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Vol. 11 No. 1 January–April 2023

Case Report

Severe Leptospirosis (Weil’s Disease) with Multiple Organ Failure

in Urban Setting: A Case Report
Samuel Halim1,2* , Bryan Arista Hartono3
1InternalMedicine Department, Hermina Hospitals Kemayoran, Jakarta, Indonesia
2Department of Internal Medicine, Faculty of Medicine, Universitas Tarumanegara, Jakarta, Indonesia
3Hermina Hospitals Kemayoran, Jakarta, Indonesia

Received: September 29th, 2022; Revised: January 1st, 2023; Accepted: March 1st, 2023

ABSTRACT
Leptospirosis is a rare disease that could cause multiple organ failures and death if left untreated. The correct
treatment will determine the recovery of patients. A 28-years old male came to the Emergency Department with
profuse diarrhea. No prior medical history; worked as a private employee recently assigned to collect rat traps one
week before. Laboratories show severe thrombocytopenia, acute liver failure, and acute renal failure support by
imaging with the conclusion of hepatomegaly with normal kidney size. During observation in the emergency room,
the patient worsens into septic shock. The patient was treated in intensive care, diagnosed with Weil's disease, and
treated given antibiotics with aggressive fluid therapy; dialysis was postponed, and close monitoring of the patient's
symptoms and organ function. After five days of care, clinical symptoms and organ function improved, and the
patient was discharged well. Diagnosis of Leptospirosis is challenging with a combination of signs and symptoms
that are not commonly found. Therefore, primary treatment is antibiotic and supportive care such as renal
replacement therapy is not routinely needed as long there are improvements in close monitoring. This objective is
to increase awareness and treatment option for further severe leptospirosis cases
Keywords: dialysis; fluid therapy; leptospirosis, multi organ failure; Weil’s Disease

Highlights: . Novelty in this case is Weil’s Disease could manifest as severe acute kidney injury without prominent
icteric whilst hepatomegaly with increase liver function occur will be reversable with appropriate conservative
management. It benefits as reference to postpone dialysis with proper conservative management.

How to Cite: Halim, S., Hartono, B. A. Severe Leptospirosis (Weil’s Disease) with Multiple Organ Failure in
Urban Setting: A Case Report. Indonesian Journal of Tropical and Infectious Disease. 11(1). 12–17. Apr. 2023.

DOI: 10.20473/ijtid.v11i1.39466

* Corresponding Author:
[email protected]

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Indonesian Journal of Tropical and Infectious Disease, Vol. 11 No. 1 January–April 2023: 12–17 13

INTRODUCTION Physical examination on admission shows

vital signs of low blood pressure (109/75
Leptospirosis is a zoonotic infection that mmHg), regular pulse, breath and no fever
affects both humans and animals.1According
(36.5C). Conjunctival suffusion, normal
to WHO, in 2019, there were 920 cases
breath and heart sound, abdominal pain at the
reported in Indonesia, with 122 deaths.
epigastric, and no swelling nor jaundice on
However, this reported case number is a
the extremities. The patient was suspected of
severe underestimate of leptospirosis
having a Hepatitis A infection.
occurrence in Indonesia, given that the annual
Laboratories and imaging did the further
morbidity of leptospirosis in the population
investigation. Laboratory finding shows
was recently estimated at 39.2 per 100,000
anaemia, leucocytosis, thrombocytopenia,
people.2Clinical symptoms are
hyponatremia, increased bilirubin level,
undistinguishable from other infectious
slight hypo albumin, normal blood
diseases such as hepatitis, dengue, and
coagulation test, liver injury and renal
typhoid. Severe cases, rather known as Weil’s
failure—serologic tests of anti-HAV,
Syndrome, are the triad of haemorrhage,
HBsAg, anti-HCV, and anti-HIV show
jaundice, and acute kidney injury.3The
negative results (Table 1). Chest x-ray
primary treatment for leptospirosis is
(Figure 1) was clear, and abdominal
antibiotic such as penicillin and supportive
ultrasonography (Figure 2) shows non-
care. Hemodialysis as the early supportive
specific hepatomegaly without other organs
therapy for kidney injury did not associate
abnormality. By the time examination was
with the mortality rate in a critically ill
done, blood pressure had dropped to 85/34
patient.4 The objective of this report is to
mmHg, pulse rate 102 times per minute,
increase awareness and as the reference
respiratory rate 25 times per minute, with a
consideration to treat severe leptospirosis in
normal temperature of 38.2C, fall into the
further cases.
diagnosis of septic shock then given
norepinephrine 0,1 mcg per bodyweight per
CASE REPORT minute. Transfusion of one unit thrombocyte
concentrate followed by hydration of NaCl
A 28th-year-old man from Kemayoran, 3% 500 ml with crystalloid 2000 ml over 24
Central Jakarta, was admitted to the hours, antibiotic, proton-pump inhibitor (PPI)
Emergency Department with profuse and attapulgite was given as initial therapy.
diarrhoea, nausea, yellowish-red sclera, The patient was admitted to the ICU for
malaise, and muscle pain, especially below further monitoring.
the knee. The stool is brown-yellow with soft
consistency without blood; meanwhile, the
urine is dark. Symptoms occur around two
days before admission with a fever that has
never been felt before. There is no prior
medical history or high-risk lifestyles such as
needle injection and promiscuity. Patient
work as a private employee. One week before
admission, he was assigned to collect rat traps
around the corner of a warehouse. He did not
catch a single rat and managed to clear up the
trap. No evidence of rat bite or prior flood Figure 1. Chest X-Ray, Shows No Abnormality
was recorded during that time. in Lungs and Heart

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14 Samuel Halim, et al. Severe Leptospirosis (Weil’s Disease)

Figure 2. Abdominal Ultrasonography, Shows A Non-Specific Hepatomegaly with Normal Kidney

Structure

During intensive care, the patient clinical was done and shows a positive result.
was improved with normal vital signs, Treatment of antibiotics, rehydration, and PPI
decreasing icteric, and no other symptoms. was continued. The patient was hospitalized
Follow-up laboratory findings were done for another three days. On the last day, the
with anaemic, improving leucocytes, patient clinically improves, and symptoms
thrombocytes, and liver and renal function. are all gone but icteric slightly remains. Stool
Norepinephrine support was tapered down, and urine are within normal colours. The
and the patient planned to move to the general patient then discharges with antibiotics and
wards. Additional test IgM anti-leptospirosis PPI as home medicine.

Table 1. Laboratory Examination

Result
Examination
22/8 23/8 24/8 25/8 26/8
Hemoglobin (g/dL) 10.3 9.5 9.8 10.1 10.2
Hematocrit (%) 27.8 25.3 27.0 27.8 28.1
Leucocyte (/uL) 20,400 27,680 12,600 6,080 5,950
Thrombocyte (/uL) 36,000 71,000 91,000 119000 163,000
Natrium (mmol/L) 126.0 - - - -
Kalium (mmol/L) 3.67 - - - -
Chloride (mmol/L) 95.5 - - - -
ALT (g/dL) 79.7 - - - -
AST (g/dL) 170.4 - - - -
Albumin (mg/dL) 2.8 - - - -
Creatine (mg/dL) 11.45 8.76 - - 2.29
Urea (mg/dL) 236.1 283.1 - - 145.7
eGFR ( mL/min/1.73m2) 6 8 - - 39
Anti HAV Non-reactive - - - -
HBsAg Non-reactive - - - -
Anti HCV Non-reactive - - - -
Anti HIV Non-reactive - - - -
Total Bilirubin (mg/dL) 8.0 - - - 5.05
Conjugated Bilirubin (mg/dL) 6.45 - - - 3.93
Unconjugated Bilirubin (mg/dL) 1.55 - - - 1.12
PT (second) 17.8 - - - -
Control PT 14 - - - -
APTT (second) 31.4 - - - -
Control APTT 31.3 - - - -
IgM Anti-Leptospira - - - - Reactive
Abbreviations: g = grams; dL = deciliter; uL = microliter; mm = millimeter; U = unit; L = liter; mEq = milliequivalent, min =
minutes

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Indonesian Journal of Tropical and Infectious Disease, Vol. 11 No. 1 January–April 2023: 12–17 15

DISCUSSION leptospirosis, which suggested a mechanism

caused by peripheral platelet consumption due
In this report, we have described a case of
to widespread haemorrhages, immune-
severe leptospirosis or known as Weil’s
mediated platelet destruction caused by
Disease.1,3 On admission, the patient
antiplatelet antibodies, and inhibited platelet
presented with fever, conjunctiva suffusion,
production by bone marrow.8 It aggravates
dark urine, and myalgia with leucocytosis,
hemorrhagic manifestation, as does installation
thrombocytopenia, AKI, liver failure, and
access for dialysis if needed. Therefore,
hyperbilirubinemia. Patients experience
transfusion of thrombocyte concentrate was
septic shock in the ER and are given
given as a preventative strategy.9Septic shock
norepinephrine as support. Treatment given
occurs because of severe infection from
was antibiotics and aggressive hydration.
leptospira which causes vasculitis and systemic
Dialysis was postponed while watchful
inflammatory response syndrome.10 It could
waiting for the improvement of kidney
develop into an immunosuppressive state as it
functions by fluid therapy. Strict monitoring
evolves until the death of the host.11 Early
of kidney function and haematology was
administration of the vasoactive drug
done. Symptoms and kidney function then
norepinephrine is beneficial in restoring organ
recover with the treatment given.
perfusion in septic shock patients.12
Leptospira is a zoonotic disease that is an
Treatment of leptospirosis consists of
emerging global public health problem.
antibiotics and supportive therapy. Antibiotics
Indonesia, with a high incidence of flooding
chosen are penicillin group or cephalosporin
and subsequent presence of stagnant water and such as ceftriaxone that was given to our
poor sanitation conditions in some housing patient. Leptospira are highly susceptible to a
areas, is at high risk for leptospirosis. The broad range of antibiotics. A Jarisch-
transmission from infected animals through Herxheimer reaction may occur as a response
their urine (rodents, dogs, livestock, pigs, to the clearance of spirochetes from the
horses, wildlife) can survive for weeks to circulation. It is an acute inflammatory
months in water and soil. A human can be response characterized by fever, rigors, and
infected through direct contact with the urine, hypotension with a 21% incidence according
urine-contaminated water, and wet soil, or to Guerrier et al which is not found in this
ingestion of urine-contaminated food or report.13,14 Supportive therapies are based on
water.1,5,6 In the present case, there is no contact clinical manifestation with renal replacement
with water or soil, but our patient does risk therapy, ventilatory support, and blood
contact with a rat trap which could be products. A study in Brazil shows that
contaminated with rodent urine. High-risk leptospirosis patients with complications of
infection activities include wading, swimming, acute respiratory distress syndrome and AKI
boating, and activities that could lead to skin benefit from daily hemodialysis to lower the
abrasion and water or soil exposure. mortality rate.15 While the STARRT-AKI
Leptospirosis symptoms are usually a flu- (Standard versus Accelerated Initiation of
like illness of sudden onset, fever, headache, Renal-Replacement Therapy in Acute Kidney
nausea, vomiting, abdominal pain, conjunctival Injury) investigation concluded that among
suffusion, and myalgia, typically on the calves critically ill patients with AKI, an accelerated
and lower back. Severe cases have a classic renal-replacement strategy within 12 hours
presentation known as Weil’s syndrome was not associated with a lower risk of death
consists of the triad of haemorrhage, jaundice, than the standard strategy.4 This study
and AKI.1,3,5 Incidence of severe leptopirosis supports the present case in which dialysis, as
estimated 5% to 15% of patients.7Symptoms renal replacement therapy, was not given to
that occur in our patients fulfil the severe the patient and, as a result of clinical
symptoms. Thrombocytopenia is common in laboratories, does improve with aggressive

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16 Samuel Halim, et al. Severe Leptospirosis (Weil’s Disease)

fluid therapy alone. The choice made was AUTHOR CONTRIBUTION

risky yet convenient and promising as for the
Conceptualization and supervision: SH.
patient condition and psychology that he did
Data curation, writing-original draft,
not need dialysis.
review, and editing: BAH.

STRENGTHS AND LIMITATIONS

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