Multivisceral organ failure related to leptospirosis in pregnant patient
A 35-year-old multiparous woman in 36th week of gestation with no significant past history presented to emergency with a short history of 8 days of malaise, chills, myalgia, jaundice, abdominal pain, and asthenia. At admission, the clinical parameters were - heart rate 120/min, blood pressure 105 / 66 mmHg, respiratory rate 17/min, axillary temperature 38°C, and oliguria of 500 ml in last 24 hours. The patient was conscious but irritable with dark icterious conjunctive and bruises in all extremities.\nEarlier during her pregnancy both systolic and diastolic arterial pressures were noted to be stable. There was no history of travel abroad, contact with animals, or fever. The obstetrical examination did not reveal any genital bleeding. The laboratory parameters were: hemoglobin 10 g/dL; leukocyte count: 15,2 × 109/L including 75% neutrophils, platelets count: 40 × 109/L; C reactive protein (CRP): 115 mg/L, glucose: 0,92 g/L, creatinine: 18 mg/L and urea: 1.05 g/L, AST: 165 U/L, ALT: 145 U/L, bilirubin total: 7 mg/dl, conjugated bilirubin: 5,8 mg/dl. A moderate coagulopathy was found (PT 45%, ACT 220 seconds, D-dimer 600 ng/ml, fibrinogen 1,5 g/L), CPK: 355 U/L, troponin Ic: 0.4., Blood and urine cultures were sterile, and the serology tests for hepatitis A, B, C, cytomegalovirus, and HIV were all negative. Leptospira IgM antibodies by enzyme-linked immunosorbent assay were positive at 1/300 dilution. The electrocardiogram revealed negative T waves in DII, DIII, and AVF. Ultrasound showed a single live pregnancy with oligohydramnios; Kidneys, spleen, and liver were normal and without any dilatation of the biliary canaliculi. The fetal cardiotocography was reactive. The interview of the family revealed that the patient had visited a public bath 15 days earlier. The initial management in the intensive care unit consisted of intravenous Penicillin G at 4 000 000 UI four times daily, hydration with crystalloid solutions, oxygenation by facemask. 10 hours after admission, she became severely icteric and developed severe respiratory distress with crackles on pulmonary auscultation requiring intubation and mechanical ventilation. An emergency cesarean section was performed. A healthy female weighing 2.9 kg was delivered with an Apgar of 6 and 8 respectively at 1 min and 2 min after delivery. Postoperatively, X-ray chest showed bilateral diffuse opacities; blood gases showed PaO2/FiO2 < 200 and transthoracic echocardiography showed absence of increased left filling pressures fulfilling the American-European criteria for acute respiratory distress syndrome (ARDS). PAOP was not measured in the absence of Swan Ganz.\nThe post delivery treatment included mechanical ventilation with intravenous sedation, central venous pressure monitoring, restriction of fluid infusion and antibiotics (penicillin G). 4 days after delivery, the laboratory tests showed: hemoglobin 9.8 g/dL, leukocytes: 11 × 109/L, CRP: 52 mg/L, platelet: 106 × 109/L, PT: t 60%, fibrinogen: 3.5 g/l, urea: 0.55 g/L, creatinine: 11 mg/L, AST: 60 U/L, ALT: 52 U/L, troponin Ic: 0,08. Five days later, the patient's neurological and respiratory status improved, and 1 week later, she was discharged discharged from the ICU with antibiotics continued for 12 days. At follow up after 1 month of discharge the blood and urine were negative for leptospira and the neonate showed no signs of active infection.