Diffuse alveolar hemorrhage as a presentation of severe anicteric leptospirosis

An 18-year-old Colombian male soldier was referred to our institution for a febrile illness that had progressively worsened over 8 days. His symptoms included fever, general malaise, cough, and hemoptysis, which progressed to respiratory distress, necessitating orotracheal intubation. Chest radiography revealed diffuse bilateral mixed opacities (Figure 1A). A complete blood count showed leukocytosis and neutrophilia, and blood biochemistry showed elevated creatine and phosphokinase levels. Both a rapid IgM test and an IgM ELISA were positive for Leptospira. High-resolution chest computed tomography (Figure 2A and 2B ) revealed a classic pattern of diffuse alveolar hemorrhage, which was subsequently confirmed by bronchoscopy and bronchoalveolar lavage. We initiated ceftriaxone and methylprednisolone pulse therapy at a dose of 1000 mg/day for 3 days, followed by 1 mg/kg/day for 7 days. After treatment, the patient’s clinical condition rapidly improved, enabling successful weaning from mechanical ventilation (Figure 1B). A serum sample collected on day 8 of illness was retrospectively tested using a microscopic agglutination test, which yielded a positive result for Leptospira kirschneri serogroup Cynopteri with a dilution of 1:3,200.

FIGURE 1:
Chest radiograph showing mixed opacities distributed in the parenchyma of all four quadrants of both lungs, without consolidations (A); and complete resolution of the lung infiltrates following treatment (B).

FIGURE 2:
High-resolution chest computed tomography (coronal (A) and transverse (B) planes) showing alteration in the attenuation coefficients of the lung parenchyma due to diffuse ground-glass attenuation of the parenchyma of both lungs, with thickening of the interlobular and intralobular septa and bilateral consolidation in the lower lobes, primarily in the basal segments.

Diffuse alveolar hemorrhage is a rare but potentially life-threatening presentation of human leptospirosis that usually occurs during the icteric phase of the illness^1,2. However, it can occur during the anicteric phase in a small percentage of patients, posing a clinical diagnostic challenge, particularly in critically ill patients^1,2. Although randomized clinical trials are lacking, the use of steroids for the treatment of leptospirosis with diffuse alveolar hemorrhage leads to favorable outcomes and is generally safe³.

ACKNOWLEDGEMENTS

We wish to thank Dr. Lucas S. Blanton for proofreading, editing, and providing constructive review of the manuscript.

REFERENCES

• ¹
  Dolhnikoff M, Mauad T, Bethlem EP, Carvalho CRR. Leptospiral pneumonias. Curr Opin Pulm Med. 2007;13(3):230-5. Available from: https://doi.org/10.1097/MCP.0b013e3280f9df74
  » https://doi.org/10.1097/MCP.0b013e3280f9df74
• ²
  Dong WH, Chen Z. Leptospirosis with pulmonary haemorrhage and multiple organ failure: a case report and literature review. J Int Med Res. 2021;49(5):3000605211019665. Available from: https://doi.org/10.1177/03000605211019665
  » https://doi.org/10.1177/03000605211019665
• ³
  Thunga G, John J, Sam KG, Khera K, Khan S, Pandey S, et al. Role of high-dose corticosteroid for the treatment of leptospirosis-induced pulmonary hemorrhage. J Clin Pharmacol. 2012;52(1):114-6. Available from: https://doi.org/10.1177/0091270010393341
  » https://doi.org/10.1177/0091270010393341

• Financial Support: This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Publication Dates

• Publication in this collection
  05 Feb 2024
• Date of issue
  2024

History

• Received
  01 Dec 2023
• Accepted
  12 Dec 2023