A case of severe leptospirosis complicated with massive rhabdomyolysis and acute kidney injury: a case report | Journal of Medical Case Reports

Leptospirosis is a reemerging infectious disease and one of the most widespread zoonotic diseases, posing considerable medical and veterinary concerns [20]. The illness follows a biphasic pattern consisting of two distinct stages: the septicemic and immune phases. The septicemic phase typically spans 3 to 7 days and is characterized by abrupt onset of symptoms such as fever, chills, severe headache, myalgias, dehydration, and instability in cardiovascular function [21]. Typically, the incubation period ranges from 5 to 14 days, though it can extend from 2 to 30 days in some cases [22, 23].

Our patient exhibited a unique clinical manifestation of severe leptospirosis characterized by massive rhabdomyolysis and acute kidney injury (AKI), with respiratory distress and absence of cardiac failure. So far, there is no report on leptospirosis-associated rhabdomyolysis in Iran. Moreover, the global reports of rhabdomyolysis due to leptospirosis are very limited in number [21, 24,25,26,27,28].

Rhabdomyolysis caused by the disruption of skeletal muscle integrity is a rare and an atypical clinical manifestation of leptospirosis [21], leading to a substantial release of intracellular components (e.g., creatine phosphokinase, lactate dehydrogenase, aldolase, myoglobin, aspartate transaminase, and electrolytes) into the bloodstream [29]. It is associated with AKI, hyperkalemia, hyperphosphatemia, and hypovolemia, which can cause death if no early treatment is conducted [29]. Rhabdomyolysis-induced AKI has been predominantly observed in patients with severe forms of the disease and the mortality rate resulting from this condition is approximately 20% [29, 30].

Climatic conditions play a significant role in the transmission of the infection, as warm, humid environments are essential for the bacteria’s survival. After being excreted into water or moist soil, the bacteria can persist for weeks to months [31]. It is widely acknowledged that pathogenic species of Leptospira can persist in soils and freshwater environments (e.g., mud, swamps, streams, lakes, and rivers), particularly when the conditions are neutral to slightly alkaline [7]. It is frequently categorized as a waterborne disease due to the consistent link between outbreaks and exposure to contaminated water sources, underscoring the importance of water safety in preventing the spread of the infection [18].

Leptospirosis is predominantly concentrated in tropical and subtropical regions worldwide. However, there are significant gaps in our understanding of its prevalence, especially in regions where the disease burden is likely to be high. Central Asia and southern Latin America are among the areas lacking comprehensive data on leptospirosis. This disease remains a critical public health issue in many developing countries, posing persistent challenges for healthcare systems and communities. Regions such as North Africa, the Middle East, and virtually all of sub-Saharan Africa are deeply affected by leptospirosis [2].

In numerous developing nations where lifestyles, climates, and ecological conditions are conducive to leptospirosis, there is a lack of reliable data regarding the actual extent of this reemerging zoonotic disease. Due to its nonspecific clinical symptoms and challenging biological diagnosis, leptospirosis may often be overlooked in these regions [2].

In our study, anti-Leptospira IgM was detected using NovaTec ELISA kit. According to the manufacturer’s validation data and published review, the test has been proven to have 93.3% sensitivity and 97.5% specificity for the presence of anti-Leptospira IgM antibodies [32].

In Iran, a review and meta-analysis study demonstrated that the seroprevalence of leptospirosis in humans was 27.84% and 19.71% using ELISA and microscopic agglutination test (MAT), respectively [33]. A cross-sectional study in Khuzestan, southwest Iran, showed that 65 out of 288 samples (22.5%) tested positive for IgM anti-Leptospira antibodies. Among the positive cases, 52 (36.1%) were from the case group (rice farmers), and 14 (9.7%) were from the control group [34].

In another study conducted in the tribal areas of Farsan and Koohrang in west-central Iran, 194 out of 400 serum samples (48.5%) showed positive results for different leptospiral serovars at a minimum titer of 1:100. The highest seroprevalence was observed for serovar Hardjo, representing 54.1% of the positive cases, while serovar Grippotyphosa had the lowest seroprevalence at just 1% [35].

A cross-sectional descriptive study conducted in Sari and Qaemshahr, northern Iran, found that 36 out of 63 patients suspected of having leptospirosis tested positive through serologic testing. The majority of the cases (86.1%) were farmers, and 83.4% resided in rural areas [36].

An investigation involving 995 patients with a history and clinical signs suggestive of leptospirosis, admitted to general hospitals in Guilan Province, northern Iran, revealed that 62.7% of the positive cases were male, and around 86% were farmers [37].

Managing leptospirosis, particularly in its severe manifestations, involves supportive care such as maintaining adequate hydration, administering fluid and electrolyte therapy, providing advanced respiratory support, and initiating renal replacement therapy at an early stage. Prompt initiation of these supportive measures, combined with early antibiotic therapy, has been demonstrated to significantly enhance outcomes and lower morbidity and mortality rates [38]. For patients who are not expected to have significant exposure to water but are at potential risk of contracting leptospirosis, it might be advisable to offer a 7-day regimen of doxycycline, 100 mg twice daily. Patients would be instructed to commence treatment if they develop a feverish illness consistent with leptospirosis [39]. In rhabdomyolysis, the primary treatment involves administering fluids and alkalinizing the urine [40].

Leptospirosis prevention can be accomplished through various methods such as eliminating environmental risks, developing protection through vaccination in advance, or administering prophylactic antibiotics to at-risk populations. Controlling leptospirosis through environmental measures is ineffective, as the ecology of the species and serovars is constantly changing, partly owing to animal vaccination strategies [41, 42].

Current studies have shown that the use of antibiotics such as doxycycline, amoxicillin, or ceftriaxone can reduce the duration of illness significantly, prevent severe complications, and improve outcomes in leptospirosis [19, 43, 44]. Early broad-spectrum antibiotics, including doxycycline and amoxicillin, were given to our patient with clinical improvement, which is consistent with current evidence supporting early antibiotic therapy in leptospirosis.