A case of leptospirosis presenting as TTP
摘要
In their recent article, Booth et al. describe a number of cases of systemic infection with reduced a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) activity, whose presenting clinical features mimicked thrombotic thrombocytopenic purpura (TTP) 1. In the past, a small number of cases of leptospirosis have been reported to be associated with TTP 2-4. We describe a further such case of leptospirosis, with presenting features suggestive of TTP and report, for the first time, an associated reduction in ADAMTS activity. A previously well 49-year-old Caucasian male was hospitalized with 11-day history of general malaise and 5 days of increasingly severe lower limb muscle pain. On physical examination, he was jaundiced and had generalized tenderness of his legs. He had low grade fevers with a maximum temperature of 37.8°C. There was no history of headache or rigors. Complete blood count (CBC) revealed hemoglobin of 12.9 g/dl with a white cell count of 9.8 × 109/l and platelets 21 × 109/l. Both kidney and liver functions were shown to be deranged, with urea of 35.5 mmol/l, creatinine of 698 µmol/l, bilirubin of 198 µmol/l, alanine aminotransferase of 244 IU/l, and alkaline phosphatase of 180 IU/l, and hypoalbuminemia of 30 g/l. Serum lactate dehydrogenase was 1,677 IU/l. Blood film examination showed severe thrombocytopenia and fragmented red cells. In light of this patient's acute kidney injury, thrombocytopenia, and anemia, a working diagnosis of TTP was made and subsequently daily therapeutic plasma exchange (TPE) and high dose intravenous corticosteroids were commenced. Due to worsening renal function, with a serum creatinine of 759 µmol/l, and the onset of oliguria on day 2 of admission, hemodialysis was initiated. On day 3 of TPE and high dose IV corticosteroid treatment, a CBC revealed no improvement in the thrombocytopenia, with a platelet count of 8 ×109/l. There was still a marked transaminitis which had not improved sin