At the emergency department, he was dyspneic and hypotensive (blood pressure 87/40mm Hg). He had paraparesis (grade 2/5 of motor power), and no sensory or nitric oxide synthase inhibitors abnormalities. Examination of cranial nerves and cerebellar system did not reveal any remarkable findings; there were no meningeal signs. The results of laboratory testing were as follows: hemoglobin level 14.4g/dL; white blood cell count 9140 cells/mL; bandemia (band form neutrophils: 25–52%); platelet count 18,000/mL (nadir at 10,000/mL); C-reactive protein 16.39mg/dL; fibrinogen 282.9mg/dL and D-dimer 2947.74ng/mL; blood urea nitrogen 31mg/dL; serum creatinine 2mg/dL; sodium 133 meq/L; potassium 3.4 meq/L; serum calcium 1.69mmol/L; inorganic phosphorus 3.4mg/dL; total bilirubin 2.0mg/dL; direct bilirubin 1.1mg/dL; aspartate aminotransferase 228IU/L; alanine aminotransferase 70IU/L; serum total protein 4.9g/dL; albumin 2.4g/dL; amylase 313IU/L; lipase 212IU/L; creatinine phosphokinase 4148 U/L; creatinine kinase-MB 63IU/L; troponin I 0.21μg/L; and lactate dehydrogenase 434IU/L. Lumbar puncture was not done because of bleeding tendency Urinalysis showed 1+ proteinuria, microscopic hematuria (red blood cells: 35–40/high power field, occult blood: 4+), and mild pyuria (white blood cells: 3–5/high power field, pus cells: 1+). Urine and blood cultures were all sterile.
Considering his occupational exposure combined with acute renal and hepatic insufficiency, leptospirosis or Weil’s disease was suspected and penicillin was given. Dopamine with normal saline and platelet transfusion were given to support his blood pressure and prevent spontaneous bleeding. Then, he was admitted to our medical intensive care unit for further care. Intravenous cotrimoxazole was subsequently added to the antibiotic regimen to treat possible Staphylococcus aureus discitis. Respiratory distress was treated with bi-level positive airway pressure and methylprednisolone (40mg every 8hours). Chest X-ray showed cardiomegaly and increased interstitial infiltration of both lungs, consistent with pulmonary vascular congestion. Patchy consolidation in bilateral lungs was suspicious for active infectious process (Fig. 1). Intravenous fluids were reduced due to congested lung on the fourth day in hospital, and methylprednisolone was tapered to 20mg every 12hours on the sixth day in hospital. Acute serum Mycoplasma pneumoniae antibody was negative (<1:40), IgM antibodies for Leptospira detected with indirect hemagglutination test (Focus Diagnostics, Cypress, CA, USA; associated with 92% sensitivity and 95% specificity), and the microscopic agglutination test (MAT) was negative. High-dose methylprednisolone therapy resulted in a dramatic improvement of thrombocytopenia, pneumonia and resulting acute respiratory distress syndrome. His blood pressure became normal and dopamine was tapered and discontinued, and he had no weakness or numbness of both legs by the second day in hospital. He was then transferred to a medical ward with stable vital signs.
After he was transferred to our ward, magnetic resonance imaging of the lumbar spine was normal, and discitis excluded. Intravenous cotrimoxazole was switched to levofloxacin on the seventh day in hospital to cover most respiratory pathogens, including Mycoplasma and other atypical microorganisms. Nerve conduction studies were suggestive of early polyneuropathy of the right peroneal nerve and bilateral sural nerves. Intravenous methyprednisolone and levofloxacin were discontinued on the 10th and 14th days in hospital, respectively. Gallium scan showed no remarkable findings. C-reactive protein declined to 0.30mg/dL and complete blood count became normal with no bandemia after treatment. He was discharged in an ambulatory state with a normal plate count of 205,000/μL. Other laboratory data, including fibrinogen, creatinine, liver function tests, amylase, lipase, cardiac enzymes, and lactate dehydrogenase all returned to normal. A convalescent serum sample obtained 2 weeks from the date of collection of the first sample showed that M. pneumoniae antibody was 1:160, IgM antibody for Leptospira was weakly positive, and the MAT showed seroconversion with significant antibody titers for Leptospira shermani (1:3200) and Leptospira bataviae (1:400). Blood nested polymerase chain reaction (PCR) demonstrated Leptospira interrogans.