|Year : 2022 | Volume
| Issue : 1 | Page : 34-36
Weil’s disease: A diagnostic dilemma
Trinayani Barua, Anupam Dutta, Sreemanta Madhab Baruah, Sanchu T K Sreeraj, Arijit Das
Department of Internal Medicine, Assam Medical College and Hospital, Dibrugarh, Assam, India
|Date of Submission||08-Nov-2021|
|Date of Acceptance||11-Feb-2022|
|Date of Web Publication||18-Apr-2022|
Department of Internal Medicine, Assam Medical College and Hospital, Dibrugarh, Assam
Source of Support: None, Conflict of Interest: None
Leptospirosis is a zoonotic disease that predominantly occurs in tropical and subtropical areas. It is caused by the spirochete Leptospira interrogans complex and may lead to syndromes that can vary from a subclinical infection or a mild febrile infection to a severe icterohemorrhagic condition. This is a case report on a 52-year-old farmer who had presented with upper gastrointestinal (GI) bleed. He was initially thought to be a case of complications of Chronic Liver Disease. However, he was later found to have icterus, renal failure, and hemorrhagic manifestations and his IgM ELISA for leptospira was positive. It was later confirmed by MAT. He was treated with antibacterials and supportive measures and his clinical and biochemical parameters improved. The occurrence of Weil’s disease in the month of November and its occurrence in the state of Assam, India was unpredictable and hence posed as a diagnostic dilemma. It is a curable disease and hence needs timely intervention and treatment. This highlights the need for a better understanding of the natural course of this disease and improvement of public health measures.
Keywords: Assam, IgM ELISA, leptospirosis, Weil’s disease
|How to cite this article:|
Barua T, Dutta A, Baruah SM, Sreeraj ST, Das A. Weil’s disease: A diagnostic dilemma. Assam J Intern Med 2022;12:34-6
| Introduction|| |
Leptospira interrogans complex, a pathogenic spirochete, causes a zoonosis of worldwide distribution known as Leptospirosis. This disease has a worldwide occurrence with higher prevalence in tropical and subtropical climates than temperate regions and with susceptibility during flooding in monsoon seasons. Rodents, predominantly rats are important reservoirs of this spirochete and urinary shedding of organisms from infected animals is the most significant source of Leptospira spp. Adults are more frequently involved especially in reported cases of severe illness. Majority of cases are mild, febrile illness with gradual improvement in days to weeks but a minority of patients develop a severe form with multiorgan involvement. Weil’s disease is characterized by multiorgan involvement presenting with significant jaundice (mostly conjugated hyperbilirubinemia), very high fever, acute renal failure, hepatic necrosis, pulmonary involvement, cardiovascular complications (arrhythmias and heart failure), neurologic changes, and hemorrhagic diathesis. We encounter cases of Leptospirosis in the Brahmaputra valley of upper Assam, mostly during the monsoon season, frequently in adults involved with cultivation and farming. Cases show a higher prevalence in those years when there are heavy rains and floods. A high level of suspicion is required to diagnose such cases as they mimic septicemia, acute on chronic liver failure (ACLF), chronic kidney disease (CKD), and other febrile illnesses with multisystem involvement.
| Case Presentation|| |
A 52-year-old male, farmer by occupation, in the month of November, presented to emergency department in shock (Blood pressure 80/40 mmHg) with the chief complaints of four episodes of hematemesis and three episodes of melena. With a significant background history of chronic ethanol use, a provisional diagnosis of Chronic liver disease with upper gastrointestinal (UGI) bleed was made. Intravenous line was secured and management was focused toward hemodynamic stabilization with urgent requisition of packed red blood cells. On questioning further, a history of fever with myalgia 2 days prior to admission which had subsided already, was extracted. On examination, patient was febrile (temperature 100˚F), had tachycardia (110/min), sclera and skin showed presence of icterus and ecchymosis.
Preliminary investigations showed hemoglobin to be 9.2g/dl, TLC 10,100 with 85% neutrophils, platelet 90,000, total bilirubin 14.8 mg/dl with direct bilirubin 10 mg/dl and indirect bilirubin 4.8 mg/dl, AST 160U/L and ALT 53U/L, albumin 2.9g/dl, creatinine 2 mg/dl, PT INR 2.1. Patient was treated in line of Acute on Chronic Liver Failure and his vitals were stabilized. However, on Day 3, he developed anuria, pain abdomen and confusion. His creatinine rose to 7.7 mg/dl and liver function tests showed Total bilirubin to be 26 mg/dl with direct bilirubin being 23.1 mg/dl and indirect bilirubin 2.9 mg/dl. His total counts were 19000 and hemoglobin was 8.2 mg/dl. Due to complaint of pain in abdomen, his serum amylase and lipase were also sent which came out to be 322U/L and 1300U/L respectively. His plan of treatment was now in line of Sepsis with Multiorgan failure. He had to undergo 2 settings of hemodialysis. Meanwhile, he was tested for Hepatitis A,B,C,E, dengue serology, Malarial antigen, HIV1 and 2 all of which came out to be negative. However, his Elisa for IgM Leptospira was positive which was confirmed by MAT. Doxycycline was added at 100 mg IV BD after a loading dose of 200 mg IV along with other supportive treatment. Subsequently, the patient gradually improved clinically and on day 12, his blood parameters showed decline in creatinine, bilirubin, total count to 2 mg/dl, 8.1 mg/dl and 11,000 respectively. After a stay of 18 days in hospital, the patient was finally discharged and was asked to follow up.
| Discussion|| |
Leptospirosis is one of the most widely prevalent zoonosis which is often neglected. It is caused by the spirochete genus of Leptospira. Human infection results from coming into contact with carriers such as rodents or environment contaminated with urine of chronically infected rodents and mammals. Farmers, sewer workers, and plumbers are at higher risk of acquiring the disease.
The spectrum of disease varies from a mild to a fatal disease. The mild form of leptospirosis presents as a nonspecific flu-like illness while a few may progress to a severe form of leptospirosis which is known as Weil’s disease. It presents as a multiorgan dysfunction involving the kidney, liver, brain, and lungs. Renal failure is a hallmark of this form. This icterohemorrhagic form presents with signs of bleeding like petechiae, ecchymoses, epistaxis as well as severe gastrointestinal bleed and pulmonary hemorrhage. A high degree of suspicion is required to diagnose this condition. Timely initiation of antibiotics may prevent its progression to severe forms and prevent mortality of patients.
In our patient, leptospirosis was not considered as the initial diagnosis as it is quite uncommon in this part of the country. Very few cases have been reported from Assam. Moreover, the patient presented in the month of November which was an unlikely time for Weil’s disease to occur. He was initially treated as a case of upper GI bleed. However, the advent of acute renal dysfunction, acute liver failure and acute pancreatitis with history of fever and myalgia helped us to suspect Weil’s disease. His clinical as well as biochemical parameters began to improve after initiating the regimen against leptospirosis. Clinical as well as serological diagnosis of this condition are the prerequisites for saving one’s life. This is a curable disease and hence proper treatment should be started at the earliest.
| Conclusion|| |
Weil’s disease is a great masquerader. It may present as mild as a flu or as severe as icterohemorrhagic fever. A high clinical suspicion with the help of serological investigation can help us to diagnose this condition. Epidemiologically, this disease is uncommon in the state of Assam as well as in the month of November. This throws light towards the need for a better understanding of the natural course and pathogenesis of this disease. Moreover, an improvement in public health measures are of utmost importance. A high index of clinical suspicion is needed for early commencement of antibiotic therapy and revert this potentially fatal disease.
We would like to thank Dr. Mridusmita Handique, assistant professor of Internal Medicine, Assam Medical College and Hospital for her help toward completing this report.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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