1School of Medicine, Queen’s University; 2Department of Medicine; 3Division of Infectious Diseases; 4Division of Nephrology, Kingston General Hospital, Kingston, Ontario Correspondence: Dr Gerald A Evans, Division of Infectious Diseases, Kingston General Hospital, Etherington Hall, Room 3013, 76 Stuart Street, Kingston, Ontario K7L 2V7. Telephone 613-533-6619, fax 613-533-6825, e-mail evansg@queensu.ca CASE PRESENTATION A 32-year-old male migrant worker from St Lucia presented to the emergency department with a one-week history of myalgias, headache and fever. He was previously healthy. He was visiting Canada temporarily and had arrived in Canada 11 days before his presentation. One day after arriving in Canada, he ate commercially prepared hamburger patties, which he reported as “off-tasting”. Five days later, he became fatigued and experienced a bilateral, intermittent headache associated with photophobia and visual aura. He noticed that his eyes were bloodshot. Three days later, he developed loose, nonwatery, nonbloody diarrhea, associated with fever and rigors, which resolved completely in two days. At presentation, he complained of lethargy, lower-extremity myalgias, tea-coloured urine and intermittent epigastric discomfort. On examination, his temperature was 37.2°C, heart rate 87 beats/min, respiratory rate 18 breaths/min and blood pressure 113/72 mmHg. He had scleral icterus with conjunctival edema (Figure 1). He had no hepatosplenomegaly. His leukocyte count was 19.9×109/L, hemoglobin level 124 g/L and platelet count 24×109/L. His electrolyte levels, bicarbonate levels and anion gap were within normal limits; however, his creatinine level was 352 μmol/L and urea level was 18 mmol/L. His aspartate aminotransferase level was 310 U/L, alanine transaminase level 175 U/L, alkaline phosphatase level 79 U/L and total bilirubin level 191 μmol/L. His initial creatine kinase level was 2343 U/L and troponin I level was 1.6 μg/L. An initial electrocardiogram showed sinus rhythm with first-degree atrioventricular block and an incomplete right bundle branch block. He was admitted with an initial, presumptive diagnosis of hemolytic uremic syndrome or thrombotic thrombocytopenic purpura, and received two units of fresh frozen plasma. A hemolysis work-up returned negative: serum lactate dehydrogenase level was 353 U/L, haptoglobin level 2.9 g/L, total bilirubin level 191 μmol/L, indirect bilirubin level 60 μmol/L and direct bilirubin level 131 μmol/L. On a blood film, fragments were only rarely observed. Abdominal ultrasonography revealed hepatic periportal echogenicity, diffuse renal cortical echogenicity and no hydronephrosis. Echocardiography showed mild concentric left ventricular wall thickening and no regional wall motion abnormalities, with a preserved left ventricular ejection fraction (54%). Furthermore, serology for cytomegalovirus, hepatitis A virus, hepatitis B virus, hepatitis C virus and HIV were negative. Blood films failed to show intraerythrocytic trophozoites. Blood cultures were negative. Stool culture for Escherichia coli O157:H7 was also negative. He remained clinically stable and had good urine output with improving kidney function. However, his leukocyte count increased to 37.6×109/L and his direct bilirubin level and erythrocyte sedimentation rate increased to 169 μmol/L and 110 mm/h, respectively, suggesting progression of his hepatopathy and ongoing systemic inflammation. A diagnostic test was performed. DIAGNOSIS Leptospirosis serology was ordered. The present case contains many classic feature of severe icteric leptospirosis. Jaundice, headache, conjunctival suffusion, myalgias and diarrhea are all common symptoms (1). In severe leptospirosis, a peripheral leukocytosis with left shift occurs. There tends to be a direct hyperbilirubinemia with lesser increases in transaminase levels and slight elevation of alkaline phosphatase levels, which appear to be related to the cholestasis of sepsis. Clinical and biochemical rhabdomyolysis is common (2). Electrocardiographic abnormalities are frequent, including first-degree atrioventricular block and widespread T-wave inversion (3). Leptospirosis-associated myocarditis confers a case mortality rate as high as 54% (1). Severe thrombocytopenia can occur, but this is less common and indicates a poorer prognosis (2). After serum was obtained, the patient was started on intravenous benzylpenicillin 3×106 units every 6 h. He quickly improved clinically. Three days later, he was discharged home on ceftriaxone 1000 mg intravenously daily for a total of 14 days. Three weeks postdischarge, the patient was seen in the outpatient clinic and was clinically well. His creatinine level normalized to 92 μmol/L. His leukocyte count was 8.2×109/L, hemoglobin level 109 g/L and platelet count was 441×109/L. His liver enzyme levels remained mildly elevated (alanine transaminase 147 U/L and alkaline phosphatase 200 U/L). Retrospectively, the patient reported wading in fresh water while in St Lucia two weeks before his presentation to the authors’ hospital as well as seeing rodents around his house. The serum was sent to the National Microbiology Laboratory in Winnipeg, Manitoba. Leptospirosis ELISA for immunoglobulin M was found to be positive using the Panbio Leptospira IgM ELISA (Inverness Medical Innovations Australia Pty Ltd, Australia). Interpretation criteria were as follows: 11, positive. ELISA results were confirmed using a microagglutination test beginning at a screening dilution of 1:100. Further testing revealed Leptospira interrogans serovar Autumnalis as the most likely serovar (titre 1:800).