Life Threatening Presentation of Weil's Syndrome Complicated by Diffuse Alveolar Hemorrhage
American Journal of Respiratory and Critical Care Medicine
Introduction: Leptospirosis is a zoonotic disease caused by gram-negative Leptospira bacteria. While usually mild in presentation, in rare instances, it may progress to a severe form called Weil’s Syndrome, which can present as diffuse alveolar hemorrhage, liver, and kidney damage. Case presentation: 51-year-old female presented for flu-like symptoms with fever of 103F,generalized joint pain, and abdominal pain for 2 days. Social history was notable for a dog and cat at home. Her initial chest x-ray(CXR), urinalysis, and preliminary blood cultures were negative. Within hours, the patient was intubated for rapidly worsening hypoxic respiratory failure. Subsequently, the patient was started on vasopressors for hypotension. Repeat CXR showed pulmonary edema and vascular congestion. Bronchoscopy revealed diffuse alveolar hemorrhage. Doxycycline and cefepime were started empirically. She had mild transaminitis with hyperbilirubinemia with total bilirubin increasing from 11 to 30 mg/dL and severe thrombocytopenia with platelets decreasing from 280 to 22 bil/L within 4 days from admission. She developed significant acute kidney injury requiring continuous renal replacement therapy. Peripheral blood smear was negative for schistocytes andADAMTS13 levels were >20%. Leptospira IgM titer was initially borderline with repeat testing 1 week later returning confirmed positive. The patient had further extensive hematologic, rheumatologic, and infectious workup which was unrevealing. There were concurrent concerns for hemophagocytic lymphohistiocytosis induced by the severity of infection in which bone marrow biopsy was normocellular. Patient completed a 14 total day course of doxycycline. She was weaned from her vasopressor requirements and successfully extubated. The source of her leptospirosis is thought to be from her dog, as cats are rarely infected. Discussion: Humans are an accidental host for leptospirosis. It accounts for approximately 60,000 deaths worldwide, and only about 100 cases occur in the United States yearly1,3. It is endemic to tropical and subtropical climates. The disease progression is described in two phases. First, the mild anicteric phase, where the infection is self-limited even without treatment occasionally1.10% of cases progress to a severe form, known as Weil’s syndrome, which is characterized by hemorrhage, liver, and kidneydamage1. Mortality associated with pulmonary hemorrhage is up to 70%2. Treatment for severe disease is IV doxycycline1.Conclusion: This case highlights the importance of considering leptospirosis as a differential when encountering diffuse alveolar hemorrhage with unexplained systemic illness. Given its’ rarity in the USA, high index of suspicion for leptospirosis and early initiation of antibiotic coverage can help decrease the mortality.
Xin V, Alsabti S, Manjunath S, Shah P, Grasso-Knight G. Life threatening presentation of Weil's syndrome complicated by diffuse alveolar hemorrhage. Am J Respir Crit Care Med. 2023 May;207(Suppl.):A5655. doi:10.1164/ajrccm-conference.2023.207.1_MeetingAbstracts.A5655