Leptospirosis with Severe Acute Kidney Injury & Jaundice: A Review of 2 Cases

Abstract

Introduction: Leptospirosis is a zoonosis of global significance due to infection with Leptospira spp., a motile, obligate aerobic, spiral bacteria from contaminated soil, water or rat urine. This infection may have variable and protean manifestations. We present two cases of severe acute kidney injury (AKI), hyperbilirubinemia in association with sepsis due to Leptospiral infection seen in Hamilton, Bermuda. In many cases the disease may be mild, but severe cases with AKI and hepatic involvement with jaundice (Weil’s disease) require prompt diagnosis and institution of therapy to prevent morbidity and mortality. In some cases the diagnosis may be delayed. The aim of this paper is to report two cases in which rapid diagnosis and therapy led to good outcome and recovery. WE also review the literature on AKI in Weil’s disease.

Case Presentation: We present two cases of AKI, & jaundice & hepato-renal syndrome with oliguria of unclear etiology, in which a clinical index of suspicion of possible rat exposure with the patient’s social history led to subsequent testing that confirmed the diagnosis quickly. Both cases presented with sepsis, altered mentation and hyperbilirubinemia. The patients tested positive for Leptospira IgM antibodies suggesting likely recent exposure that precipitated the current illness. Both patients had very severe AKI, and marked conjugated hyperbiliribunimia, but only one required hemodialysis. Both patients received antibiotic therapy with third generation cephalosporins (Piperacillin-Tazobactam, Ceftazidime) & Doxycycline for 2 weeks, with improvement and resolution of AKI. One patient had residual chronic kidney disease (CKD).

Conclusion: Leptospriosis can present in severe cases with AKI and hyperbilirubinemia and organ failure (Weil’s disease). This pattern may be seen in endemic areas and occasionally in non-endemic areas. A high index of suspicion and awareness is critical to facilitate early diagnosis and therapy. It should be considered in the differential diagnosis of AKI and conjugated hyperbilirubinemia and severe sepsis. Antbiotic therapy should be instituted early while waiting for serologic confirmation to improve outcome. Recovery from AKI may be incomplete in some cases.