiring intubation. On admission, vital signs were notable for a respiratory rate of 44 breaths/min, pulse 115 bpm, blood pressure 92/54 mmHg, and temperature 98.1 °F. Laboratory findings included WBC 13.2 K/cu mm (neutrophils 83.5%, lymphocytes 4.3%, immature granulocytes 7%), hemoglobin 7.5 g/dL, platelets 10 K/cu mm, creatinine 3.68 mg/dL, and total bilirubin 15.1 mg/dL. CT chest revealed bilateral ground glass opacities and tree-in-bud nodularity. Bronchoscopy with bronchoalveolar lavage showed pulmonary hemorrhage. She was treated with broad-spectrum antibiotics and vasopressors for septic shock, along with blood transfusions for anemia and thrombocytopenia. Due to anuric acute kidney injury, hemodialysis was initiated. Leptospira DNA was detected on infectious workup, confirming Weil’s disease with pulmonary hemorrhage prompting appropriate antibiotic treatment with doxycycline. Additionally, hydrocortisone was initiated, resulting in significant improvement in respiratory failure and multiorgan dysfunction. The patient was successfully extubated and discharged home. The clinical course of leptospirosis is typically biphasic. The initial leptospirosis phase is characterized by acute fever and bacteremia, followed by a brief asymptomatic period. The subsequent “immune” phase presents with recurrent fever and the onset of complications, including hepatic, renal, and pulmonary involvement. Pulmonary hemorrhage is thought to result from direct vascular injury by Leptospira or its toxins, though the precise mechanism remains unclear - whether due to disseminated intravascular coagulation or a sepsis-like endothelial injury process. During the immune phase, a cytokine storm contributes to the multiorgan dysfunction seen in Weil’s disease. This hyperinflammatory response parallels that of COVID-19-associated ARDS. Corticosteroids, widely used in COVID-19-associated ARDS for their immunomodulatory effects, have shown potential benefit in severe leptospirosis with pulmonary involvement, although supporting data remain limited. Our case demonstrates successful use of corticosteroids in Weil’s disease-associated pulmonary hemorrhage and highlights the need for further research to define their therapeutic role. This abstract is funded by: None
Kamel et al. (Fri,) studied this question.