An Unusual Cause of Hemoptysis in a Young Male Patient

Abstract

Leptospirosis is an acute generalized infectious disease, caused by spirochaetes, Leptospira interrogans. The severity of the disease ranges from an asymptomatic subclinical course to a fatal outcome. Pulmonary involvement is common but often mild and of little clinical significance. However, over the last two decades an increasing number of cases have been reported with pulmonary haemorrhage as a prominent feature. We describe here a case of leptospirosis who presented with cough and hemoptysis. The patient acquired the disease in Saudi Arabia. Even in the absence of any travel, the association of fever, hemoptysis, jaundice, and thrombocytopenia, should lead to the suspicion of leptospirosis. Clinical and epidemiological aspects of the disease are discussed in the article.

Full text

50
An Unusual Cause of Hemoptysis in a Young Male Patient
Huda Bukhari ABM
Department of Internal Medicine, College of Medicine, King Faisal University, Dammam,
Saudi Arabia
Introduction
eptospirosis, caused by a number of
species in the genus Leptospira, has a
worldwide distribution and may have
the greatest incidence of any zoonosis 1.
Leptospires infect a variety of wild and
domestic animals, which become
reservoirs of disease when the
organisms establish persistent infection
in the animals' kidneys. The organism is
excreted in the urine of infected animals,
particularly rats and other rodents.
Leptospires enter the body through cuts,
abraded skin, or intact mucous
membranes; aerosol inhalation; and
possibly ingestion of contaminated food
or water 2. Leptospirosis can occur
among people exposed to animals,
animal products or contaminated soil or
L
Abstract
Leptospirosis is an acute generalized infectious disease, caused by spirochaetes,
Leptospira interrogans. The severity of the disease ranges from an asymptomatic
subclinical course to a fatal outcome. Pulmonary involvement is common but often
mild and of little clinical significance. However, over the last two decades an
increasing number of cases have been reported with pulmonary haemorrhage as a
prominent feature. We describe here a case of leptospirosis who presented with
cough and hemoptysis. The patient acquired the disease in Saudi Arabia. Even in the
absence of any travel, the association of fever, hemoptysis, jaundice, and
thrombocytopenia, should lead to the suspicion of leptospirosis. Clinical and
epidemiological aspects of the disease are discussed in the article.
Key words: Leptospirosis, hemoptysis
J T U Med Sc 2007; 2 (1, 2):50- 55
Correspondence to
Dr Huda Bukhari
Associate Professor, Department of Internal Medicine,
College of Medicine, King Faisal University,
,
5746 Dammam 31311
Saudi Arabia
* +966 3 8822442
9
+966 3 8987866
:
hudawe000@
y
ahoo.com
CASE STUDY

Huda Bukhari
51
J T U Med Sc 2007; 2(1, 2)
water. Veterinarians, farmers, abattoir workers, military personnel and sewer
workers are at increased risk for
occupational disease. The disease is
increasingly diagnosed in travelers 3. Of
importance to the traveler, recreational
water exposures have been associated
with individual cases and outbreaks of
disease. Leptospirosis is a rare disease in
Saudi Arabia. However its incidence is
probably underestimated, due to its
broad spectrum of presentations,
including subclinical benign forms and
the ictero-hemorragic form of the Weil's
syndrome, whose mortality is high. We
describe here a case of leptospirosis
acquired in Saudi Arabia with a
favourable outcome. Even in the
absence of any travel, the association of
jaundice, fever, lethargy, hemoptysis,
thrombocytopenia, and renal
abnormalities should lead to the
suspicion of leptospirosis. Clinical and
epidemiological aspects of the disease
are discussed in the article.
Case report
A previously healthy 34-years
Bangladeshi man presented with history
of fever, muscle pain, and headache of 5
days duration. He was seen by a family
doctor and Clavuloxin was prescribed
for him with no improvement. One
week later he started to have cough with
hemoptysis. He had also nausea and
vomiting and lost 2 kilogram of weight.
He works as a plumper and his last visit
to his country was two years before
presentation. On admission he was pale
and jaundiced, with a temperature of
40ｪ C. The liver was palpable with 14 cm
span. Initial laboratory studies revealed
anemia, thrombocytopenia and
moderate liver impairment (Table 1).
Table 1. Laboratory results
Test On Admission On Discharge
WBCs(109/L) 3.2 6
HB (g/dl) 9.5 10.7
PLTs (X109/L) 65 254
Total bilirubin (mg/dl) 6.4 1.4
Direct bilirubin 4.2 0.8
Aspartate transaminase (AST) 210 55
Alanine transminase (ALT) 199 43
Alkaline phosphatase 419 195
BUN mg/dl 22 19
Creatinine mg/dl 1.2 0.9

Hemoptysis in a young male patient
52
J T U Med Sc 2007; 2(1, 2)
His chest radiograph demonstrated
atelectatic band at the right lower lung
lobe with minimal pleural collection
seen bilaterally. He was started on
ceftriaxone for a presumed pneumonia.
The following day, he continued to have
multiple episodes of hemoptysis (< 100
ml total). Acid fast stain and malaria
smears were negative repeatedly.
Serology was sent for legionella,
leptospirosis and Q fever. His hepatic
serology was negative and blood, urine
and sputum cultures showed no
growth. Initial urine analysis was
normal. Patient continued to be spikes
of fever up to 40°C and doxycycline
100mg twice daily was added for
possible leptospirosis. One week later
his repeated urine analysis revealed 15-
20 WBCs and 30-50 RBCs per high
power field,2+ protein, 3+ blood, and
coarse granular cast, but urine culture
showed no growth. His creatinine was
in the range of 1.2-1.7 mg/dl. Diagnosis
of leptospirosis was established by
positive IgM-ELISA titer of 1: 20 (cut-off
of the assay 9U/ml). Patient was treated
with penicillin 4 million unit/6 hr
intravenously. Improvement in
laboratory and clinical findings
occurred slowly, and the patient was
finally discharged after 15 days of
hospitalization with normal
hematological and biochemical tests.
Discussion
Leptospirosis is a zoonotic disease
caused by the spirochetes of the genus
Leptospira (Figure 1). Leptospirosis has
a worldwide distribution. The incidence
of human infection is higher in the
tropics than in temperate regions but
transmission occurs in both
industrialized and developing countries.
Direct exposure to urine of infected
animals or urine – contaminated water
Figure 1: A typical leptospira interrogans
and soil, through recreational or
occupational activities represent the
main source of infection for humans 1.
Leptospirosis was formerly considered
to be primarily an occupational disease,
associated with activities such as
mining, sewer maintenance, livestock
farming and butchering, veterinary
medicine, and military maneuvers2. The
relative importance of such occupational
risks has decreased since protective
measures have been implemented. In
developed countries, many cases occur
in association with conditions of slum
living4 or with recreational activities
involving immersion in water 5. In
tropical environments, occupational
exposure such as rice farming and other
agricultural activities is still significant 6.
Leptospirosis was never reported from
Saudi Arabia possibly because it is a dry
country or it could be under diagnosed
due its variable and often nonspecific
clinical presentation, lack of awareness
of the disease and relatively inaccessible

Huda Bukhari
53
J T U Med Sc 2007; 2(1, 2)
and insufficiently rapid diagnostics.
Acute fever in patients is a diagnostic
challenge. This is especially true when
complications such as hemoptysis,
jaundice, and thrombocytopenia
supervene. Other infectious diseases,
such as malaria, dengue, yellow fever,
viral hepatitis, and tuberculosis, as well
as noninfectious disorders, such as small
vessel vasculitides, could have
conceivably explained the clinical
presentations as described7.
Leptospirosis produces numerous
clinical findings, but two general
patterns occur. In the less severe and
generally nonfatal form, often called
anicteric leptospirosis and accounting
for 90% of cases, the illness commonly
begins abruptly and includes headache,
myalgias, severe conjuctival suffusion,
fever, nausea, vomiting, rash, and
meningitis. Epistaxis or other minor
bleeding can occur or myocarditis. In
addition to these features, the more
severe form of leptospirosis, called
icteric leptospirosis or Weil disease,
causes jaundice, renal impairment, and
major hemorrhagic complications7.
Pulmonary symptoms occur in both the
nonicteric and icteric forms, including
chest pain secondary to myositis or with
a pleuritic character 8. Cough develops
in up to 57 to 63% of cases. Many case
reports, clinical series, and descriptions
of outbreaks document the frequent
occurrence of hemoptysis and diffuse
pulmonary haemorrhage 9, 10. The
severity of respiratory disease is
unrelated to the presence of jaundice 11.
Although much study has been
dedicated to the serious, sometimes
dramatic kidney lesions observed in
severe leptospirosis, such findings are
not prominent in mild leptospirosis and
may not be apparent at all in some
patients with severe forms9.
Abnormalities can be detected on urine
analysis in 80% to 90% of patients. In the
septicaemic phase, red cells, leukocytes,
or granular casts are found in the urine
of most patients. Hemoglobinuria and
hyaline casts also occur. Frequently,
there is proteinuria and myoglobinuria.
In hospitalized patients with renal
failure, they may occur within 3 to 4
days of onset. Blood urea and creatinine
levels raise rapidly, with corresponding
increases in blood potassium, uric acid,
and phosphate levels. Glomerular
function and anatomic integrity are
largely preserved, whereas severe
proximal tubular lesions do occur 12 .
Renal failure may or may not be
prerenal. Oliguria is a striking but rather
uncommon feature 12. Laboratory
abnormalities include anemia and
thrombocytopenia. Myositis may cause
elevated muscle enzymes. In icteric
leptospirosis, the serum bilirubin
typically remains < 20 mg/dL.
Transaminases are also usually raised to
two to three times above normal 2 . In 20
to 40% of icteric cases, renal impairment
develops, accompanied by elevations in
BUN (typically < 100 mg/dL) and
creatinine (usually 2.0 to 8.0 mg/dL), as
well as proteinuria, hematuria, and
pyuria 2. Fatalities, significantly more
frequent in the icteric form, typically
arise from renal, cardiac, or respiratory
failure.
Serology is the most frequently used
diagnostic approach for leptospirosis.
The microscopic agglutination test
(MAT) is the reference standard test for
serological diagnosis of leptospirosis
because of its high sensitivity and
specificity 13, 14. The MAT detects
agglutinating antibodies in serum, but
requires significant expertise from its
users, and interlaboratory variation in
results is high. Rapid genus-specific
tests have been used widely for
diagnosis. These tests have the

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