Abstract Introduction Weil’s disease is a severe form of leptospirosis, a zoonotic infection transmitted through contact with infected animal urine, often via contaminated soil or water. It can progress to multiorgan failure or death due to leptospiral dissemination triggering an intense host immune response. Case Description A 72-year-old man presented to the emergency department with two days of fatigue, dyspnea, fever, and a productive cough. On arrival, he was hypoxemic and tachypneic requiring high-flow oxygen support. Initial laboratory studies revealed hyponatremia, leukocytosis, elevated procalcitonin and brain natriuretic peptide, and an acute kidney injury. Computed tomography (Figure 1) imaging revealed ground-glass opacities and posterior lung consolidations. He started on ceftriaxone and azithromycin and was admitted to the medical intensive care unit (ICU). He developed progressive hypoxemia and septic shock, requiring intubation and triple vasopressor support. Laboratory evaluation showed new severe direct hyperbilirubinemia (25 mg/dL) with near-normal transaminases. His kidney injury progressed to oliguric renal failure requiring renal replacement therapy. Several bronchoscopies with bronchoalveolar lavage were performed during his ICU stay, each yielding tenacious bloody secretions, a neutrophilic cellular differential, negative cultures and multiplex PCR. History revealed extensive exposure to a garden with a rodent infestation. Given the combination of zoonotic exposure with culture-negative neutrophilic alveolitis, renal failure, and direct hyperbilirubinemia, leptospirosis was suspected. Leptospira qualitative urine PCR and serum IgM were positive, and Leptospira interrogans infection was confirmed by plasma cell-free microbial DNA sequencing. The patient improved after a 7-day course of IV penicillin. He was extubated two weeks later and discharged home two months after presentation with renal and hepatic recovery. Discussion Leptospirosis has a worldwide incidence of around 1.9 in 100,000 people. Most patients have mild symptoms, with serious disease called icteric leptospirosis. Standard treatment is an IV cephalosporin or penicillin. Pulmonary manifestations can include hemorrhage, acute respiratory distress syndrome, and non-cardiogenic interstitial pulmonary edema. This patient exhibited the classic triad of Weil’s disease at the time of presentation: jaundice, renal dysfunction, and pneumonitis. We propose that ceftriaxone treatment may have triggered a Jarisch-Herxheimer reaction, evidenced by quickly resolving severe shock with onset after initial antibiotic dose. Evidence suggests that corticosteroid use may reduce rates of Jarisch-Herxheimer reaction without impacting mortality. Plasma exchange for management of pulmonary hemorrhage has also been reported in case studies, but further research is necessary. Early recognition of leptospirosis can impact the trajectory of care and avoid antibiotic changes to less efficacious agents. This abstract is funded by: None
Hoyer et al. (Fri,) studied this question.