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

A thorough investigation into the patient's medical, social, and travel history revealed that he was on a scheduled break from active military service for the United States Navy; he serves on a submarine stationed in Pearl Harbor, Hawaii (HI). Past medical history was notable only for Bells palsy as a child due to Lyme disease, and he had received recommended childhood vaccinations. He had flown to Maryland from HI, and then driven to Vermont with a friend to ski and they had skied 'hard' for five days. They stayed in a cabin, which according to the friend was clean and otherwise unremarkable. Contact with medical personnel and military officials from his unit provided an accurate travel history for the antecedent 6 months of military service, which cannot be detailed here. However, we were able to confirm that he had not traveled recently to the Middle East or any areas with endemic malaria. Based on areas traveled, mild liver involvement, and the short list of infectious causes of DAH in immunocompetent patients, leptospirosis and dengue fever were suspected. Influenza remained a possibility also as the presentation occurred during influenza season, though all military members on the ship had received annual influenza vaccination. Tick-borne illnesses, while unlikely causes of DAH, were also considered based on travel to Vermont (though seasonality was not consistent). S. aureus pneumonia also was a possibility, made less likely by the presence of viral prodrome unless it had occurred as a complication of influenza. Family history was unknown as the patient had been adopted from Romania at birth, and there were no known sick contacts or disease outbreaks on his submarine.