Recreational ‘mud fever’: Leptospira interrogans induced diffuse alveolar hemorrhage and severe acute respiratory distress syndrome in a U.S. Navy seaman following ‘mud-run’ in Hawaii

Schmalzle, Sarah A; Tabatabai, Ali; Mazzeffi, Michael; Matta, Ann; Hollis, Allison; Zubrow, Marc; Rajagopal, Keshava; Thom, Kerri; Scalea, Thomas

Two days into the patient's admission to the tertiary hospital, his family recalled an important cluethey showed the medical team a digital photograph of the patient covered in mud that he had sent approximately two weeks prior to illness onset [ Fig. 2 ]. He had participated in the "Warrior Dash" in Hawaii. The event consists of fourteen outdoor obstacles, several of which involved full body exposure to mud or fresh water. Consistent with clinical suspicion, IgM for Leptospira was positive. The Centers for Disease Control and Prevention and Hawaii Department of Health (HI DOH) Disease Investigation Branch were made aware, and they provided confirmatory testing. A four-fold increase in IgM titers from acute to convalescent phase, as well as PCR positive for Leptospira interrogans serovars Icterohaemorrhagiae and Mankarao, further bolstered the diagnosis. The dominant serovar in HI is icterohaemorrhagiae; therefore transmission likely did occur while the patient was in HI, during participation in the 'Warrior Dash' two weeks prior to symptom onset. The presence of serovar mankarao is consistent either with co-infection or with cross reactivity on testing. Per HI DOH, there were no other known cases occurring in association with this event.