S3391 Severe Hyperbilirubinemia and Multi-Organ Failure in a Patient With Weil’s Disease

Introduction: Leptospirosis is the most common zoonosis worldwide. It's prevalence in the United States is low, with around 100-150 cases annually, mostly in Hawaii and Puerto Rico. It's a bacterial infection caused by Leptospira and is transmitted through direct contact with the urine of infected animals, such as rodents. Symptoms can range from asymptomatic infection to life-threatening multi-organ failure, known as Weil’s disease. Case Description/Methods: A 68-year-old retired man dentist with a medical history only for asthma, presented with 4 days of fever, rigors, nausea, non-bilious non-bloody vomiting, thirst, arthralgia, orange-colored urine, and diarrhea after he ate a tuna sandwich. In the emergency department (ED), he was febrile, tachycardic, and hypotensive despite 3 L of fluids. Physical examination revealed jaundice, and dry mucous membranes. Laboratory results indicated acute kidney injury (AKI), severe thrombocytopenia (platelets 20), leukocytosis (WBC 18,000), and conjugated hyperbilirubinemia (peaking at 22, primarily conjugated) with normal AST, ALT, and ALK. He was admitted to the intensive care unit for septic shock and was started on pressors, hemodialysis and piperacillin/tazobactam. Blood smears were negative for schistocytes. Viral hepatitis panel, including hepatitis C, Epstein-Barr virus (EBV) and cytomegalovirus (CMV) PCRs, were negative. Blood cultures, urine Legionella antigen test and Hantavirus serology were negative. Stool cultures were also negative. A subsequent computed tomography scan of the abdomen revealed large hematomas in the bilateral psoas muscles). A magnetic resonance cholangiopancreatography (MRCP) showed no bile duct dilatation, obstruction, or masses. Due to dropping hemoglobin (HgB), he received multiple blood transfusions. The patient lived near a park with several lakes containing brackish water, where rats frequently ran into his basement. Leptospira PCR returned positive in both blood and urine. He was started on doxycycline with gradual weaning off of dialysis, and made a slow recovery. Discussion: Weil’s disease is a life-threatening disease which presents with non-specific symptoms Key clues include a combination of fever, renal failure, conjugated hyperbilirubinemia with normal or slightly elevated liver enzymes. The combination of previously described symptoms, multiorgan failure, and disproportionate conjugated hyperbilirubinemia with normal to slightly elevated liver associated enzymes should raise suspicion for leptospirosis. Prompt intensive care unit admission and treatment with antibiotics can be life-saving.