Volume 26, Number 9—September 2020
Dispatch
Anicteric Leptospirosis-Associated Meningitis in a Tropical Urban Environment, Brazil
Table 1
Characteristics of patients with leptospirosis-associated meningitis, Salvador, Brazil*
| Characteristic | Patient 1 | Patient 2 | Patient 3 | Patient 4 | Patient 5 |
|---|---|---|---|---|---|
| Age, y/sex |
24/M |
18/F |
38/M |
42/F |
32/M |
| Health history |
Previously healthy |
Crack cocaine and methamphetamine use; aseptic meningitis 8 months prior† |
Previously healthy |
Diabetes mellitus type II, obesity, and hypertension |
Previously healthy |
| Risk factors |
Rats present near home and exposed to both flood and sewer water |
Rats present near home and exposed to sewer water |
Rats present near home and exposed to flood water |
Rats present near home and pet dog with outdoor exposure‡ |
Lived and worked on horse farm |
| Presenting symptoms |
5 d of fever, severe headache, emesis, anorexia, malodorous urine, and intermittent dry cough with rare streaking hemoptysis§ |
7 d of fever, severe headache, emesis, anorexia, indigestion, diarrhea, nonproductive cough, and myalgia |
8 d of fever, chills, severe headache with retroorbital pain, neck stiffness, photophobia, emesis, myalgia, and arthralgia¶ |
8 d of fever, severe headache, neck stiffness, myalgia, emesis, and abdominal pain |
4 d of fever, severe headache, myalgia, and pharyngitis |
| No. healthcare encounters before diagnosis |
2 |
0 |
2 |
1 |
1 |
| Neurologic exam |
Unremarkable |
Unremarkable |
Unremarkable |
Nuchal rigidity |
Unremarkable |
| CSF profile | |||||
| Nucleated cells, 106/L | 28 | 46 | 150 | 68 | 46 |
| Predominant cell type | Monomorphic | Monomorphic | Polymorphic | Monomorphic | Monomorphic |
| Glucose, mg/dL | 67 | 46 | 54 | 143# | 77 |
| Protein, g/L |
46 |
35 |
41 |
32 |
23 |
| Peripheral leukocytes with differential |
|||||
| Total count, 103/Ml |
15.5 |
4.9 |
10.4 |
11.5 |
6.7 |
| Neutrophils, % |
85 |
33 |
62 |
84 |
76 |
| Lymphocytes, % |
6 |
45 |
30 |
11 |
9 |
| Monocytes, % |
5 |
2 |
1 |
4 |
8 |
| Eosinophils, % |
2 |
20 |
ND |
1 |
3 |
| Platelets, 103/μL |
108 |
243 |
336 |
268 |
119 |
| Plasma chemistries | |||||
| Potassium, meq/L | 5.2 | 4.2 | 4.1 | ND | 4.3 |
| Creatinine, mg/dL | 1.8 | 0.6 | 1.2 | 1.0 | 0.8 |
| Urea, mg/dL | 16 | 18 | 46 | 39 | 14 |
| Bilirubin, direct, mg/dL | 0.1 | ND | ND | ND | ND |
| ALT, U/L |
40 |
30 |
76 |
ND |
25 |
| Confirmation criteria |
MAT seroconversion |
MAT acute titer ≥1:800† |
MAT seroconversion |
MAT seroconversion |
MAT seroconversion |
| Presumed serogroup |
Icterohaemorrhagiae |
Icterohaemorrhagiae and Cynopteri |
Canicola |
Canicola |
Icterohaemorrhagiae |
| Other diagnostics (negative or within normal limits) |
Rapid HIV; aerobic hemoculture; Rumpel-Leede test** |
Rapid HIV; urinalysis |
None |
None |
None |
| Bedside finger stick leptospirosis DPP result†† |
Negative |
Negative |
Negative |
Positive |
Positive |
| Venous whole blood leptospirosis DPP result‡‡ |
Positive |
Positive |
Negative |
Positive |
Positive |
| Antimicrobial treatment | |||||
| Regimen | Amoxicillin for 7 d | None | Ceftriaxone for 7 d | None | Ceftriaxone for 7 d |
| Day of illness started | Day 29 ‡ | Day 8 | Day 4 | ||
*ALT, alanine aminotransferase; CSF, cerebrospinal fluid; DPP, Dual Path Platform; MAT, microagglutination test; ND, not done.
†No etiology was determined at prior hospitalization. The patient’s high acute sample MAT titer (1:800) is suggestive of acute leptospirosis, but may also represent either recurrent disease or recent prior infection. No convalescent serum sample was available for this patient.
‡The patient’s pet dog tested negative for leptospirosis by serum MAT and cultures of urine and blood.
§This patient initially improved with 7 d of inpatient supportive management. However, the patient returned to the same hospital 3 d after discharge (day 15 of illness) reporting continued headache. The patient refused another CSF exam and returned home without treatment. On day 25 of illness, the patient returned with 2 d of renewed fever (39°C), headache, myalgia, emesis, and cough. Physicians suspected a viral illness and the patient returned home without antimicrobial therapy. On day 27 of illness, the patient returned to the same hospital with the additional report of malodorous, normochromic urine, at which time the patient presented the MAT results (resulted from the initial hospitalization) that confirmed the diagnosis of leptospirosis and the patient was prescribed amoxicillin on day 2 of re-admission.
¶Mild respiratory distress developed within the initial 24 h of admission and leptospirosis was included in the differential diagnosis on day 2 of hospitalization.
#Blood glucose 298 mg/dL (CSF:blood ratio 0.48)
**The Rumpel-Leede test is a clinical exam using a blood pressure cuff to screen for hemorrhagic manifestations of dengue.
††DPP was performed immediately at bedside via ventral pad finger stick (1).
‡‡DPP using venous whole blood was collected in an ethylenediamine tetraacetic acid (EDTA) tube and processed within 2 h of collection.