Extracorporeal Life Support for Severe Leptospirosis – First Reported Case in North America
CCCF ePoster library. Singh G. Oct 27, 2015; 117317; P7
Gurmeet Singh
Gurmeet Singh
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Abstract
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P7


Topic: Case Report


Extracorporeal Life Support for Severe Leptospirosis – First Reported Case in North America



Gurmeet Singh, D. Townsend, J. Nagendran, W. Sligl

Critical Care Medicine and Cardiac Surgery, University of Alberta, Edmonton, Canada | Critical Care Medicine, University of Alberta, Edmonton, Canada | Cardiac Surgery, University of Alberta, Edmonton, Canada | Critical Care Medicine and Infectious Diseases, University of Alberta, Edmonton, Canada

Introduction:

Leptospirosis is a globally important zoonosis caused by infection with the spirochete Leptospira. Its incidence in North America is low - cases occur mainly in the southern United States, Pacific coastal states or in returned travelers. Transmission occurs from contact with contaminated urine of infected animals or rodents and the incubation period is approximately 2-26 days. Most cases are subclinical or present as mild, self-limiting infection. Severe infection (Weils disease) occurs in 5-10% of cases, and usually presents with renal failure and jaundice. Severe respiratory manifestations including pulmonary hemorrhage and acute respiratory distress syndrome (ARDS) have been described with mortality rates as high as 50%.



Objectives: To describe a rare case of severe leptospirosis resulting in multi-organ failure requiring extracorporeal life support (ECLS).


Methods:

The patient's chart and electronic medical record were reviewed in detail after obtaining patient consent. We reviewed the literature on extracorporeal membrane oxygenation (ECMO) for severe leptospirosis and queried the Extracorporeal Life Support Organization (ELSO) registry (with over 16 000 cases of adult ECMO) for ECLS therapy for leptospirosis.



Results:

We describe a case of a 23 year-old male with no significant past medical history, who became ill due to severe leptospirosis 10 days after returning from vacation in Jamaica. Six days following symptom onset, the patient presented to a peripheral hospital with fever, myalgias, nausea, vomiting, icterus and respiratory failure. Laboratory investigations revealed anemia (83 g/L), marked leukocytosis (32 x 109/L), severe thrombocytopenia (9 x 109/L), hepatic dysfunction (bilirubin 280 µmol/L), and acute kidney injury (creatinine 269 µmol/L). The patient was transferred to a referral center where he rapidly developed progressive hypoxemic and hypercarbic respiratory failure and ARDS, which was refractory to conventional and advanced mechanical ventilation. Venovenous ECMO (VV-ECMO) was instituted as salvage therapy and continued for 13 days. His course was complicated by multiple organ failure (MOF), including acute kidney injury requiring continuous renal replacement therapy, and shock, necessitating vasopressor support. The patient also developed toxic megacolon and required numerous laparotomies, all performed on ECLS. Acute leptospira serology was negative, however convalescent serology was positive for IgM by enzyme-linked immunosorbent assay (ELISA), and was confirmed by microagglutination with a 1:3200 titre to Leptospira interrogans serogroup Icterohaemorrhagiae. Other microbiological investigations were all negative including, but not limited to, blood cultures, Hantavirus and Dengue virus serology, and respiratory virus nucleic acid amplification testing. The patient made a full recovery and was discharged from hospital after a total of 45 days. Only eight previous adult cases of leptospirosis were identified in the ELSO registry (geographic locations not available) with just 50% survival despite ECLS.



Conclusion:

Leptospirosis should be considered in patients with an appropriate epidemiologic exposure who present with critical illness including ARDS and multi-organ failure. ECLS for ARDS is viable for salvage in severe leptospirosis, even with established MOF. We report the first case of ECLS for this indication in North America.



References: None.
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