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A 32-year-old man presents with fever, headache and myalgia. He works as a green-keeper at the local golf course in a semirural district. Questioning reveals that over the last few weeks he has been working to refashion the water hazards at the course, spending much of the day in the water. Clinical examination reveals that he has mild neck stiffness. There is conjunctivitis present and he has a mild jaundice. His abdomen is soft; his liver edge can be palpated and is tender.
The preliminary laboratory findings of his full blood count, urea and electrolytes and liver function tests performed in the A&E department are as follows:
WBC 14.2 x 109/L, predominantly neutrophils
Urea 9.9 mmol/L
Creatinine 138 mmol/L
AST 150 IU/L
1. What do the initial blood tests show?
There is evidence of a neutrophilia, renal dysfunction and liver dysfunction.
2. What specific test would you perform?
You will need to investigate infectious causes of hepatitis. Serology for the viral hepatitides should be sent, together with tests for leptospirosis. Surgical conditions such as acute cholecystitis should be investigated by ultrasound examination.
3. What is the most likely infectious diagnosis?
This is an interesting case of a man with a relatively rare infection. The findings demonstrate that he has a hepatitis, neck stiffness and conjunctivitis — the classic triad of leptospirosis. The final clue to the diagnosis is the reported exposure to the water hazard, emphasizing the importance of taking a thorough occupational history. The neutrophilia and evidence of renal disorder are also typical of leptospirosis.
4. Are there any additional ways of making the diagnosis?
Leptospirosis can be diagnosed by culture, but this is a difficult technique and few laboratories are able to achieve it.
5. What is the significance of his occupation?
In the past, occupational exposure in sewage workers was a major risk factor for leptospirosis. This is now rare as the workers take appropriate preventive measures. Most leptospirosis is caught by exposure to open water sources during recreations such as wind surfing or fishing.
6. What is the first choice of antibiotic?
The treatment of choice is benzylpenicillin, with doxycycline as an alternative. Treatment should be given as soon as a diagnosis is suspected as delayed treatment is less effective.
7. What is the significance of the poor renal function?
The prognosis of leptospirosis is defined by the severity of renal damage. Care must be taken in this patient as he has evidence of liver and renal damage.