Haemorrhagic pneumonitis: A rare presentation of leptospirosis.

ND Pai, PM Adhikari 
 Department of Medicine Kasturba Medical College, Mangalore - 575 001, Karnataka, India. , India

Correspondence Address:
N D Pai
Department of Medicine Kasturba Medical College, Mangalore - 575 001, Karnataka, India.
India

Full Text

Leptospirosis is an uncommon zoonosis. As a systemic disease, it presents itself by multisystem involvement. Pulmonary involvement with leptospirosis often is manifested by respiratory symptoms; but pneumonia commonly is not a prominent clinical manifestation of the illness. We report a case of leptospiral pneumonia in which pulmonary manifestations were primary clinical features of the illness.

::   Case history

A 25 year old man presented with history of fever with chills, myalgia and cough with mucoid expectoration of 3 days’ duration. The patient also had confusion and haemoptysis one day prior to admission.

Physical examination on admission revealed tachycardia, tachypnoea, drowsiness (Glasgow coma scale 14/15), icterus, and conjunctival suffusion. He had neck stiffness and positive Kernig’s sign. Examination of respiratory system revealed bilateral crepitations. His oxygen saturation by oximetry was 86%. Initial laboratory studies revealed a total leukocyte count of 11,600 cells/mm3 with 86% neutrophils, 10% lymphocytes, 2% eosinophils and 2% monocytes. Haemoglobin was 14 g/dl and platelet count was 46,000 cells/mm3. Blood urea, serum creatinine, serum bilirubin, proteins, albumin, globulin, alanine aminotransferase, asparatate aminotransferase, alkaline phosphatase and serum electrolytes were within normal limits. Urine analysis was normal. Smear for malarial parasite, blood culture and Widal test were negative. Creatinine phosphokinase was elevated at 3440 IU. Chest X-ray taken on admission revealed reticulonodular shadows bilaterally.

A cerebrospinal fluid sample obtained by lumbar puncture was clear with a protein level of 36 mg/dl and a glucose value of 81 mg/dl. Grams stain revealed mononuclear cells and cells were 25/mm3. Acid-fast bacilli and culture for bacteria were negative. Sputum sample did not disclose any acid-fast bacilli. IgG and IgM antibodies for tuberculosis were negative. Ultrasonography of abdomen was normal.

IgM antibody for leptospira by ELISA technique was negative. In view of the overall condition of the patient and laboratory data, he was presumptively initiated on antitubercular treatment while awaiting culture report for acid-fast bacillus.

Even after two weeks of antitubercular treatment, fever did not subside. His platelet count dropped to 23,000cells/mm3. Blood urea and serum creatinine were raised (Urea – 81 mg/dl, serum creatinine - 1.6 mg/dl). In view of strong clinical suspicion and a falling platelet count, leptospira antibody test was repeated again, which was highly positive ?55.60 Pan Bio units (cut off > 11.00 Pan Bio units)?. The patient was initiated on crystalline Penicillin 10 lakhs IU 6 hourly intravenously. The patient made a dramatic recovery over a period of one week. The chest X-ray revealed resolution of infiltrates after one week of treatment and the patient was discharged from the hospital.

::   Discussion

Pulmonary changes in Leptospirosis are not uncommon[1],[2] but pulmonary symptoms are usually mild and often overshadowed by other organ involvement. The symptoms of Leptospirosis are variable, ranging from fever, myalgia, headache, mental confusion to hepatic-renal failure and hemorrhagic diathesis with significant mortality.[3]

The patho-physiology of pulmonary injury in leptospirosis is poorly understood. It is thought that the vascular pulmonary injury may be the result of immunologic mechanisms with a disseminated intravascular coagulation like reaction from leptospira toxins. In the lungs, the damage to the capillary endothelia, from TNF-? is manifested predominantly as hemorrhagic pneumonitis.[4]

Although pulmonary symptoms are common in Leptospirosis; extrapulmonary complaints dominate the clinical picture. A non-productive cough is the most common pulmonary symptom and occurs in leptospiremic phase. Haemoptysis has been reported in 3-25% and chest pain may occur in 10% of patients.[5]

Abnormal chest X-ray as evidenced by bilateral reticulo-nodular infiltration occurs in about 80-85% of the patients with haemoptysis.[6] These are common in lower lobes and peripheral lung fields. Bilateral interstitial infiltrates on chest X-ray and small pleural effusions are less common.[7] The resolution of infiltrates on chest X-ray occurs faster than in other forms of bacterial pneumonia with complete resolution between 7- 10 days. Patients with severe respiratory disease may require ventilatory support and steroids may be needed for massive haemoptysis. The outcome of patients is determined by circulatory disturbance, serum creatinine and serum potassium levels.[8]

The aim of this case report is to highlight a rare presentation of leptospirosis with pulmonary manifestation and chest X-ray changes that promptly resolved on institution of appropriate therapy. It also brings to the forefront that leptospira antibody may be negative early in course of the disease.[9]

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