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A5177 - Oh Rats, Weil’s Disease and Fulminant Hepatic Failure Complicated by Cerebral Candidiasis
Author Block: S. Iusim1, D. R. Fraidenburg2; 1Medicine, University of Illinois at Chicago, Chicago, IL, United States, 2Medicine - Pulmonary/Critical Care, Chicago, IL, United States.
Introduction: Leptospirosis is the most widespread zoonotic disease in the world but is relatively rare in the United States. Disease manifestations can vary from subclinical to severe multi-organ failure ultimately leading to death. Weil’s disease is the clinical syndrome of liver and renal failure in the setting of leptospirosis infection. Here we present a case of Weil’s disease complicated by systemic candidiasis and cerebral abscess.
Case: A 46 year old construction worker with no past medical history presents with weakness and leg pain for five days that progressed to multi-organ failure requiring vasopressors, endotracheal intubation, renal replacement therapy for anuric acute kidney injury and fulminant hepatic failure prior to being transferred to our tertiary care center. Initial concern was for urosepsis however cultures were unrevealing. Despite broad spectrum antibiotics and stress dose steroids his clinical condition remained critical. CT abdomen showed evidence of fatty liver, but was otherwise unremarkable. Extensive work-up for fulminant hepatic failure, including hepatitis serologies, legionella antigen, and autoimmune studies were negative. Complement levels and ceruloplasmin were low but he had no further stigmata of Wilson’s disease. Ultimately, leptospirosis PCR returned positive. He was maintained on treatment with ceftriaxone for Weil’s disease. Despite appropriate antibiotics; renal failure, liver failure, and severe encephalopathy persisted. Candidemia and fungal peritonitis were identified and treated with amphotericin B. Further deterioration in his mentation prompted imaging that revealed a right frontal cerebral abscess as complication of disseminated candidiasis. Severe, treatment-resistant fungemia and abscesses were presumably a complication of his critical illness and hepatic failure from which he ultimately succumbed.
Discussion: Fulminant leptospirosis, otherwise known as Weil’s disease, is a rare but important cause of multiorgan failure. Infection of Leptospira interrogans, a pathogenic spirochete, is often transmitted by infected rodents shedding the organism from their urine into the environment. It has a variable presentation in humans requiring an astute physician to make the diagnosis. Patients with leptospirosis sent to the ICU have over 50% mortality, yet as a treatable infectious disease it is thought that early recognition and appropriate antimicrobials can prevent these severe complications. Chicago has seen a surge in its rat population and the 46,879 rat complaints in 2016 were considered the highest in the country by Orkin pest control. This patient’s likely exposure was through contaminated water in his construction job. This case raises concerns for a rise in leptospirosis and other zoonotic infections given our rapidly increasing rat population.