Leptospirosis manifested with severe pulmonary haemorrhagic syndrome successfully treated with venovenous extracorporeal membrane oxygenation

Current antibiotics for leptospirosis: Are still effective?

Leptospirosis is a recurring zoonotic disease of global significance. Leptospirosis is curable, and antibiotics are available for its treatment. However, little is known about the effectiveness of the currently used antibiotics against different Leptospira species, serovars, and strains. This review aimed to give insight into the anti-leptospiral activities of the currently available antibiotics towards Leptospira strains and their effectiveness in treating and preventing leptospirosis. Anti-leptospiral activities from natural resources were also reviewed. The literature search was conducted using several databases. The majority of Leptospira strains were sensitive to the current antibiotics. Antibiotics can accelerate the defervescence and reduced the occurrence of leptospirosis cases, nevertheless, there is no affirmative evidence on the beneficial effects of the antibiotics compared to placebo in preventing death. Adverse reactions like Jarisch-Herxheimer reactions (JHR) in patients treated with the current antibiotics were also reported. Plants, marine actinobacteria and propolis are shown as potential sources of new anti-leptospiral compounds. Although leptospirosis can still be adequately treated with current antibiotics, continuous susceptibility testing and the development of novel antibiotics especially from natural resources are highly encouraged.

Leptospirosis manifested with severe pulmonary hemorrhagic syndrome successfully treated with veno-venous extracorporeal membrane oxygenation: A case report and literature review

RATIONALE

The mortality rate associated with pulmonary hemorrhage induced by leptospirosis is notably high. Available treatment modalities are limited, and their efficacy has not been fully demonstrated. Here, we present the case report of a patient with leptospirosis-induced pulmonary hemorrhagic syndrome. A 49-year-old male patient was admitted to the Surgical Ward of the Department of Intensive Care Medicine of Fuyang Infectious Disease Clinical College of Anhui Medical University. The patient had initially sought medical attention at a local hospital due to symptoms of fever persisting for 4 days and chest tightness accompanied by hemoptysis for 1 day.

PATIENT CONCERNS

We present the case report of a patient with leptospirosis-induced pulmonary hemorrhagic syndrome. Hemoptysis persisted in our patient during VV-ECMO, although we adjusted the heparin regimen to maintain an activated partial thromboplastin time target value of 50 to 55 seconds.

DIAGNOSES

Leptospirosis-induced pulmonary hemorrhagic syndrome.

INTERVENTIONS

He was immediately intubated and mechanically ventilated and then transferred to our hospital for further medical intervention. Upon arrival at our hospital, he was treated with veno-venous extracorporeal membrane oxygenation (VV-ECMO). Consequently, he was administered penicillin and omacycline for anti-infective therapy. Anti-inflammatory agents, high-dose vasoactive drugs to enhance blood pressure, continuous renal replacement therapy, tracheal sputum aspiration, and ventilator-assisted ventilation were also administered as part of the treatment protocol.

OUTCOMES

After treatment, his inflammation index was significantly decreased, the amount of pulmonary bleeding was reduced, his oxygenation ratio was improved, and the pulmonary lesions were absorbed. Consequently, he was discharged on the 34th day of hospitalization.

LESSONS

We successfully treated a case of leptospirosis pulmonary hemorrhagic syndrome using VV-ECMO combined with prudent anticoagulant therapy.

Leptospirosis transmitted from a pet dog

Leptospirosis is a widespread zoonosis in tropical regions and it is not frequently recognised in developed countries. We report a case of leptospirosis transmitted from a pet dog. A middle-aged woman was referred to our emergency department with a 7-day history of fever and diarrhoea. She presented with hypotension, tachycardia, grasping pain in the entire muscle and petechiae. A detailed medical interview revealed that her pet dog had been to the veterinarian 1 month earlier with similar symptoms. We treated her with intravenous antibiotics. The patient's diagnosis of leptospirosis was confirmed by serological testing and the detection of DNA in her urine. We contacted the veterinarian and shared the information. We found that the dog had suffered from leptospirosis based on serological testing. We emphasise the possibility of leptospirosis being transmitted from pet dogs. Persistent suspicion of leptospirosis will contribute to its diagnosis and improved public health.

The Na/K-ATPase role as a signal transducer in lung inflammation

Acute respiratory distress syndrome (ARDS) is marked by damage to the capillary endothelium and alveolar epithelium following edema formation and cell infiltration. Currently, there are no effective treatments for severe ARDS. Pathologies such as sepsis, pneumonia, fat embolism, and severe trauma may cause ARDS with respiratory failure. The primary mechanism of edema clearance is the epithelial cells' Na/K-ATPase (NKA) activity. NKA is an enzyme that maintains the electrochemical gradient and cell homeostasis by transporting Na+ and K+ ions across the cell membrane. Direct injury on alveolar cells or changes in ion transport caused by infections decreases the NKA activity, loosening tight junctions in epithelial cells and causing edema formation. In addition, NKA acts as a receptor triggering signal transduction in response to the binding of cardiac glycosides. The ouabain (a cardiac glycoside) and oleic acid induce lung injury by targeting NKA. Besides enzymatic inhibition, the NKA triggers intracellular signal transduction, fostering proinflammatory cytokines production and contributing to lung injury. Herein, we reviewed and discussed the crucial role of NKA in edema clearance, lung injury, and intracellular signaling pathway activation leading to lung inflammation, thus putting the NKA as a protagonist in lung injury pathology.

Leptospirosis in Malaysia: current status, insights, and future prospects

Among zoonotic infections, leptospirosis has a worldwide distribution and high prevalence in tropical regions. It has a broad clinical presentation from mild to severe, life-threatening infection. Leptospires, the etiological agent of leptospirosis, are found in varied ecological niches and animal species, providing a significant source of human infection. This review aims to provide the current status of leptospirosis in Malaysia and the direction for future studies. The literature search for this review was performed using PubMed, Web of Sciences, and Google Scholar databases. The incidence of leptospirosis in Malaysia from 2004 to 2020 varied; however, a large number of cases occurred during floods. Leptospira has been isolated from wild and domestic animals as well as from the environment; among them, several novel species have been identified. In Malaysia, leptospirosis infection and death were mostly associated with recreational and non-recreational water activities. Despite the endemicity of leptospirosis, the public's knowledge, attitude, and practice level are relatively low in this country. More studies are needed in Malaysia to explore the extent of leptospirosis in different settings and locations.

Outcome of severe leptospirosis presenting with ARDS in respiratory ICU

Introduction

Acute Respiratory Distress Syndrome (ARDS) is a rare presentation and a major complication of leptospirosis associated with high mortality despite advances in management.

Methods

We conducted a retrospective observational study, in 48 patients presenting with ARDS due to leptospirosis. Clinical presentation, risk factors, management and outcome of patients were noted. Factors associated with survival and mortality were studied.

Results

Our study showed a male preponderance (87%) with a mean age of presentation of 31.5 years. All patients presented with multiorgan failure. PaO2/FiO2 ratio less than 100 on 3rd day was associated with 90% mortality. The requirement for invasive mechanical ventilation carried a mortality risk of 70.4%. Overall mortality was 39.6%.

Conclusion

Leptospirosis can cause serious ARDS with a high case fatality. Prompt treatment with non-invasive mechanical ventilation to maintain haemodynamic stability and intravenous steroids can improve the outcome.

Leptospirosis with pulmonary haemorrhage and multiple organ failure: a case report and literature review

Pulmonary haemorrhage is an important complication of leptospirosis. We herein report an uncommon case of severe pulmonary haemorrhage and multiple organ failure caused by leptospirosis in a 49-year-old man who was previously healthy. He was a farm worker who was admitted to the hospital because of haemoptysis. He had worked in a paddy field 4 days prior to admission. Chest computed tomography revealed pulmonary haemorrhage, which rapidly deteriorated into haemorrhagic shock and multiple organ failure. Based on the patient’s possible history of contact with contaminated water and the DNA sequence of Leptospira detected in his bronchoalveolar lavage fluid, the patient was diagnosed with pulmonary haemorrhagic leptospirosis. Despite the administration of a fluid bolus, norepinephrine, broad-spectrum antibiotics, and haemostatics, and even with administration of a blood transfusion and extracorporeal life support, the pulmonary haemorrhage could not be controlled effectively. The patient eventually died of haemorrhagic shock. Leptospirosis can be a life-threatening disease despite aggressive treatment, even with extracorporeal life support. Next-generation sequencing can provide important diagnostic clues for patients with atypical leptospirotic symptoms.

Leptospirosis as an important differential of pulmonary haemorrhage on the intensive care unit: a case managed with VV-ECMO

Background

Leptospirosis is a potentially fatal zoonosis. It can cause a wide range of symptoms, including diffuse alveolar haemorrhage which occurs in a minority of cases but carries a mortality of over 70%. These patients may present with severe acute respiratory failure. The differential diagnosis for diffuse alveolar haemorrhage is broad whereas prompt diagnosis and treatment can be lifesaving.

Case presentation

A 20-year-old previously fit and well trout farm worker presented with a 3-day history of malaise, fevers, diarrhoea, vomiting and jaundice. He developed haemoptysis, severe headaches, neck stiffness and photophobia on the day of emergency admission. He was anaemic and thrombocytopenic. Anuric acute kidney injury (urea 32, creat 507) required immediate haemofiltration. In view of progressive respiratory failure with four-quadrant lung infiltrates on imaging, he was given broad spectrum antibiotics and pulsed methylprednisolone empirically, in case of a vasculitic pulmonary-renal presentation. He was intubated within 48 h of admission. Despite attempted protective ventilatory management, he remained hypoxaemic and developed pneumomediastinum. He was retrieved to a specialist cardiorespiratory intensive care unit on femoro-femoral mobile VV-ECMO. Three days from admission, results showed positive Leptospira IgM and real-time PCR. Serial bronchoscopies showed old and fresh clots, but not the classical progressive late red tinge of the returned lavage fluid. After eight days, VV-ECMO was weaned, he was extubated three days later, and made a full recovery. At 9 months follow-up, he was clinically better, with resolution of the CT scan findings and near normal lung function, albeit with low normal gas transfer.

Conclusions

Leptospirosis is a rare but important differential to be considered in diffuse alveolar haemorrhage presenting to the ICU, especially in young males. A thorough history for occupational or recreational risk factors may offer the diagnostic clue. Most patients recover fully with antibiotics. However, resulting acute severe respiratory failure can ensue. In this situation, early consideration for respiratory ECMO support offers time for clearance of endobronchial clot, parenchymal recovery, and prevention of ventilator-induced lung injury. Steroids have no clear evidence but may be used to avoid delay in treating suspected vasculitic or autoimmune causes of diffuse alveolar haemorrhage.