Mark O'Lepsy is a 47 year old man who has presented very unwell to the Emegency Assessment Unit. He has had generalised aches and pains and a headache for a few days now, and currently has a temperature of 38.4 degrees celcius. He states he has had flu-like symptoms and his skin has changed colour over the last 2 days. He has had a cough, and has coughed up blood. Mark has no past medical history. He has never had blood transfusions and works for a sewage company. He has had the same partner for 6 years and no one around him appears to be unwell.
On examination his airway is intact and he is talking in full sentences. His chest sounds clear. He is tender in the right upper quadrant of his abdomen and there is hepatomegaly. He appears to be confused and is not presently aware that he is in hospital. He has scleral icterus and is jaundiced.
Initial blood tests:
Hb 124
WCC 14.3
Urea 17.1
Creatinine 290
ALT 60
ALP 150
Over to you - what would you like?
CXR report: patchy shadowing, perhaps indicative of alveolar haemorrhage
HIV serology: negative
Hepatitis B serology: negative
Hepatitis C: negative
Now select your winner!
You picked:
Correct answer:Leptospirosis
This is a case designed to identify the most likely causative organism for a clear infection. Most of the possibilities are causes of pneumonia, which could be causing the haemoptysis. However, there is also jaundice, indicating liver involvement. An acute hepatitis, however would be unlikely to cause the presentation. Moreover, there are no risk factors for hepatitis. Therefore, we are likely looking at a causative organism which causes both hepatic and respiratory symptoms. CXR shows indications of alveolar haemorrhage. A clue here is that he works for a sewage company: classically rat urine, causing leptospirosis, can be associated with groups working in areas where rats are prevalent. This causes jaundice, alveolar haemorrhage and haemoptysis. It may also cause renal impairment, clear here with an AKI.
