Case Discussion
|
A 27-year-old man presented to our emergency room on Aug
22, 2000 with a 5-day history of fever, chills, and bilateral
calf pain. He also complained of diarrhea and mild cough and
hemoptysis. The past history was not remarkable and he had a
part-time job at a Chinese desert company during summer
vacations. He denied recent travel to other countries. Physical
examination revealed a temperature of 38o C and clear breath
sounds. Laboratory studies at the emergency room (Aug 23,
2000) showed leukocytosis, anemia, thrombocytopenia,
hyperbilirubinemia, and renal insufficiency. The abdominal
sonography revealed only a tiny gallbladder polyp. The initial
chest radiograph was clear (Figure 1). Unfortunately,
respiratory distress occurred 1 day later. Physical
examination disclosed icteric sclera, pale conjunctive, coarse
breathing sounds and bilateral basal crackle but without heart
murmur. There was no skin rash, hepatosplenomegaly or
peripheral lymphadenopathy. The follow-up chest radiographs
showed diffuse alveolar infiltrates with rapid progression to
a pattern compatible with acute respiratory distress syndrome
(Figure 2). The
computed tomography of the chest also revealed dense alveolar
consolidation over the dependent portions of both lungs (Figure 3
).
Severe hypoxemia (PaO2 41.9 mmHg) and hypotension
(69/37 mmHg) were noted on Aug 23, so he was intubated and
transferred to the intensive care unit. There was rapid
deterioration of both renal and liver functions (bilirubin
15.3 mg/dL; AST 162 U/L; ALT 57 U/L; ALP 141 U/L; BUN 91
mg/dL; and Creatinine 6.7 mg/dL). The urine legionella antigen
and cultures of blood, urine, and sputum were all negative.
Diagnosis of leptospirosis was highly suspected and was
confirmed based on an initial microagglutination antibody
titer of 1:200 and an 8-fold rise in the paired serum 7 days
later. Penicillin G 12 MU/day was administered but was shifted
to minocycline 400 mg/day on Aug 29 because of drug allergy.
Inverse ratio pressure-controlled ventilation and intermittent
prone positioning were required to maintain arterial oxygen
saturation >= 90%. His chest radiograph and multi-organ failure
improved gradually after Aug 29 and was finally liberated from
mechanical ventilation on Sep 6. Minocycline therapy was
maintained for 2 weeks and he was discharged in a stable
condition on the 20th hospital day. When he was last seen at
the outpatient clinic on Oct 2, he was rather well and the
chest radiograph and all laboratory data were normal.
Laboratory
data
1. CBC/DC:
|
WBC |
RBC |
Hb |
Hct |
MCV |
PLT |
|
K/uL |
M/uL |
G/dL |
% |
fL |
K/uL |
890822 |
11.10 |
4.01 |
11.7 |
34.6 |
86.3 |
27 |
890828 |
29.08 |
3.92 |
11.7 |
33.9 |
86.5 |
159 |
890902 |
9.02 |
4.58 |
13.2 |
40.2 |
88.2 |
23.1 |
2. Coagulation:
|
PT |
PT Cont |
PTT |
PTT Cont |
INR |
|
Sec |
Sec |
Sec |
Sec |
|
890823 |
16.8 |
11.6 |
64.8 |
37.5 |
1.4 |
890902 |
14.7 |
12.1 |
42.8 |
37.9 |
1.2 | 3. DIC Profile
|
3P |
FDP |
D-Dimer |
|
|
ug/ml |
ug/ml |
890824 |
4+ |
40-80 |
2.38 |
890828 |
Negative |
20-40 |
1.16 |
4. Biochemistry
|
BUN |
Cre |
Na |
K |
T-Bil |
D-Bil |
GOT |
GPT |
|
mg/dl |
mg/dl |
mmole/l |
mmole/l |
mg/dl |
mg/dl |
U/l |
U/l |
890822 |
15 |
1.4 |
137 |
3.6 |
5.8 |
890822 |
183 |
|
890823 |
15 |
1.4 |
137 |
3.6 |
5.8 |
|
168 |
162 |
890824 |
91 |
6.7 |
140 |
3.2 |
15.3 |
12.0 |
162 |
57 |
890828 |
63 |
2.8 |
152 |
3.6 |
18.7 |
|
105 |
168 |
890904 |
34 |
1.5 |
141 |
4.6 |
3.7 |
1.1 |
26 |
22 |
5. ABG
|
pH |
PCO2 |
PO2 |
HCO3- |
BE |
condition |
|
* |
mmHg |
mmHg |
mEq/l |
mEq/l |
|
890823 |
7.28 |
38.9 |
82.5 |
17.7 |
-8.0 |
mask, 10 L, FiO2 = 80% |
890830 |
7.31 |
59.3 |
61.0 |
28.9 |
2.0 |
PCV, 80%, I/E:2/1 |
890831 |
7.41 |
46.6 |
69.2 |
28.8 |
4.0 |
PCV, 45%, I/E:1/1,prone |
890907 |
7.38 |
38.2 |
73.8 |
21.8 |
-2.5 |
Mask, 10L, 40% |
6. Legionella urinary Antigen: negative
7. Blood cultures: no aerobic and anaerobic pathogens
Urine cultures: no aerobic pathogens
Sputum cultures: no aerobic pathogens
8. Bronchoscopy: bleeding from right B6 and B10;
Cultures of PSB (protected sheath
brushing): no growt; Cultures of
bronchoalveolar (BAL) fluid : no growth
9. Leptospira titer: (08-24) 1:200 ; (08-31) 1:1600
本病例為一原本身體健康的年輕人。突然產生高燒、畏寒、雙腿肌肉酸痛,輕微咳嗽及咳血之症狀,且有拉肚子及血尿之現象。可推測大概為一全身性之感染症。後來迅速造成肝、腎功能異常且有嚴重的黃疸、出血傾血及呼吸衰竭,可推測可能為較特殊的致病原之嚴重感染,如寄生蟲、較特殊之細菌或病毒等。有拉肚子、腎功能異常、肺炎及呼吸衰竭應考慮
legionellosis, 但legionellosis
少在初期出現嚴重黃疸及咳血。出現黃疸、發燒、腎功能異常會使人聯想到的致病菌中,鉤端螺旋體是必須列入鑑別診斷的。患者曾任職食品工場業務員,工作場所有不少鼠類出沒。職業上也符合應列入leptospirosis的感染對象。因為能及早診斷,及早治療,此病患能於兩週內出院,為一成功治療之典範。
|
|
繼續教育考題
|
|
1.
(D) |
Which of the following
descriptions of leptospirosis is WRONG? |
A | Is caused by spirochete (or
spiral shaped) bacteria |
B | People can catch the disease
from direct contact with animals, such as rodents, raccoons, skunks
and cattle. The disease can also be spread by indirect contact with
the contamination on vegetation, food and water, soil and bedding
materials |
C | The bacteria enter the body
via cuts to the skin, or via the nose, mouth or other mucous
membranes. |
D | Disease can be spread
frequently from person to person |
2.
(C) |
Which of the following
conditions is most compatible with this patient's clinical
manifestations? |
A | Good past eur's syndrome |
B | Hemophagocytic syndrome |
C | Weil's syndrome |
D | Hemolytic uremic
syndrome |
3.
(D) |
Which evidence below
is helpful in the diagnosis of the patient's syndrome? (1) fever
(2) renal dysfunction (3) jaundice (4) consciousness disturbance (5)
cardiovascular collapse |
A | (1), (2), (4) |
B | (2), (3), (4) |
C | (1), (3), (4), (5) |
D | (1), (2), (3), (4), (5) |
4.
(B) |
What kind of the
following occupations are at risk of getting leptospirosis EXCEPT |
A | Farmers |
B | School teachers |
C | Cattle or pig owners |
D | Occupation involving contact
with rats and dogs |
5.
(D) |
Which of the following
conditions should be listed in the differential diagnosis of
leptospirosis? (1) Richettsiosis, (2) Malaria, (3) Yellow fever,
(3) Toxic shock syndrome (4) Hantaan virus infection (5)
Legionnaires’ disease |
A | (1), (2), (4) |
B | (2), (3), (4) |
C | (1), (3), (4), (5) |
D | (1), (2), (3), (4), (5) |
6.
(C) |
Which statement about
the laboratory diagnosis of leptospirosis is WRONG? |
A | A common diagnostic method is
microscopic agglutination test (MAT), which measures the presence of
IgG antibodies. |
B | Positive results of MAT are
represented by a rise in antibody titer greater than 4-fold in the
paired serum (drawn 2 weeks apart) |
C | A positive blood or urine
culture may be obtained within 3 weeks |
D | ELISA to measure IgM
antibodies may also be helpful. |
7.
(C) |
Which of the following
description about the pulmonary involvement of leptospirosis is
wrong? |
A | Reported in 20% to 70% of
patients. |
B | Symptoms are cough,
hemoptysis, and chest pain (usually caused by pulmonary
hemorrhage) |
C | Frequently leads to acute
respiratory distress syndrome (ARDS) |
D | CxR may show patchy alveolar
infiltrates and accentuated lung marking; usually in the lower lung
fields |
8.
(C) |
From the aspect of
public health, which of the following descriptions about
leptospirosis is WRONG? |
A | Worldwide, leptospirosis
infection increases with flooded conditions |
B | Public health authorities
suggest keeping dogs away from children's play areas, including
sandboxes and wading pools in areas with risk for
leptospirosis |
C | There is still no vaccine for
this disease |
D | Farmers or dog owners at risk
for this infection may use oral doxycycline for prevention |
9.
(A) |
Which kind of drug is
recommended for the initial treatment of leptospirosis? |
A | Penicillin G |
B | Third-generation
cephalosporins |
C | Ciprofloxacin |
D | Sulfur drugs |
10.
(D) |
About the treatment of
the leptospirosis, which statement below is WRONG? |
A | Antibiotics should be given
early in the course of the disease |
B | Intravenous antibiotics may be
required for persons with more severe symptoms. |
C | The recommended duration of
treatment is 2 weeks |
D | Drug resistance is seen in
about 40% of
cases |
|