Title : Unexpected Spiral of Events
Abstract:
A 51-year-old Spanish speaking male presented with bilateral calf pain starting after he flew from Puerto Rico to Philadelphia. The patient reported difficulty with ambulation, fevers and chills as well as darker urine, dry throat and motrin use. On admission, his creatinine kinase (CK) was elevated to 800. Bilateral LE ultrasound was negative for DVT. The patient was treated with aggressive IVF resuscitation. An infectious workup for typhoid, dengue, zika, leptospirosis and hepatitis were sent. He was empirically started on ceftriaxone and doxycycline. That night, the patient became hypotensive, febrile and unresponsive to fluids. He was started on pressor support, CXR now showed pulmonary edema. The patient was broadened to vancomycin, cefepime and doxycycline. The next day, the patients blood pressure normalized off of pressors, thick/thin smears were taken which ruled out malaria. CK peaked at 2500.
Leptospirosis IgM antibody came back positive and the rest of the workup came back negative. It was thought that the patient had undergone a Jarish-Herxheimer reaction. It was only after the results came back, on further history, the patient endorsed sleeping outside for fear his house would collapse from earthquakes. It was thought he may have come in contact with rat urine in this situation as a mode of transmission of leptospirosis.
This case illustrates the importance of a doing a proper history, especially when there is a language barrier to ensure key information won’t be missed. As well, this case demonstrates the symptoms of leptospirosis and how treatments may not be so benign, with spirochetes having the ability to cause the Jarish-Herxheimer reaction when treated.
