QJM Advance Access published April 29, 2015 QJM: An International Journal of Medicine, 2015, 1–2 doi: 10.1093/qjmed/hcv077 Advance Access Publication Date: 10 April 2015 Case report

CASE REPORT

Leptospirosis and Jarisch–Herxheimer reaction

From the 1Department of Medicine and 2Center for Global Health, Mito Kyodo General Hospital, University of Tsukuba, Ibaraki, Japan Address correspondence to Dr H. Gomi, Center for Global Health, Mito Kyodo General Hospital, University of Tsukuba, 3-2-7 Miyamachi, Mito, Ibaraki 3100015, Japan. email: [email protected]

Learning points for clinicians Although not commonly seen in Japan, the incidence of leptospirosis reported in 2014 was the highest in the past 6 years. It is important to consider leptospirosis among patients who traveled to Okinawa, Japan, and to keep in mind Jarisch–Herxheimer reaction when administering antimicrobial agents to patients with leptospirosis.

likely Jarisch–Herxheimer reaction, not septic shock due to different organisms. The patient got stabilized successfully. The serum taken on admission was sent to the National Institute of Infectious Diseases in Japan, and leptospirosis due to Leptospira kirschneri serovar Grippotyphosa was confirmed by polymerase chain reaction and serology.

Discussion Case report A 59-year-old Japanese man with a history of hypertension presented with a complaint of fever and watery diarrhea. He climbed mountains, got lost accidentally and drunk 2 l of fresh water in the swamp in Okinawa, Japan 2 weeks prior to admission. Physical examinations showed blood pressure 129/ 89 mmHg, heart rate 112/min, respiratory rate 30/min, temperature of 38.5 C and oxygen saturation of 97% on room air. His bilateral palpebral conjunctivas were significantly injected with jaundice. The patient had tenderness to bilateral thighs and lower legs. Table 1 shows the laboratory data on admission. He was admitted to our intensive care unit for severe sepsis and significant hypokalemia. He was also started on ceftriaxone 1 g intravenously every 12 h and levofloxacin 250 mg intravenously every 24 h with a working diagnosis of leptospirosis given his travel history and fresh water exposure. Two hours after administration of ceftriaxone, he started to have shaking chills and fever of 40 C. Systolic blood pressure decreased to 80 mmHg, and diffuse maculopapular skin rash appeared on the trunk and upper and lower extremities. He was immediately intubated and resuscitated with fluids and vasopressors vigorously. At the bedside, this reaction was thought to be most

In Japan, 20–30 cases per year have been reported since 2004.1 In 2014, a total of 28 cases were reported in Okinawa, which was the highest in the past 6 years.2 The serotype of Leptospira detected in this patient was one of the strains found in the previous outbreak in 1999.3 This may suggest that the same strain of Leptospira has been prevalent since 1999. This patient’s clinical course was consistent with Weil’s disease, the most severe disease type of leptospirosis. Jarisch–Herxheimer reaction is known that fever, chills and decreased blood pressure can occur within a few hours after administration of b-lactam antimicrobial agents in patients with infection due to spirochetes. This reaction can be severe enough for significant morbidity and mortality. It is much more often found in the treatment of patients with syphilis. It is relatively rare in patients with leptospirosis. It is reported in 92 people out of 1 228 people (7.49%) who were treated for leptospirosis from 1955 to 2012.4 It is also very difficult to distinguish from other critical illness among returning travelers from endemic areas for multiple diseases such as typhoid and Rickettsial disease. In this patient, we had expected this reaction before administration of antimicrobial treatment in advance, and continued the same treatment without changing antimicrobial agents when he turned into a shock state. When we treat leptospirosis, we

Submitted: 24 March 2015; Revised (in revised form): 29 March 2015 C The Author 2015. Published by Oxford University Press on behalf of the Association of Physicians. V

All rights reserved. For Permissions, please email: [email protected]

1

Downloaded from http://qjmed.oxfordjournals.org/ at Purdue University Libraries ADMN on February 1, 2016

S. Takamizawa1, H. Gomi2, Y. Shimizu1, H. Isono1, T. Shirokawa1,2 and M. Kato1

2

|

QJM: An International Journal of Medicine, 2015, Vol. 0, No. 0

Table 1. Laboratory data On admission

Variable

On admission

Hemoglobin (g/dl) Platelets (per ml) White blood cell count (per ml) Differential count (%) Stab cells Segmented cells Eosinophils Monocytes Sodium (mEq/l) Potassium (mEq/l) Chloride (mEq/l) Calcium (mg/dl) Blood urea nitrogen (mg/dl) Creatinine (mg/dl) Glucose (mg/dl) Uric acid (mg/dl) Protein (g/dl) Total Albumin Alkaline phosphatase (IU/l) c-glutamyltransferase (IU/l) Asparate aminotransferase (IU/l) Alanine aminotransferase (IU/l)

13.0 8.4  104 6600

Lactate dehydrogenase (IU/l) Creatine phosphokinase (IU/l) Total bilirubin (mg/dl) Direct bilirubin (mg/dl) C-reactive protein (mg/dl) Prothrombin time (sec) PT-INR PT% (%) Activated partial thromboplastin time (sec) Fibrinogen (mg/dl) Blood fibrinogen/fibrin degradation products (mg/ml) D-dimer (mg/ml) Urine test Urinary protein (mg/dl) Occult blood reaction Blood gases pH Partial pressure of carbon dioxide (mmHg) Partial pressure of carbon oxygen (mmHg) Bicarbonate (mmol/l) Base excess (mmol/l) Lactate (mmol/l)

290 599 3.5 2.3 18.97 14.5 1.27 64.8 47.5 923 12.9 3.1

23.0 62.0 2.0 3.0 137 2.8 100 7.8 70 3.25 107 11.2 6.2 2.4 651 338 104 84

need to expect this reaction in advance. This reaction is an important reminder for clinicians. Although not common in Japan, the increasing incidence of leptospirosis is an important public health problem. Leptospirosis requires prompt diagnosis and treatment to prevent adverse outcomes. It is necessary to manage patients with potentially fatal illness. Leptospirosis is one of the top differential diagnoses among febrile patients with a travel history to Okinawa, Japan. Thorough history taking of exposure to fresh water while traveling would help focus on differential diagnosis among patients returned from endemic areas. This case provides an instructive reminder to clinicians to consider leptospirosis among patients with a travel history to Okinawa, Japan, and Jarisch–Herxheimer reaction when managing patients with leptospirosis. Conflict of interest: None declared.

100 3þ 7.459 25.8 85.5 18.0 3.5 1.40

References 1. Infectious Disease Surveillance Center, Okinawa. Incidence of leptospirosis. http://www.idsc-okinawa.jp/news/leptospir osis/leptospirosis_2006-2013.pdf (21 March 2015, date last accessed) (in Japanese). 2. Infectious Disease Surveillance Center, Okinawa. Incidence of leptospirosis. http://www.idsc-okinawa.jp/news/leptospir osis/leptospirosis_2014.pdf (21 March 2015, date last accessed) (in Japanese). 3. Narita M, Fujitani S, Haake DA, Paterson DL. Leptospirosis after recreational exposure to water in the Yaeyama islands, Japan. Am J Trop Med Hyg 2005; 73:652–6. 4. Guerrier G, D’Ortenzio E. The Jarisch-Herxheimer reaction in leptospirosis: a systematic review. PLoS One 2013; 8: e59266.

Downloaded from http://qjmed.oxfordjournals.org/ at Purdue University Libraries ADMN on February 1, 2016

Variable

Leptospirosis and Jarisch-Herxheimer reaction.

Leptospirosis and Jarisch-Herxheimer reaction. - PDF Download Free
53KB Sizes 1 Downloads 12 Views