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Leptospirosis presenting as atypical pneumonia, respiratory failure and pyogenic meningitis
Journal of Infection (1993) 27, 281-283
CASE REPORT L e p t o s p i r o s i s p r e s e n t i n g as a t y p i c a l p n e u m o n i a , r e s p i r a t o r y failure and pyogenic meningitis F. S. S. Alani, M. P. Mahoney, L. P. Ormerod, P. A. Wright and M. Garrues
Departments of Medicine and Bacteriology, Blackburn Royal Infirmary, Blackburn, Lancashire BB2 3LR, U.K. Accepted for publication I4 May I993 Summary A 2o-year-old man who looked after a pack of hounds was admitted with a short history of headache, fever, haemoptysis and muscle cramps. Investigations showed type I respiratory failure with diffuse pneumonitis, pyogenic meningitis and raised liver enzymes. Leptospirosis was suspected and treated with the appropriate antibiotics leading to a full recovery. The diagnosis was confirmed by a titre of 1/256o to Leptospira icterohaemorrhagiae.The case illustrates an unusual presentation of this infection and argues for early antibiotic treatment.
Introduction Leptospirosis is an occupational hazard of farmers, agricultural workers, those engaged in recreational activities involving contact with inland natural waterways, 1'~ and nowadays, less frequently, of sewermen, miners and fishworkers. In the British Isles only two serovars are common, namely i cterohaemorrhagiae and hardjo with rats and cattle as their respective natural reservoirs. 3 T h e disease varies from subclinical infection, an influenza-like episode, to a severe illness with multi-organ involvement dominated by hepatic and renal failure and aseptic meningitis. 2 T h e latter is thought to be mediated by the immunological response to infection. 3 Respiratory involvement as shown by haemoptysis and X-ray abnormalities appears to be common but respiratory failure and adult respiratory distress syndrome ( A R D S ) are unusual. 4-7 We report a case of Leptospira icterohaemorrhagiae presenting as atypical pneumonia with respiratory failure and pyogenic meningitis early in the course of the disease.
Case report A previously healthy 2o-year-old male hunt servant, whose job involved looking after hounds and horses, was admitted with a 4 day history of fever, headache, vomiting, cough, haemoptysis and muscle cramps. H e had retrieved hounds from a sewage ditch a few days before developing symptoms. On admission he was febrile at 39"2 °C, had injected conjunctivae, a tachycardia of I 2 o / m i n and tachypnoea. Scattered crackles were present in both lungs b u t oi63-4453/93/o6o281 +03 $08.00/0
© I993 T h e British Society for the Study of Infection
F. S. S. ALANI ET AL.
282
T a b l e I Laboratory results Parameter ESR Hb WBC Platelets Urea Creatinine Albumen ALT GammaGT Bilirubin Alkaline phosphatase
On admission
5 days
98 i2. 3 4"9 44 io 130 36 43 5o r6 80
II5 io 7'0 39 I7 339 39 78 2Ol 43 94
IO
days 8.6 6-6 i26 29 32o 3o9 23 I44
On discharge
Range/Units
70 I2' 4 x5 367 5"2 97 42 347 298 15 166
< 30 mm/h > I2-5 g/dl 3'5-IO x io9/1 > ioo x lO9/1 3"0-6"6 mmol/1 60-I 20/zmol/1 35-52 g/1 < 45 U/1 < 65 U/1 < r 7 rnmol/1 3o-13o U/1
there were no other signs o f cardiac failure and he had no m u r m u r s . H e had signs of meningeal irritation b u t no focal neurological deficit. Investigations s h o w e d a mild n o r m o c h r o m i c n o r m o c y t i c anaemia, raised liver enzymes and mild renal failure ( T a b l e I). Coagulation tests s h o w e d a p r o t h r o m b i n time o f I6 s (control I4 s), normal kaolin cephalin clotting time and fibrinogen level b u t a raised fibrin degradation p r o d u c t s level o f IOO m g / d l (normal < 50). Cold agglutinins were not detected and direct C o o m b s test was negative. Chest X - r a y (Plate I) showed diffuse nodular shadowing t h r o u g h o u t b o t h lungs. T h e r e was severe arterial hypoxia on air, p O 2 being 6"4 kPa, p C O 2 4"27 kPa, and p H 7"40. T h e E C G was normal except for tachycardia. T h e C S F was t u r b i d and contained 80 R B C and I2OO l e u c o c y t e s / m l , 95 % o f which were p o l y m o r p h o n u c l e a r . T h e C S F protein was 3"5 g/1 with a glucose of 3" I mmol/1. G r a m staining s h o w e d no organisms and tests for p n e u m o c o c c a l and meningococcal antigens were negative. Serological tests s h o w e d a rise in the icterohaemorrhagiae titre on Elisa I g M and micro agglutination test from 40 on admission to 2560 Io days later. T h e initial diagnosis was of atypical p n e u m o n i a and t r e a t m e n t was started with high dose ampicillin (2 g 4 hourly), e r y t h r o m y c i n (I g 6 hourly) and, later, cefotaxime (I g 8 hourly) to cover the possibility of Klebsiella infection. H e m a d e a full recovery with radiological clearance b y the end of the first week. H e was discharged h o m e on day I2 o f admission. Discussion
T h e patient presented, very unusually, with respiratory failure d u e to severe bilateral p n e u m o n i a early in the course o f l e p t o s p i r o s i s ) '5'7 T h e X - r a y picture was consistent with p n e u m o n i a / A R D S with no features to suggest cardiac failure although myocarditis has been r e p o r t e d in leptospirosisfl Chest X - r a y changes have o c c u r r e d in 2 3 - 6 4 % patients in the acute p h a s e ) ' 8, 9 T h e y usually comprise small nodular densities, areas of consolidation or diffuse g r o u n d glass opacities. Several mechanisms including toxin effects, alveolar
Journal of Infection
Plate r
.~
Plate I.
F. S. S. ALANI ET AL.
(Facing p. 282)
Leptospirosis
283
h a e m o r r h a g e and i m m u n e complex reactions 5 are t h o u g h t to u n d e r l y the pathological changes in the lung, b u t the organism can be isolated f r o m the lung in fatal cases with respiratory failure. 1° A n o t h e r possible cause of this failure in leptospirosis is severe and progressive weakness of the respiratory muscles due to i n t r a m u s c u l a r haemorrhage. 5 T h i s patient's response to antibiotics and oxygen was dramatic and argues for the effectiveness o f antibiotics w h e n used in the early phase o f the illness. T h e other interesting feature of the case was the pyogenic meningitis which also presented early in the illness. Meningitis in leptospirosis is usually l y m p h o c y t i c and often occurs d u r i n g the second phase, coinciding with d e v e l o p m e n t o f the i m m u n e response. 3 T h e p o l y m o r p h i c picture and early occurrence suggest that in our patient it was due to the direct effect of infection, b u t the C S F was n o t c u l t u r e d for leptospira. Leptospirosis should be considered in cases of atypical p n e u m o n i a and pyogenic meningitis, especially if there is occupational risk. Early antibiotic t r e a t m e n t , as in this case, m a y have a dramatic effect on the course of the disease. (We wish to thank Dr I. R. Ferguson, County Hospital for carrying out the serological tests and for advice and encouragement.)
I. z. 3. 45. 6. 7. 8. 9. 10.
References Christie AB. Infectious diseases, Vol 2, 4th Ed. Chichester: Churchill Livingstone, I987: 1159-1182. Ferguson IR. Leptospirosis update. Br Med J I991; 3oz: I28-I29. Ferguson IR. Uncommon infections: I. Leptospirosis. Prescribers J I99I; 3I: I85-I89. Ramachandra S, Perera MVF. Cardiac and pulmonary involvement in leptospirosis. Trans R Soc Trop Med Hyg I977; 7I: 56. Overstreet DS, Bowen MG, Hawkins SC, Roy MT. The respiratory complications of leptospirosis. K M A f f 1991 ; 89:27o-273 • Zaltzman M, Kallenbach JM, Goss GD, Lewis M, Zwi S, Gear JHS. Adult Respiratory Distress Syndrome in Leptospira canicola infection. Br Med J I981; z83: 519-52o. Turner JS, Willcox PA. Respiratory failure in leptospirosis. Quart ff Med 1989; 7z: 841-847. Im JG, Yeon KM, Han MC, et al. Leptospirosis of the lung: radiological findings in 58 patients. Am ff Radiol I989; ISZ: 955-959. Lee RG, Terry DTM, Walker TM, Urqhuart AE. The chest radiograph in Leptospirosis in Jamaica. Br ff Radiol I98I ; 54: 935-943Park SK, Lee SH, Rhee YK, et al. Leptospirosis in Chonbuk province of Korea in I987: study of 93 patients. Am J Trop Med Hyg I989; 4I : 345-351.
CASE REPORT L e p t o s p i r o s i s p r e s e n t i n g as a t y p i c a l p n e u m o n i a , r e s p i r a t o r y failure and pyogenic meningitis F. S. S. Alani, M. P. Mahoney, L. P. Ormerod, P. A. Wright and M. Garrues
Departments of Medicine and Bacteriology, Blackburn Royal Infirmary, Blackburn, Lancashire BB2 3LR, U.K. Accepted for publication I4 May I993 Summary A 2o-year-old man who looked after a pack of hounds was admitted with a short history of headache, fever, haemoptysis and muscle cramps. Investigations showed type I respiratory failure with diffuse pneumonitis, pyogenic meningitis and raised liver enzymes. Leptospirosis was suspected and treated with the appropriate antibiotics leading to a full recovery. The diagnosis was confirmed by a titre of 1/256o to Leptospira icterohaemorrhagiae.The case illustrates an unusual presentation of this infection and argues for early antibiotic treatment.
Introduction Leptospirosis is an occupational hazard of farmers, agricultural workers, those engaged in recreational activities involving contact with inland natural waterways, 1'~ and nowadays, less frequently, of sewermen, miners and fishworkers. In the British Isles only two serovars are common, namely i cterohaemorrhagiae and hardjo with rats and cattle as their respective natural reservoirs. 3 T h e disease varies from subclinical infection, an influenza-like episode, to a severe illness with multi-organ involvement dominated by hepatic and renal failure and aseptic meningitis. 2 T h e latter is thought to be mediated by the immunological response to infection. 3 Respiratory involvement as shown by haemoptysis and X-ray abnormalities appears to be common but respiratory failure and adult respiratory distress syndrome ( A R D S ) are unusual. 4-7 We report a case of Leptospira icterohaemorrhagiae presenting as atypical pneumonia with respiratory failure and pyogenic meningitis early in the course of the disease.
Case report A previously healthy 2o-year-old male hunt servant, whose job involved looking after hounds and horses, was admitted with a 4 day history of fever, headache, vomiting, cough, haemoptysis and muscle cramps. H e had retrieved hounds from a sewage ditch a few days before developing symptoms. On admission he was febrile at 39"2 °C, had injected conjunctivae, a tachycardia of I 2 o / m i n and tachypnoea. Scattered crackles were present in both lungs b u t oi63-4453/93/o6o281 +03 $08.00/0
© I993 T h e British Society for the Study of Infection
F. S. S. ALANI ET AL.
282
T a b l e I Laboratory results Parameter ESR Hb WBC Platelets Urea Creatinine Albumen ALT GammaGT Bilirubin Alkaline phosphatase
On admission
5 days
98 i2. 3 4"9 44 io 130 36 43 5o r6 80
II5 io 7'0 39 I7 339 39 78 2Ol 43 94
IO
days 8.6 6-6 i26 29 32o 3o9 23 I44
On discharge
Range/Units
70 I2' 4 x5 367 5"2 97 42 347 298 15 166
< 30 mm/h > I2-5 g/dl 3'5-IO x io9/1 > ioo x lO9/1 3"0-6"6 mmol/1 60-I 20/zmol/1 35-52 g/1 < 45 U/1 < 65 U/1 < r 7 rnmol/1 3o-13o U/1
there were no other signs o f cardiac failure and he had no m u r m u r s . H e had signs of meningeal irritation b u t no focal neurological deficit. Investigations s h o w e d a mild n o r m o c h r o m i c n o r m o c y t i c anaemia, raised liver enzymes and mild renal failure ( T a b l e I). Coagulation tests s h o w e d a p r o t h r o m b i n time o f I6 s (control I4 s), normal kaolin cephalin clotting time and fibrinogen level b u t a raised fibrin degradation p r o d u c t s level o f IOO m g / d l (normal < 50). Cold agglutinins were not detected and direct C o o m b s test was negative. Chest X - r a y (Plate I) showed diffuse nodular shadowing t h r o u g h o u t b o t h lungs. T h e r e was severe arterial hypoxia on air, p O 2 being 6"4 kPa, p C O 2 4"27 kPa, and p H 7"40. T h e E C G was normal except for tachycardia. T h e C S F was t u r b i d and contained 80 R B C and I2OO l e u c o c y t e s / m l , 95 % o f which were p o l y m o r p h o n u c l e a r . T h e C S F protein was 3"5 g/1 with a glucose of 3" I mmol/1. G r a m staining s h o w e d no organisms and tests for p n e u m o c o c c a l and meningococcal antigens were negative. Serological tests s h o w e d a rise in the icterohaemorrhagiae titre on Elisa I g M and micro agglutination test from 40 on admission to 2560 Io days later. T h e initial diagnosis was of atypical p n e u m o n i a and t r e a t m e n t was started with high dose ampicillin (2 g 4 hourly), e r y t h r o m y c i n (I g 6 hourly) and, later, cefotaxime (I g 8 hourly) to cover the possibility of Klebsiella infection. H e m a d e a full recovery with radiological clearance b y the end of the first week. H e was discharged h o m e on day I2 o f admission. Discussion
T h e patient presented, very unusually, with respiratory failure d u e to severe bilateral p n e u m o n i a early in the course o f l e p t o s p i r o s i s ) '5'7 T h e X - r a y picture was consistent with p n e u m o n i a / A R D S with no features to suggest cardiac failure although myocarditis has been r e p o r t e d in leptospirosisfl Chest X - r a y changes have o c c u r r e d in 2 3 - 6 4 % patients in the acute p h a s e ) ' 8, 9 T h e y usually comprise small nodular densities, areas of consolidation or diffuse g r o u n d glass opacities. Several mechanisms including toxin effects, alveolar
Journal of Infection
Plate r
.~
Plate I.
F. S. S. ALANI ET AL.
(Facing p. 282)
Leptospirosis
283
h a e m o r r h a g e and i m m u n e complex reactions 5 are t h o u g h t to u n d e r l y the pathological changes in the lung, b u t the organism can be isolated f r o m the lung in fatal cases with respiratory failure. 1° A n o t h e r possible cause of this failure in leptospirosis is severe and progressive weakness of the respiratory muscles due to i n t r a m u s c u l a r haemorrhage. 5 T h i s patient's response to antibiotics and oxygen was dramatic and argues for the effectiveness o f antibiotics w h e n used in the early phase o f the illness. T h e other interesting feature of the case was the pyogenic meningitis which also presented early in the illness. Meningitis in leptospirosis is usually l y m p h o c y t i c and often occurs d u r i n g the second phase, coinciding with d e v e l o p m e n t o f the i m m u n e response. 3 T h e p o l y m o r p h i c picture and early occurrence suggest that in our patient it was due to the direct effect of infection, b u t the C S F was n o t c u l t u r e d for leptospira. Leptospirosis should be considered in cases of atypical p n e u m o n i a and pyogenic meningitis, especially if there is occupational risk. Early antibiotic t r e a t m e n t , as in this case, m a y have a dramatic effect on the course of the disease. (We wish to thank Dr I. R. Ferguson, County Hospital for carrying out the serological tests and for advice and encouragement.)
I. z. 3. 45. 6. 7. 8. 9. 10.
References Christie AB. Infectious diseases, Vol 2, 4th Ed. Chichester: Churchill Livingstone, I987: 1159-1182. Ferguson IR. Leptospirosis update. Br Med J I991; 3oz: I28-I29. Ferguson IR. Uncommon infections: I. Leptospirosis. Prescribers J I99I; 3I: I85-I89. Ramachandra S, Perera MVF. Cardiac and pulmonary involvement in leptospirosis. Trans R Soc Trop Med Hyg I977; 7I: 56. Overstreet DS, Bowen MG, Hawkins SC, Roy MT. The respiratory complications of leptospirosis. K M A f f 1991 ; 89:27o-273 • Zaltzman M, Kallenbach JM, Goss GD, Lewis M, Zwi S, Gear JHS. Adult Respiratory Distress Syndrome in Leptospira canicola infection. Br Med J I981; z83: 519-52o. Turner JS, Willcox PA. Respiratory failure in leptospirosis. Quart ff Med 1989; 7z: 841-847. Im JG, Yeon KM, Han MC, et al. Leptospirosis of the lung: radiological findings in 58 patients. Am ff Radiol I989; ISZ: 955-959. Lee RG, Terry DTM, Walker TM, Urqhuart AE. The chest radiograph in Leptospirosis in Jamaica. Br ff Radiol I98I ; 54: 935-943Park SK, Lee SH, Rhee YK, et al. Leptospirosis in Chonbuk province of Korea in I987: study of 93 patients. Am J Trop Med Hyg I989; 4I : 345-351.