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

DAH is a rare, sometimes life-threatening manifestation of several unrelated diseases including capillaritis associated with systemic autoimmune diseases, coagulation disorders, inhalational injury, pulmonary veno-occlusive disease, and certain infections [3] . Immunocompetent hosts presenting with DAH and signs of infection should raise concern for dengue fever, malaria, influenza A, leptospirosis, hantavirus pulmonary syndrome, and Staphylococcus aureus (S. aureus) pneumonia, while DAH secondary to A 23-year-old man presented in March of 2014 to a community hospital in Maryland with four days of fever, chills, severe malaise, and myalgias, which he reportedly attributed to overexertion on a recent five-day ski trip to Vermont. Chest x-ray was unremarkable (Fig. 1a) . He was given a diagnosis of viral upper respiratory infection and dehydration, and discharged from the Emergency Department in haste, as he needed to 'catch a flight to Hawaii' per hospital documentation. However, he returned later that day with severe dyspnea. Vital signs included maximum temperature to 102.7 Fahrenheit, heart rate 131 beats per minute, respiratory rate 48 breaths per minute, blood pressure 94/40, and arterial oxygen saturation was 55% on 100% oxygen via nasal cannula. He was emergently endotracheally intubated and copious bloody secretions from the endotracheal tube were noted. Other abnormalities included mild elevation of transaminases and total bilirubin, acute kidney injury (serum creatinine 2.3 mg/dL with protein and blood on urinalysis), rhabdomyolysis (creatinine kinase 2811 U/L), abnormal coagulation profile (prothrombin time 16.9 s, partial thromboplastin time 29 s, international normalized ratio 1.4), leukocytosis (18.3 K/l), anemia (hemoglobin 7.0 g/dL), and thrombocytopenia (96 K/ ml). CXR showed development of interstitial opacities (Fig. 1b) . Vancomycin, ceftriaxone, azithromycin, and oseltamivir were initiated empirically at the community hospital, to cover for usual bacterial pathogens associated with communityacquired pneumonia including methicillin-resistant Staphylococcus aureus (MRSA), and influenza.