Anas Almoghrabi, MD, Alexander Nguyen, MD, Amit Patel, MD, Bashar M. Attar, MD, PhD
Cook County Health and Hospital Systems, Chicago, IL
Introduction: The broad differential in the workup of infectious causes of abnormal liver enzymes can be narrowed by a good history and physical. Bilateral Conjunctival suffusion, characterized by non-purulent conjunctivitis, is present in 55% of patients with leptospirosis and is uncommon in other infectious diseases. We report a case of leptospirosis in a patient with conjunctival suffusion, abnormal liver enzymes, jaundice, and recurrent fevers.
Case Description/Methods: A 44-year-old previously healthy Hispanic male presented with painless jaundice, subjective fevers, nonproductive cough, and a morbilliform rash for 14 days. He reported no recent travel, sick contacts, bad habits, or hepatotoxic herbal medications, and he worked in a slaughterhouse. He denied joint pain, abdominal pain, and pruritus. On exam, he had a temperature of 38.2°C and was tachycardic to 117 with normal blood pressure. He had bilateral non-purulent conjunctivitis with mild scleral icterus and a faint morbilliform rash over both his thighs. Laboratory data was remarkable for leukocytosis (14.9 WBC/mm3), elevated bilirubin (4 mg/dL total, 2.3 mg/dL direct), Alkaline phosphatase (517 U/L), AST (84 U/L) and ALT (162 U/L). Imaging studies revealed hepatic steatosis with no other findings. Infectious workup indicated that leptospira antibody to IgM were likely present based on DOT BLOT testing (ARUP labs). Serologic testing for other infectious causes were unremarkable. The patient was started on doxycycline 100mg twice a day for one week for mild leptospirosis with improvement in his symptoms, labs, and clinical exam.
Discussion: Leptospirosis, although endemic in the tropics, is a rare cause of jaundice and abnormal liver enzymes in the United States. It is associated with environmental exposure such as animal urine, contaminated water or soil, or infected animal tissue. Gastrointestinal clinical features include abdominal pain, jaundice, elevated hepatic transaminases and serum bilirubin. An important but frequently overlooked clinical finding is bilateral conjunctival suffusion, which is rare in other infectious diseases. Diagnosis is made by serologic testing for IgM antibodies. Treatment involves supportive care with oral doxycycline in mild cases and IV antibiotics for hospitalized patients. An astute physician should have a high index of suspicion for leptospirosis if non-purulent conjunctivitis is found in the infectious workup of fever and abnormal liver enzymes as it may save time and prevent excessive testing.
Citation: Anas Almoghrabi, MD, Alexander Nguyen, MD, Amit Patel, MD, Bashar M. Attar, MD, PhD. P2491 - SEEING IS BELIEVING: CONJUNCTIVAL SUFFUSION IN A JAUNDICED PATIENT DIAGNOSED WITH LEPTOSPIROSIS. Program No. P2491. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.