Tuesday, November 4, 2008

Day #118 - Probable Leptospirosis

Today we heard a case of a returning traveller who suffered complete cardiorespiratory collapse as part of a sepsis syndrome. In this syndrome the patient was hypotensive requiring inopressors, hypoxemic/hypercapnic requiring ventillation, coagulopathic with a microangiopathic hemolytic anemia (see TTP blog and previous anemia/thrombocytopenia blogs) from DIC, and in acute renal failure. In the context of this illness he suffered either myocarditis or a myocardial infarction related to hypoperfusion.

This was as sick as anyone can be and survive and it is a testiment to our critical care system that he did indeed survive.

We spent time discussing the approach to diarrhea, which was his initial presenting symptom.



We then defined sepsis

SIRS Criteria:
  • Fever or hypothermia
  • WBC >12,000 or less than 4,000
  • HR >90
  • RR >20
Sepsis = 2 or more SIRS criteria of presumed infective etiology
Severe sepsis includes sepsis with end organ dysfunction or lactate >4
Septic shock includes severe sepsis with refractory hypotension requiring inopressors

We then talked about the approach to early goal directed therapy in sepsis.

In this case, I believe early appropriate antibiotic therapy would include:
  • Vancomycin (in case of community associated MRSA in a young man)
  • Meropenem (to cover streptococcus, gram negatives including ESBL/drug resistant)
  • Doxycycline to cover leptospirosis
In general, in a critically ill patient like this, I will draw cultures and then use very broad spectrum coverage empirically with a plan to de-escallate when culture results are available




The etiology in this case is unclear but I wonder about leptospirosis. I didn't really want to talk about leptospirosis in detail during the case presentation.... This is the case of leptospirosis in NEJM that I elluded to.

I have provided you with a copy of a talk I once gave on leptospirosis here.



Free tidbits:

Here is an article on fever in the returning traveller
A good review of typhoid fever is here.

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