Case Presentation – Infections 5

History

A 35-year-old male presented to the emergency department with a 5-day history of fever, headache, myalgia, and jaundice. He reported recent exposure to floodwaters while cleaning his basement. He had no significant past medical history and was not on any regular medications.

Examination

On examination, the patient appeared ill and icteric. Key findings included:

  • Vital Signs:
    • Temperature: 39.5°C
    • Blood Pressure: 110/70 mmHg
    • Heart Rate: 100 bpm
    • Respiratory Rate: 18 breaths per minute
  • General Examination:
    • Icterus present
    • Conjunctival suffusion (redness without exudate)
  • Cardiovascular System:
    • Normal heart sounds, no murmurs
  • Respiratory System:
    • Clear breath sounds bilaterally
  • Abdominal Examination:
    • Mild tenderness in the right upper quadrant
    • No hepatosplenomegaly
  • Neurological Examination:
    • No focal neurological deficits

Laboratory Investigations

Initial laboratory investigations revealed:

  • Complete Blood Count (CBC):
    • WBC: 15,000 cells/mm³ (Elevated)
    • Hemoglobin: 12 g/dL (Normal)
    • Platelets: 100,000 cells/mm³ (Low)
  • Liver Function Tests (LFTs):
    • Total Bilirubin: 5 mg/dL (Elevated)
    • Direct Bilirubin: 3 mg/dL (Elevated)
    • AST: 200 IU/L (Elevated)
    • ALT: 180 IU/L (Elevated)
    • Alkaline Phosphatase: 150 IU/L (Elevated)
  • Renal Function Tests:
    • Blood Urea Nitrogen (BUN): 30 mg/dL (Elevated)
    • Creatinine: 2.0 mg/dL (Elevated)
  • Urinalysis:
    • Proteinuria: +++
    • Microscopic hematuria: Present
  • Serology:
    • Leptospira IgM: Positive

Differential Diagnosis

Given the clinical presentation and initial laboratory findings, the differential diagnosis included:

  1. Leptospirosis
  2. Viral Hepatitis (A, B, C)
  3. Malaria
  4. Dengue Fever
  5. Sepsis of unknown origin

Ruling Out Differentials

  1. Viral Hepatitis:
  • Serology for Hepatitis A, B, and C were negative.
  • Liver function tests were elevated, but the serological markers were not supportive of viral hepatitis.
  1. Malaria:
  • Peripheral blood smear for malaria parasites was negative.
  • Rapid diagnostic tests for Plasmodium species were negative.
  1. Dengue Fever:
  • Dengue NS1 antigen and IgM/IgG were negative.
  • The presentation of jaundice and renal dysfunction was less typical for dengue.
  1. Sepsis:
  • Blood cultures were negative.
  • The absence of a clear source of infection and the specific history of exposure to floodwaters made leptospirosis more likely.

Final Diagnosis

The patient’s history of exposure to contaminated water, along with the clinical presentation of fever, myalgia, jaundice, conjunctival suffusion, and renal involvement, were highly suggestive of leptospirosis. This diagnosis was confirmed by the positive serology for Leptospira IgM antibodies.

Conclusion

Leptospirosis should be considered in patients presenting with a febrile illness, jaundice, renal dysfunction, and conjunctival suffusion, particularly with a history of exposure to potentially contaminated water. The diagnosis relies on a combination of clinical suspicion and confirmatory serological tests. In this case, the prompt identification and differentiation from other similar conditions were crucial for the effective management and recovery of the patient.

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