19 Year Old

Female with
Flank Pain
 Patient Data
Patient: J.I.

Age/Sex: 19/F

Address: Project 6, Quezon City

Chief Complaint:
Flank pain
 History of Present Illness

3 days PTA, patient was using a public restroom which was slightly flooded.
Patient noted also wound at her left foot, onset of dysuria, associated
with febrile episodes tmax 39 C, flank pain, calf pain bilateral, loss of
appetite and vomiting episodes approximately 1 cup, self medicated
with Paracetamol with partial relief.

2 days PTA, still with above symptoms, sought consult with AP, labs were
done, urinalysis was unremarkable, but patient was started with
Ciprofloxacin 500mg tab BID. Persistence of symptoms prompted
admission.
Past Medical History
● No history of diabetes mellitus
● No history of hypertension
● (+) PCOS
○ February 2020
○ Took Drospirenone+Ethinyl Personal & Social
Estradiol (Yaz) pills for 6 History
months
● (+) Recurrent UTI ● Non alcohol beverage drinker
○ Unrecalled onset & medications ● Non smoker
● No food or drug allergy
OB/Gyne History ● Complete COVID vaccine

● Menarche: 11 years old

● Interval: Irregular
● Duration: 2-7 days
● Amount: 3-4 pads; fully soaked
 Review of Systems
General: (-) significant weight loss, (-) weakness
Skin: (-) jaundice, (-) rash
HEENT: (-) diplopia, (-) blurry vision, (-) epistaxis, (-) sore throat
Respiratory: (-) cough, (-) dyspnea, (-) hemoptysis
Cardiovascular: (-) chest pain, (-) palpitations
Gastrointestinal: (-) change in bowel movement, (-) abdominal pain
Extremities: (-) edema, (+) arthralgia, ankle
Urinary: (-) hematuria, (-) urgency
Endocrine: (-) heat or cold intolerance, (-) thirst)
Neuro: (-) headache, (-) numbness
 Physical Examination
Vital Signs: Bp 100/70, HR 102, RR 20, T 38.2 (febrile)
General: Awake and not in respiratory distress
HEENT: Anicteric sclerae, pink palpebral conjunctiva, PERRLA
Chest and Lungs: Clear breath sounds, equal chest expansion
Cardiac: Adynamic precordium, no murmurs, distinct heart sounds
Abdomen: Soft and non tender abdomen, (+) kidney punch sign, bilateral
Extremities: Full pulses, (-) edema
 Laboratory Tests Done
CBC Aug. 9 (OPD) Aug. 11 Serum Creatinine (Aug. 9, OPD)
62 umol/L
WBC (4.0-10.0) 5.8 3.1
N (0.55-0.65) 0.77 0.79 Serum Electrolytes (Aug. 11)
L (0.35-0.55) 0.10 0.14 Mg 0.88
M (0.02-0.09) 0.07 Ca 1.06 L
E (0.02-0.04) 0.00 Na 129 L
B (0.00-0.02) 0.00 K 2.83 L

RBC (4.5-6.2) –N/A– 5.3

Hgb (13-18) 14.7 14.3

Hct (0.4-0.5) 0.43 0.43

Plt (150-400) 288 220

 Laboratory Tests Done
Urinalysis, Aug. 11 (Aug. 9*, OPD)

Parameter Result Flow Cytometry Result Reference Range

Color Dark yellow WBC 1 (0-1*) 0-3/hpf

Character Hazy RBC 1 (1-2*) 0-2/hpf

pH 6.0 Epith. cells 4 (4*) 0-3/hpf

Specific Gravity 1.030 Renal cells 9

Albumin + Cast 0 0-3/hpf

Sugar neg Bacteria 92 0-50/hpf

Urine Gram Stain Urine Culture and Sensitivity

Pus cells: Few Organisms isolated: Non-significant bacterial growth
Epithelial cells: Rare
Chest X-Ray (8/11/22)
Primary Impression:
Mild Leptospirosis
Acute Pyelonephritis
 Medications Given & Patient Plans

Ceftriaxone 2 g IV q24h
Paracetamol 500 mg/tab 1 tab q4h PRN for fever
Metoclopramide 1 amp q8h PRN for vomiting
Orphenadrine citrate + Paracetamol (Norgesic Forte) 50mg/
650 mg per tab, 1 tab q6h prn for flank pain

Admit
VS q4h
I/O qshift
DAT
IVF PNSS 1L at 100cc/hr
Leptospirosis
 Leptospirosis
● Zoonotic disease, outbreaks on all continents
● Pathogenic Leptospira species
● Varies from an asymptomatic infection to fulminant fatal disease
● Mild form: fever, headache, and myalgia
● Severe leptospirosis: jaundice, renal dysfunction and hemorrhagic
diathesis (Weil’s syndrome)
○ Severe pulmonary hemorrhage with or without jaundice
● Leptospires
○ Coiled, thin, highly motile, with hooked ends + two periplasmic
flagella, with polar extrusions from the cytoplasmic membrane
○ 6-20 um long, about 0.1 um in diameter
○ Seen on dark field examination & silver impregnation tissue stain or
basic fuschin stain
○ Weeks or months for cultures to be (+)
 Epidemiology
● Common: tropics or subtropics (climate, poor hygienic conditions)
● Peak: summer and fall in northern and southern hemispheres & rainy season in tropics
● Men

Transmission

● Important reservoir: rodents (rats) ● Prominent sources: recreational exposure &

● Important vehicle: water
○ Exposure to floodwaters
● Direct contact (urine, blood, tissue from
infected animal) or exposure to
environmental contamination
domestic animal contact
○ Recreational freshwater activities: canoeing,
windsurfing, swimming, waterskiing
○ Adventurous activities: whitewater rafting,
jungle trekking, caving
○ Animal bite
○ Unanticipated immersion in contaminated
water (e.g. vehicular accident, flash floods)
Pathogenesis
 Clinical Manifestations
● IP: 1-2 weeks (2 to 30 days)
● Biphasic (leptospiremic and immune phase)
● Potentially fatal
● Hallmarks: bleeding & multiorgan failure

Mild Leptospirosis ● PE:

● Flu-like illness of sudden onset ○ Pharyngeal injection
○ Fever ○ Lymphadenopathy
○ Chills ○ Meningismus
○ Headache (frontal/retro-orbital region w/ or w/o ○ Hepatomegaly
photophobia) ○ Splenomegaly
○ Nausea & vomiting ○ Crackles
○ Abdominal pain ○ Transient rash
○ Conjunctival suffusion (redness w/o exudate) ■ Macular, maculopapular,
○ Myalgia (calves, back, abdomen) erythematous, hemorrhagic
● Spontaneous resolution: 7-10 days (petechial or ecchymotic)
 Clinical Manifestations
Severe Leptospirosis
● Weil’s syndrome: hemorrhage, jaundice, AKI
● Die of septic shock w/ MOF and/or severe
bleeding complications
○ Pulmonary hemorrhage
■ With or without jaundice
■ Cough, chest pain, respiratory
distress, hemoptysis
○ Jaundice
○ Melena, hemoptysis
○ Hematuria
○ Petechiae, ecchymosis, bleeding from
venipuncture sites
● Acute kidney injury
○ Nonoliguric or oliguric
○ Hypokalemia, hyponatremia
○ Loss of magnesium in the urine
● Hypotension
○ Acute tubular necrosis, oliguria, anuria
○ Requires fluid resuscitation or vasopressor
therapy
● Leptospiral meningitis
○ Altered mental status
 Clinical Manifestations
Severe Leptospirosis

Other syndromes
○ Necrotizing pancreatitis
○ Cholecystitis
○ Rhabdomyolysis w/ moderately elevated serum creatinine
○ Nonspecific ST and T wave changes
○ Arrhythmias
○ Myocarditis

Long term symptoms

○ Fatigue
○ Myalgia
○ Malaise
○ Headache persisting for years
○ Autoimmune associated uveitis
 Diagnosis
History
● Recreational freshwater activities
● Contact with contaminated surfaces/waters/soil
● Direct/indirect animal contact

CBC & Blood chemistries

● Leukocytosis w/ left shift
● Thrombocytopenia (≤ 100 x 10^9/L)
● ↑ CRP, ESR, procalcitonin
● Mod. ↑ in ALT, AST, ALP
● ↑ Serum bilirubin levels
● ↑ Amylase
● Mild azotemia
 Diagnosis
Urinalysis:
● Nonoliguric hypokalemic renal insufficiency
○ ↑ WBCs, RBCs, hyaline/granular casts
○ Mild ↑ protein

CSF
● Pleocytosis (>1000 cells/uL)
● ↑ PMN/lymphocytes, slight ↑ protein

Radiographic findings
● Patchy bilateral alveolar pattern (scattered alveolar hemorrhage in the lower lobes)
● Diffuse glass attenuation (ARDs)
● Pleura-based densities (hemorrhage)
 Definitive Diagnosis
● Microscopy (day 7-10)
● (+) Real-time PCR (day 1-5)
● Isolation of organism
● Seroconversion/rise in antibody titer on ELISA or MAT
● Single antibody titer 1:200-1:800 on MAT
 Treatment
Treatment Indication Regimen

Mild Leptospirosis First line agent: Doxycycline (100 mg PO BID)

Alternative agents:
Amoxicillin (500 mg PO TID) or
Ampicillin (500 mg PO TID)

Moderate/Severe Leptospirosis Penicillin (1.5 million units IV or IM q6h) or

Ceftriaxone (2 g/d IV) or
Cefotaxime (1 g IV q6h) or
Doxycycline (loading dose 200 mg IV then 100 mg IV q12h)
 Prevention Prognosis
● PPE ● Most recover
● Vaccines for agricultural and companion animals ● High mortality rates: fetal, elderly & severe dse
● Chemoprophylaxis ● Post-leptospirosis symptoms
○ Doxycycline
○ Azithromycin 250 mg PO 1-2x a week

Low Risk Moderate Risk High Risk

Single exposure Single exposure Continuous exposure

Skin lesions W/ or w/o lesions
Accidental ingestion of cont. water Swimming in flooded waters

Doxycycline 200 mg Doxycycline 200 mg Doxycycline 200 mg

SD within 24-72h OD x 3-5d Once weekly until end of
exposure