Short-course treatment with ceftriaxone for leptospirosis: A retrospective study in a single center in Eastern France

Tropical Fever Unveiling an Asymptomatic Case of Polycythemia Vera

We report a case of fulminant hepatic failure due to the Budd–Chiari syndrome following preservation with a tropical fever. A young lady came with fever, altered mental status, jaundice, and renal failure. Following tropical workup, it was diagnosed as a case of leptospirosis (WHO Faine's criteria) with multi-organ dysfunction. Despite adequate antimicrobial cover, she progressed to hepatic coma (hyperammonemia) and was noted to have worsening conjugated hyperbilirubinemia. Following history review and evaluation for other causes of hepatic failure, hepatic vein thrombosis was detected in addition to the presence of antibodies against Leptospira antigen. Further studies into the causes of thrombosis and persistent hemoconcentration despite aggressive fluid resuscitation led to the diagnosis of polycythemia vera (cytometric analysis). During her stay, she further worsened despite aggressive organ support including dialysis but she succumbed to gram-negative sepsis that occurred during her stay in ICU. This is an interesting and rare case of leptospirosis that unveiled a case of previously asymptomatic polycythemia vera.

Clinical characteristics, outcomes, and predictors of leptospirosis in patients admitted to the medical intensive care unit: A retrospective analysis

BACKGROUND

Early diagnosis and detection of clinical deterioration of leptospirosis are challenges to all clinicians. This study aimed to report the characteristics and outcomes of patients admitted to the medical intensive care unit (MICU) for severe leptospirosis and to identify the clinical predictors of MICU admission.

METHODS

This was a 10-year retrospective study that included all patients diagnosed as leptospirosis, based on either serology or a Thai-Lepto score (TLS) of >4. All clinical characteristics and laboratory data were collected and compared between MICU cases and general ward cases. Binary logistic regression was applied to identify the independent factors for MICU admission.

RESULTS

Of the 68 patients who were diagnosed as leptospirosis based on inclusion criteria, 43 serologically-confirmed cases were subsequently analyzed. Fifty percent of the cases were admitted to the MICU and, compared with those admitted to the general ward, had higher Sequential Organ Failure Assessment (SOFA) score [10 (7-13) vs. 5 (2.2-5.6), p < 0.001]; higher TLS [7.5 (6.5-9.25) vs. 5.5 (3.5-6.5), p < 0.001]; lower mean arterial blood pressure (74.7 ± 15 mmHg vs. 84.2 ± 16.3 mmHg, p = 0.04); lower platelet count in ×10³ cell/mm³ [65 (52.8-105.8) vs. 159 (87.3-181.5), p = 0.008); higher total bilirubin level [4.4 (1.5-8.7) mg/dL vs. 1.2 (0.7-2.8) mg/dL, p = 0.01]; and required more inotropes and vasopressors (87% vs. 4.3%, p < 0.001), mechanical ventilator support (91.3% vs. 4.3%, p < 0.001), and renal replacement therapy (39.1% vs. 0%, p < 0.001). TLS, SOFA score, requirement for mechanical ventilation, and use of inotropes and vasopressors were the predictors of MICU admission. TLS > 6 and SOFA score >6 gave similar power to predict MICU admission.

CONCLUSION

Among patients with leptospirosis, TLS, SOFA score, inotrope or vasopressor requirement, and mechanical ventilator support were the independent predictors of MICU admission. TLS > 6 and SOFA score >6 indicated the need for MICU admission.

Acute painless pancreatitis as an unusual presentation of leptospirosis in a low-incidence country

A healthy, urban-dwelling man presented with lassitude, jaundice without increased liver enzymes or obstructive features on imaging, brief acute kidney injury, leucocytosis with near-normal C reactive protein and markedly increased serum amylase and lipase. Leptospirosis was not considered for 10 days because of the low incidence of the disease in the country, absent animal contact and physicians' low index of suspicion. Presentation without fever and without the commonly associated abdominal pain, myalgia, headache, thrombocytopaenia or elevated serum creatine kinase added to the diagnostic challenge. Once an infectious cause of acute pancreatitis was contemplated, leptospirosis was immediately sought and diagnosed by PCR of urine and microscopic agglutination test, and he fully recovered on ceftriaxone. Physicians in countries with a low incidence of leptospirosis should be more aware of the possibility of the disease even when several key features such as fever or pain are missing and the patient has a rare infectious acute pancreatitis.

Infections tropicales graves dans les départements français d’Amérique, Antilles françaises et Guyane

Les Antilles-Guyane (AG) sont les départements français du continent américain, situés en zone intertropicale. La diversité des écosystèmes ainsi que le climat tropical à très forte pluviosité exposent à un vaste panel de pathologies infectieuses. Ces territoires sont de plus l’objet de mouvements importants de populations, voyageurs ou migrants, ce qui joue un rôle significatif dans le développement d’épidémies et/ou de pathologies émergentes. Ces pathologies infectieuses dites « tropicales » peuvent nécessiter une prise en charge en réanimation. Nous rapportons ici les principales données récentes concernant ces pathologies (hors infection liée au VIH) ainsi que les stratégies diagnostiques et thérapeutiques, à l’usage des réanimateurs amenés à exercer en zone tropicale AG ou recevant en métropole des patients issus de cette région.

[Update on leptospirosis]

Leptospirosis is a worldwide spirochetal zoonosis whose global incidence is increasing and is probably underestimated. Leptospirosis has long been associated with occupational contact with animals (rats and cattle) and has become in developed countries a pathology more related to recreational activities with exposure to fresh water (canoeing, swimming, canyoning) and to an environment contaminated by urine from leptospires excretory rodents. Leptospirosis should be one of the differential diagnoses to be considered when returning from travel to tropical areas, particularly Southeast Asia, and particularly during the rainy season. The clinical symptoms, particularly in the initial phase, are not specific and can limit to a flu-like syndrome or "dengue-like" making diagnosis often difficult. It is then necessary to look carefully for clinical (muscle pain, cough, conjunctival involvement, jaundice) and biological arguments (thrombocytopenia, cholestasis, rhabdomyolysis, frank elevation of CRP) that will help to diagnose leptospirosis and lead to quick antibiotic therapy before the progression to a severe icterohaemorrhagic (Weil's disease) or respiratory form associated with significant mortality. Treatment is based on injectable beta-lactams in severe forms (mainly cephalosporins) and amoxicillin, doxycycline or azithromycin in non-severe forms. Some atypical or delayed forms of leptospirosis occurring in the late immune phase of the disease are to know. Rapid diagnostic tools are currently being studied to improve diagnosis in remote areas and facilitate access to early treatment.