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Brain & Heart Cardiac involvement in leptospirosis

In a series of five patients with cardiac involvement oropharyngeal erythema and diffuse abdominal tenderness
reported by Jayathilaka et al., all experienced hypotensive but no guarding or rebound tenderness.
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shock and acute kidney injury. Four out of the five His epidemiological history revealed that he worked
patients received positive inotropic support. One patient in livestock farming but had no history of animal or
exhibited EKG findings suggestive of myocarditis during arthropod bites. He was admitted to the internal intensive
shock, whereas an echocardiogram (ECHO) confirmed care unit, and blood and urine cultures were taken.
myocarditis in another case. All five patients exhibited a Empirical treatment with meropenem was started. Testing
positive cardiac troponin I titer, either low or high, and included serology for Brucella, hepatitis, and human
eventually recovered from the illness.
immunodeficiency virus; serology and PCR testing for
In another study by Shah et al., autopsies of 24 patients Crimean-Congo hemorrhagic fever virus; and PCR testing
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who died from leptospirosis revealed myocarditis in 96% for leptospirosis in urine and serum. A peripheral blood
of the patients. Endocardial inflammation was observed in smear was conducted to rule out acute hematological
50% of these patients and was associated with vasculitis. malignancy, and a consultation with the hematology
Cardiac involvement in leptospirosis is thought to be department was requested.
due to a glycoprotein component of the leptospiral cell Laboratory results indicated elevated HSTI levels
wall that inhibits Na–K ATPase, causing arrhythmias and (normal range, 0 – 58 ng/L), prompting a cardiology
vasculitis. 5,6 consultation. A 12-lead EKG performed at the bedside in
Elevated creatine kinase-myocardial band (CK-MB) the intensive care unit showed no significant ST-segment
and troponin levels are found in nearly half of leptospirosis changes, T-wave abnormalities, or other pathological
cases, but their importance in predicting cardiac findings (Figures 1A and B). His heart rate was recorded
involvement is unclear. 7,8 at 92 beats/min. Bedside transthoracic ECHO revealed
hypokinesia in the anteroseptal wall of the left ventricle
Further investigations are needed to confirm cardiac (Figures 2A and B). The cardiac valves appeared normal,
involvement. In cases of leptospirosis with cardiac with no significant stenosis, regurgitation, vegetation,
involvement, non-specific EKG changes such as conduction or intracardiac thrombus. Anti-ischemic treatment was
disorders, ST-T changes, and atrial arrhythmias are often started based on a preliminary diagnosis of acute coronary
observed. However, very few cases report an absence of syndrome, and inotropic support was provided for the
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EKG changes despite cardiac involvement. Although patient’s hypotension. The patient was closely monitored
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cardiac involvement has been frequently reported in the for further differential diagnoses.
literature, our case, which was initially considered to have
th
cardiac involvement, showed elevated creatine kinase On the 8 day of intensive care unit admission, the patient’s
(CK), CK-MB, and high-sensitivity troponin I (HSTI) condition improved and he was transferred to the infectious
th
levels but no EKG changes. diseases ward for continued treatment. On the 11 day of
treatment, PCR analysis of the serum sample confirmed
This rare condition, often overlooked owing to its broad the presence of Leptospira, confirming the diagnosis of
clinical presentation and lack of distinctive symptoms, leptospirosis. The urine Leptospira PCR test was negative.
is highlighted in our case. We present a case that was Given the patient’s initial signs of septic shock, severe
initially managed as an acute coronary syndrome but later hypotension, and elevated cardiac biomarkers, and with the
re-evaluated as cardiac involvement due to leptospirosis re-evaluation of EKG and ECHO findings, we reconsidered
based on serum polymerase chain reaction (PCR) results.
the diagnosis of acute coronary syndrome. Instead, based on
2. Case presentation the clinical and laboratory findings, we suspected myocardial
involvement (myocarditis) due to leptospirosis.
A 46-year-old male with no known chronic conditions arrived
at our hospital’s emergency department with symptoms of The patient completed 14 days of inpatient treatment
weakness, fever, palpitations, and widespread muscle and joint and was discharged in good health with follow-up
pain. He had previously visited the emergency department recommendations for infectious diseases and cardiology
twice in the past 4 days for similar issues and was diagnosed clinics. Laboratory test results from admission and
with an upper respiratory tract infection and prescribed subsequent days are summarized in Table 1.
amoxicillin-clavulanate. At the time of this presentation, 3. Discussion
he had a fever of 40°C and a blood pressure of 50/30
mm Hg. His overall condition was poor, with drowsiness Leptospirosis is a contagious disease that affects both
but responsiveness. Physical examination revealed mild animals and humans and is the most common zoonotic

Volume 2 Issue 4 (2024) 2 doi: 10.36922/bh.3496