Authors: Swathi Kiran Pothumarthy , Praveen Kumar Tirlangi , Kavitha Saravu , Asish Kishore , Basrur Roopa Acharya , Swamy M. Kanur , Sreeja Gandhamsetty

Abstract

Background: Leptospirosis, a zoonotic infection caused by Leptospira bacteria, presents with symptoms ranging from mild flu-like signs to severe multiorgan failure. A rare but serious complication of leptospirosis is thrombotic microangiopathy (TMA). This case report discusses the treatment of a 52-year-old female with leptospirosis complicated by TMA, highlighting the effectiveness of plasma exchange and corticosteroids in her recovery.
Case Presentation: A 52-year-old female presented with a five-day history of fever and progressive shortness of breath. Upon
admission, she had tachypnoea, a partial pressure of oxygen in arterial blood (PaO2) to the fraction of inspiratory oxygen
concentration (FiO2) ratio of 61, and bilateral lung infiltrates, requiring invasive mechanical ventilation and prone positioning.
Laboratory tests revealed anemia, thrombocytopenia, schistocytes, and elevated lactate dehydrogenase, suggesting TMA. The
patient also showed elevated liver enzymes and signs of a potential diagnosis of thrombotic thrombocytopenic purpura, though serological tests for tropical infections, including leptospirosis, were initially negative. The patient was treated with plasma exchange and corticosteroids, leading to improvements in her hematological parameters and acute respiratory distress syndrome (ARDS). However, she developed unexplained blood pressure and heart rate fluctuations, and electroencephalogram confirmed focal seizures, which were treated with levetiracetam and propofol. Subsequent serological testing confirmed leptospirosis with positive Immunoglobulin M antibodies and Leptospira polymerase chain reaction testing. The patient was treated with doxycycline and ceftriaxone, resulting in significant improvement, successful extubation, and eventual discharge.
Conclusion: This case highlights the challenges of managing leptospirosis complicated by TMA and severe ARDS. Plasma
exchange and corticosteroids were essential in the patient’s recovery. The initial delay in diagnosis due to negative serological
tests underscores the importance of maintaining a high index of suspicion for leptospirosis in severe tropical illness cases with
TMA. The patient’s positive response to treatment, including resolution of seizures and hemodynamic instability, demonstrates
the value of prompt and targeted interventions. The case emphasizes the need for a multidisciplinary approach in managing
complex leptospirosis cases with severe complications.

Keywords: Plasma exchange, corticosteroids, thrombotic microangiopathies, acute respiratory distress syndrome, leptospirosis.