Thrombotic thrombocytopenic purpura (TTP) complicating leptospirosis: a previously undescribed association

Weil's Disease in an HIV-Infected Patient: A Case Report and Literature Review

Weil's disease, an icterohemorrhagic infection, is the most severe and fatal form of leptospirosis and is characterized by jaundice, renal dysfunction, and hemorrhagic predisposition. Weil's disease with HIV infection has rarely been reported. A 68-year-old male with HIV infection presented to our hospital with fever and dyspnea that progressed to severe hemoptysis and systemic multiple organ failure, necessitating a tracheal intubation ventilator. A diagnosis of Weil's disease was made after Leptospira interrogans was identified via metagenomic next-generation sequencing (mNGS) in bronchoalveolar lavage fluid (BALF). After immediately receiving supportive therapy and targeted antimicrobial agents, the patient achieved complete recovery upon discharge. The co-infection of HIV infection and leptospirosis resulting in systemic multi-organ failure is rare, but awareness should be raised of the differential diagnosis. mNGS can help identify pathogens and facilitate the use of targeted and efficacious antimicrobial therapy in unusual clinical environments.

Leptospirosis in an asplenic patient -case report

Background

The presentation of clinical leptospirosis has been historically associated with animal workers, slaughterhouse workers and medical veterinarians. This association has shifted to be related to flooding events and outdoor activities; few cases are related to high-risk factors found in immunosuppressed patients. Scarcely a handful of cases have serological evidence of immune response against Leptospira serovar Bratislava representing serogroup Australis, a serovar associated with poor reproductive performance in swine and horses, and recently with cats.

Case presentation

Herein, we describe a rare clinical presentation of disseminated Leptospira infection in an immunosuppressed 65-year-old woman. She was admitted to the emergency room with fever, bacteraemia, bilateral uveitis and pulmonary involvement. The patient denied outdoor activities; she only had wide exposure to faeces and urine from cats living in her home. Her medical history included idiopathic thrombocytopenic purpura (ITP) diagnosed at the age of 18. She did not respond to medical treatment, and a splenectomy was performed. At age 60, she was diagnosed with Chronic Myeloid Leukemia (CML), and was treated with a tyrosine kinase inhibitor (TKI) –Imatinib. The patient voluntarily discontinued the treatment for the last 6 months. After extensive workup, no microorganisms were identified by the commonly used stains in microbiology. The diagnosis was performed through dark-field microscopy, microagglutination test (MAT), Leptospira genus-specific PCR, the IS1500 PCR for identification of pathogenic species, and 16S based sequencing for the genus identification.

Conclusion

Immunosuppressed patients may acquire uncommon infections from ubiquitous microorganisms. In this case, serology evidence of exposure to Leptospira serovar Bratislava by MAT and the presence of the Leptospira genus were identified. It should be on mind for the diagnosis in otherwise healthy patients, and thoroughly search on splenectomised patients exposed to animals. Additionally, this report highlights the usefulness of PCR for diagnosis of this potentially life-threatening illness.

Leptospirosis complicated with Guillain Barre syndrome, papillitis and thrombotic thrombocytopenic Purpura; a case report

Background

Leptospirosis is a zoonosis commonly prevalent in tropical countries. Clinical course of leptospirosis varies from mild to severe disease. Here we present a case of leptospirosis complicated with Guillain-Barre Syndrome (GBS), papillitis, and Thrombotic Thrombocytopenic Purpura(TTP).

Case presentation

A 21-year-old Asian male presented with fever, myalgia, oliguria and dyspnoea where he was managed as for leptospirosis complicated with pulmonary haemorrhages and acute renal failure. Leptospirosis was confirmed by Microscopic Agglutination Test(MAT) with a fourfold rise in antibody titre between acute and convalescent serum. The highest antibody titre was against Leptospira antigen serogroup Semaranga (strain Patoc) (1:1280) followed by serogroup Australis (strain Australis) (1:640) and serogroup Autumnalis (strain Bankgkinang) (1:320). Two weeks later he developed blindness, ascending weakness of lower limbs with global areflexia and an acute inflammatory demyelinating polyradiculopathy(AIDP) variant GBS was confirmed with nerve conduction studies. TTP complicated the picture several days later. He was initiated on plasmapheresis where clinical improvement was seen after 14 cycles. He had an incomplete neurological recovery with permanent vision loss but completely recovered from TTP. He also had permanent renal impairment.

Conclusion

Leptospirosis should be suspected and treated empirically in the relevant clinical settings where it can present with an atypical clinical picture as in our case with an acute febrile illness followed by GBS as well as TTP.

Cavernous sinus thrombosis syndrome and brainstem involvement in patient with leptospirosis: Two rare complications of leptospirosis

Leptospirosis is a bacterial disease that is caused by pathogenic spirochetes of the genus Leptospira. It can affect humans and animals. In humans, it can lead to a wide spectrum of symptoms. It is known as the most common zoonosis in the world. The typical presentation of the disease is an acute biphasic febrile illness with or without jaundice. Less common clinical manifestations may result from involvement of different human body systems. In many places, this disease may be under-diagnosed, especially when associated with neurological complications. Moreover, without treatment, leptospirosis can lead to organ damages, and even death. Neurological complications are uncommon and are reported in a few cases. Cavernous sinus thrombosis syndrome and brainstem involvement are rare complications of leptospirosis and are associated with a high mortality risk. To our knowledge, no such cases have been reported in the literature.

A leptospirosis case presenting with thrombotic thrombocytopenic purpura

BACKGROUND

Leptospirosis is a zoonotic disease caused by spirochetes of the genus Leptospira. While the majority of leptospirosis cases occur in the tropics, some cases are also observed in temperate regions of developing countries. The disease has various clinical presentations ranging from a mild influenza-like form to a severe potentially fatal illness accompanied by multi-organ failure. However, atypical presentations of leptospirosis have occasionally been described. Here, a case of leptospirosis presenting as thrombotic thrombocytopenic purpura (TTP) is reported.

CASE REPORT

A 58-years-old male presented with fever, oliguria, darkening of urine, and visual hallucinations. Laboratory investigations revealed anaemia, severe thrombocytopaenia, elevated total bilirubin with indirect predominance, high lactate dehydrogenase, and increased urea (293 mg/dL) and creatinine (7.6 mg/dL) levels. He was diagnosed with TTP. Patient was thought leptospirosis due to atypical clinical manifestations. Leptospirosis was confirmed by strongly positive Microscopic Agglutination Test. Patient recovered completely with antibiotics and plasmapheresis.

CONCLUSION

Leptospirosis may be accompanied by thrombotic thrombocytopenic purpura in particular subtropic regions.

Systemic infections mimicking thrombotic thrombocytopenic purpura

The absence of specific diagnostic criteria, the urgency to begin plasma exchange treatment, and the risk for complications from plasma exchange make the initial evaluation of patients with suspected thrombotic thrombocytopenic purpura (TTP) difficult. Systemic infections may mimic the presenting clinical features of TTP. In the Oklahoma TTP-HUS (hemolytic-uremic syndrome) Registry, 1989-2010, 415 consecutive patients have been clinically diagnosed with their first episode of TTP; in 31 (7%) the presenting clinical features were subsequently attributed to a systemic infection. All 31 patients had diagnostic criteria for TTP; 16 (52%) had the complete "pentad" of microangiopathic hemolytic anemia, thrombocytopenia, neurologic abnormalities, renal failure, and fever. Four (16%) of 25 patients who had ADAMTS13 measurements had <10% activity; three patients had a demonstrable ADAMTS13 inhibitor. Compared with 62 patients with severe ADAMTS13 deficiency (<10%) who had no recognized alternative disorders, patients with systemic infections had more frequent fever, coma, renal failure, and the complete "pentad" of clinical features. Seventeen different infectious etiologies were documented. A systematic literature review identified 67 additional patients with a diagnosis of TTP or HUS and also a systemic infection. Among all 98 patients, infections with 41 different bacteria, viruses, and fungi were documented, suggesting that many different systemic infections may mimic the presenting clinical features of TTP. Initial plasma exchange treatment is appropriate in critically ill patients with diagnostic features of TTP, even if a systemic infection is suspected. Continuing evaluation to document a systemic infection is essential to determine the appropriateness of continued plasma exchange.

Leptospirosis-associated disturbances of blood vessels, lungs and hemostasis

The frequency of massive pulmonary hemorrhages seems to be increasing in different geographic areas; however, there is no clear explanation for this trend. Although data on the pathogenesis of such complications are scarce, recent research indicates a potential role of autoimmunity and/or multifactorial mechanisms. However, much information is already available on the disturbance of hemostasis and blood vessels in leptospirosis-related literature, even if some contradictory concepts coexist. The purpose of this review is to integrate both new and classical information from human and animal studies on severe pulmonary forms of leptospirosis and disorders of hemostasis and blood vessels. We propose that the involvement of blood vessels in leptospirosis must be understood as a sepsis-like, diffuse process of endothelial activation/damage rather than as a classical systemic vasculitis. Pulmonary hemorrhages are most likely multifactorial and there has recently been evidence against the role of autoimmunity; however, further investigation of strain variations, exposure to hydrocarbons and association with renal dysfunction is required. Thrombocytopenia is a consistent feature of leptospirosis but it is not clear whether it is attributable to sepsis-related mechanisms. In addition, further investigation is required to define whether platelet function is activated or inhibited during severe leptospirosis.

Do infections provoke exacerbations and relapses of thrombotic thrombocytopenic purpura?

Several case reports have suggested an association between infections and thrombotic thrombocytopenic purpura (TTP). In Case 1, a 37-year-old female presented with TTP 6 times over 7 years, requiring 242 therapeutic plasma exchanges (TPE), for a per-course range of 4-57 TPE (median 48), and treatment durations of 4-241 days (median 71 days), largely on account of multiple exacerbations (range 0-3, median 3). Twelve of 17 (71%) of her presentations or exacerbations were associated with suspected infections, with confirmation in 9 episodes. These included pulmonary TB, CMV pneumonitis, mucocutaneous HSV, ventilator-associated or urinary tract-associated gram-negative sepsis, central line-associated staphylococcal bacteremia, and cellulitis. Except for TB, all infections occurred after splenectomy, which had been performed on day 33 of presentation 1. In Case 2, a 24-year-old female presented with TTP 3 times over 15 months. Her courses were managed with brief courses of TPE (5-11 treatments per course, median 5). Suppressed ADAMTS13 levels due to inhibitors were confirmed twice. Presentation 1 was antedated by atypical community acquired pneumonia. Presentation 3 (and possibly 2) followed prolonged, progressive, antibiotic-refractory periodontal infections ultimately requiring exodontic surgery. Our cases add to a literature that suggests that infection may be associated with exacerbations or relapses of TTP in some patients. Our patients demonstrated repeated TTP exacerbations in association with different infectious agents. A better understanding of the possible relationship between infection and clinical expression of TTP might lead to improved treatment decisions for patients with this complex illness.

What role do coagulation disorders play in the pathogenesis of leptospirosis?

Leptospirosis is a zoonosis of worldwide distribution, spread by the urine of infected animals. It is a major public health problem, especially in developing countries, where circumstances for transmission are most favourable. The clinical picture varies from mild disease to a severe illness with haemostatic derangements and multiorgan failure eventually leading to death. Although the haemorrhagic complications of severe disease are serious, the pathophysiology is scarcely elucidated. The complex mechanisms involved in inflammation-induced coagulation activation are extensively studied in various infectious diseases, i.e. Gram-negative sepsis. Tissue factor-mediated coagulation activation, impairment of anticoagulant and fibrinolytic pathways in close concert with the cytokine network are thought to be important. But for human leptospirosis, data are limited. Because of the growing interest in this field, the impact of leptospirosis, and the availability of new therapeutic strategies, we reviewed the evidence regarding the role of coagulation in leptospirosis and provide suggestions for future research.

Thrombocytopenia complicating the clinical course of leptospiral infection

Leptospirosis can present with a wide clinical spectrum, and haematological manifestations are often apparent. We retrospectively analysed platelet counts in 49 patients with leptospirosis. Forty-three patients (87.8%) had thrombocytopenia. Mean baseline platelet counts rose from 69 x 10(9)/l to 151 x 10(9)/l following treatment. Haemorrhagic episodes were observed in 11 patients. Platelet nadir was 29 x 10(9)/l in the group experiencing bleeding and 64 x 10(9)/l in the remainder. Six patients died due to bleeding and one due to sepsis. Thirty-six patients (73.5%) had acute renal failure; their means platelet count was 46 x 10(9)/l. Liver enzyme levels were elevated in all patients. Thrombocyte count, liver enzyme levels and bilirubin levels were significantly correlated. Forty-three (87.8%) patients showed signs of sepsis; mean thrombocyte count was 46 x 10(9)/l in these patients, and 133 x 10(9)/l in those without sepsis. Multiple organ involvement and fulminant disease is usually associated with renal failure and/or thrombocytopenia in leptospirosis.

Leptospirosis

Leptospirosis is a worldwide zoonotic infection with a much greater incidence in tropical regions and has now been identified as one of the emerging infectious diseases. The epidemiology of leptospirosis has been modified by changes in animal husbandry, climate, and human behavior. Resurgent interest in leptospirosis has resulted from large outbreaks that have received significant publicity. The development of simpler, rapid assays for diagnosis has been based largely on the recognition that early initiation of antibiotic therapy is important in acute disease but also on the need for assays which can be used more widely. In this review, the complex taxonomy of leptospires, previously based on serology and recently modified by a genotypic classification, is discussed, and the clinical and epidemiological value of molecular diagnosis and typing is also evaluated.

The hemorrhagic syndrome of leptospirosis: an experimental study in guinea pigs

The hemorrhagic syndrome of leptospirosis was studied in guinea pigs. The study correlates hematological, histopathological and immunohistochemical alterations in sixty animals inoculated by the intraperitoneal route with 1ml of the culture of virulent strain of Leptospira interrogans serovar copenhageni. Leptospirae antigens were detected by immunoperoxidase, chiefly in liver, kidney and heart muscle capillaries. Possible pathogenic mechanisms responsible for hemorrhagic syndrome are discussed with emphasis on toxic and anoxic attacks causing damage to endothelia, platelet depletion and alterations to hemostasia rates: prothrombin time [PT], partial thromboplastin time [PTT] and fibrinogen concentrations. The clinical-laboratory picture is compatible with the histopathological observation of disseminated intravascular coagulation [DIC] in most of the guinea pigs from day 4 of infection.

Thrombotic thrombocytopenic purpura associated with primary tuberculosis

Thrombotic thrombocytopenic purpura (TTP) during infectious diseases is a known, but rare event. In this paper a case of TTP associated with primary infection by Mycobacterium tuberculosis is described. Various therapeutic approaches were used with the patient: fresh frozen plasma infusions and plasma exchange, specific anti-tuberculous therapy, anti-platelet drugs and steroids. A complete remission occurred 3 months after the onset of the acute disease. A hypothesis on the pathogenesis of TTP might be an increased pro-coagulant activity of interleukin 1 (IL-1) on endothelial cells.