A 65-year-old Sinhalese man from Kandy district in the central hill region of Sri Lanka presented to us on day 4 of the illness with high fever, headache, arthralgia, myalgia, nausea, dry cough, chest pain, sore throat, and passing of watery stools and dark urine. Upon examination, he was dehydrated, temperature was 38 C, pulse rate was 120/minute, and blood pressure was 70/40 mm Hg, and there were few basal crepitations on his right lung with mild epigastric tenderness. There was no lymphadenopathy or any other remarkable findings. He was admitted during the height of an outbreak of dengue, so suspecting dengue hemorrhagic fever (DHF), inward hematocrit was checked and it was 48%. A bedside ultrasound scan of the abdomen demonstrated edema of the gall bladder wall and a small amount of free fluid. He was resuscitated with intravenous fluid, and blood was sent for workup suspecting DHF or leptospirosis (he owns a small dairy farm and a pet dog, and leptospirosis is common locally). As illustrated in Table 1, his liver transaminases, serum creatine, and blood urea levels were high, and the percentage of neutrophils remained high in the full (complete) blood count.
His CRP levels remained high from day 4 to day 6. Therefore, our first differential diagnosis was leptospirosis, and the second was DHF with possible secondary bacterial infection. We maintained fluid balance and supportive therapy as for DHF according to the current national guidelines which are broadly similar to the World Health Organization (WHO) 2009 guidelines and added intravenous (IV) ceftriaxone 1 g twice daily until day 11 to cover leptospirosis. The common secondary bacterial infection in DHF patients we see here is IV cannula site infections or skin infections with Staphylococcus aureus. There was no evidence of such infections in this patient, and the neutrophil percentage was above 90% even in the results of the first test done on admission. His first ECG (EKG) showed inverted T wave in leads 5 and 6 and in the repeated ECGs that was present only in lead 5. His troponin I levels were also high. A 2D echocardiogram revealed global hypokinesia with a grade II aortic regurgitation. Nevertheless, we were unable to exclude any preexisting mild aortic regurgitation as this patient had never undergone an echocardiogram before. The patient was reassessed by a consultant cardiologist on day 8, the same findings plus a grade III mitral regurgitation and a grade II tricuspid regurgitation were detected, and the left ventricular ejection fraction (LVEF) was 30%. Congestive cardiac failure due to possible leptospiral myocarditis was diagnosed. Dobutamine and furosemide infusions were administered between days 4 and 10, and supportive therapy continued. Considering his lung and cardiac involvement, 1 g of intravenous methylprednisolone was administered daily for 3 days starting from day 5 and followed by 40 mg oral prednisolone daily. His blood sugar level rose after that and was controlled by subcutaneous soluble insulin injections. Few months before his admission, we received several influenza A H1N1 patients. Influenza A H1N1 also can cause similar symptoms. Until the report of throat swab for influenza A and B viral RNA becomes available, the patient was given oral oseltamivir 75 mg twice daily from days 4-9. Throat swabs were negative for influenza A and B (report arrived later). Test for both IgM and IgG against the dengue virus was negative on day 6. This patient was never icteric. There was no conjunctival suffusion and myalgia in his calf and was minimal in the back of the neck. Considering absence of those common clinical features of Weil's disease, we have tested for possible rickettsial infection despite the absence of any inoculation eschar (tache noire) or any other cutaneous lesions. We started 100 mg doxycyline twice on day 6 and continued 100 mg daily for a subsequent 6 days. On day 8, in the immunofluorescence antibody test (IFAT) in the blood sample with 1 : 32 dilution, IgG against Rickettsia conorii was positive (++), and with 1 : 48, 1 : 96, and 1 : 192 dilutions, IgM against Rickettsia conorii was positive. However, tests for further dilutions were not performed due to shortage of test kits. On day 13, the ELISA test for IgM against leptospirosis in 1 : 100 dilution became negative. The patient was discharged on day 14 on 40 mg oral furosemide and 25 mg spironolactone twice a day and reassessed after a month. He had only a mild dyspnea and moderate tiredness while performing his daily routine, and a repeated 2D echocardiogram showed a global left ventricular hypokinesia, but the right ventricular functions were normal. A grade I mitral regurgitation and mild aortic regurgitation were detected, and the LVEF was 35%. After that, he defaulted follow-up but continued taking same drugs irregularly. A 2D echocardiogram, repeated after eight months, showed apical, apicoseptal, and anterior hypokinesia and reduced muscle mass of the left ventricle without scarring and LVEF of 40%. A grade I aortic regurgitation was present. However, he has been continuing his daily routine without any symptoms.