Skip to main navigation menu Skip to main content Skip to site footer
Padjadjaran of Nursing Journal

Case

Vol. 11 No. 1 (2023): Jurnal Keperawatan Padjadjaran

ST-elevation myocardial infarction, severe cardiogenic shock, and myocarditis secondary to leptospirosis: A rare case report

DOI
https://doi.org/10.24198/jkp.v11i1.2176
Submitted
December 1, 2022
Published
2023-04-27

Abstract

Background: Leptospirosis is a bacterial infection that can lead to several organ dysfunctions. However, cardiac involvements in leptospirosis are uncommon findings. The unknown pathogenesis and association between leptospirosis and cardiac involvements can lead to a diagnostic challenge and case rarity. This study aims to report a diagnosis challenge through physical and laboratory examination of a patient with ST-elevation myocardial infarction (STEMI) and myocarditis without common leptospiral-associated organ dysfunction features. We also report the therapeutic strategies in this case, despite its clinical guideline limitation. Case: A 35-year-old male patient came to the emergency department with flu-like symptoms. Twenty-four hours later, the patient showed acute angina, STEMI, and elevated high-sensitivity cardiac troponin followed by cardiogenic shock without significant modifiable and non-modifiable risk factors for heart diseases. The patient received fibrinolytic, supportive therapy and correction of hemodynamic derangement. We found thrombocytopenia on the second day. Surprisingly, the immunoserology showed positive anti-leptospira IgM and negative anti-dengue IgM and IgG. Further, there was echocardiography suspected myocarditis due to high echogenicity in the left ventricle's basal-apical lateral endocardium. Thus, we diagnosed this case as leptospirosis with cardiac involvement. Direct cardiac tissue damage due to systemic vasculitis, disseminated intravascular coagulation, and pro-inflammatory cytokine storm is believed to be pathomechanism in leptospirosis with cardiac involvement. After diagnosis establishment, his final therapies in the hospital were Aspirin, Atorvastatin, Clopidogrel, Spironolactone, Ramipril, Carvedilol, Omeprazole, Doxycycline, and Ceftriaxone. Subsequently, he was discharged from hospital and continued to receive cardiovascular medications, antibiotics, antiplatelet, potassium-sparing diuretics, and omeprazole. Conclusion: This case highlights the importance of thorough clinical-laboratory evaluation in a patient with an atypical leptospiral presentation. Although  leptospirosis is not a common cause of heart diseases such as STEMI, cardiogenic shock, and myocarditis, we recommend supportive therapy and correction of hemodynamic derangement for leptospirosis with cardiac involvement, in addition to leptospiral antibiotic drug itself.

Article Matrics
Abstract views : 587 times PDF Downloads: 498

Downloads

Download data is not yet available.

References

  1. de Alencar Neto, J. N. (2018). Morphine, oxygen, nitrates, and mortality reducing pharmacological treatment for acute coronary syndrome: An evidence-based review. Cureus, 10(1), e2114. https://doi.org/10.7759/cureus.2114
  2. Becirovic, A., Numanovic, F., Dzafic, F., & Piljic, D. (2020). Analysis of clinical and laboratory characteristics of patients with leptospirosis in five-year period. Materia Socio Medica, 32(1), 15. https://doi.org/10.5455/msm.2020.32.15-19
  3. Britto, C., Pollard, A. J., Voysey, M., & Blohmke, C. J. (2017). An appraisal of the clinical features of pediatric enteric fever: Systematic review and meta-analysis of the age-stratified disease occurrence. Clinical Infectious Diseases, 64(11), 1604-1611. https://doi.org/10.1093/cid/cix229
  4. Chen, X., Xie, X., Wu, D., Zhang, S., Zhang, W., & Cao, Y. (2020). The pre-activated immune response induced by LPS protects host from leptospirosis. PLOS ONE, 15(11), e0242742. https://doi.org/10.1371/journal.pone.0242742
  5. Costa, F., Hagan, J. E., Calcagno, J., Kane, M., Torgerson, P., Martinez-Silveira, M. S., Stein, C., Abela-Ridder, B., & Ko, A. I. (2015). Global morbidity and mortality of leptospirosis: A systematic review. PLoS Neglected Tropical Diseases, 9(9). https://doi.org/10.1371/JOURNAL.PNTD.0003898
  6. De Brito, T., Silva, A. M. G. da, & Abreu, P. A. E. (2018). Pathology and pathogenesis of human leptospirosis: A commented review. Revista Do Instituto de Medicina Tropical de São Paulo, 60, e23. https://doi.org/10.1590/s1678-9946201860023
  7. Evangelista, K. V, & Coburn, J. (2010). Leptospira as an emerging pathogen: A review of its biology, pathogenesis and host immune responses. Future Microbiology, 5(9), 1413-1425. https://doi.org/10.2217/fmb.10.102
  8. Fraga, T. R., Barbosa, A. S., & Isaac, L. (2011). Leptospirosis: Aspects of innate immunity, immunopathogenesis and immune evasion from the complement system. Scandinavian Journal of Immunology, 73(5), 408-419. https://doi.org/10.1111/j.1365-3083.2010.02505.x
  9. Gasem, M. H., Hadi, U., Alisjahbana, B., Tjitra, E., Hapsari, M. M. D. E. A. H., Lestari, E. S., Aman, A. T., Lokida, D., Salim, G., Kosasih, H., Merati, K. T. P., Laras, K., Arif, M., Lukman, N., Sudarmono, P., Lisdawati, V., Lau, C.-Y., Neal, A., & Karyana, M. (2020). Leptospirosis in Indonesia: Diagnostic challenges associated with atypical clinical manifestations and limited laboratory capacity. BMC Infectious Diseases, 20(1), 179. https://doi.org/10.1186/s12879-020-4903-5
  10. Guzmán Pérez, M., Blanch Sancho, J. J., Segura Luque, J. C., Mateos Rodriguez, F., Martínez Alfaro, E., & Solís García del Pozo, J. (2021). Current evidence on the antimicrobial treatment and chemoprophylaxis of human leptospirosis: A meta-analysis. Pathogens, 10(9), 1125. https://doi.org/10.3390/pathogens10091125
  11. Haake, D. A., & Levett, P. N. (2015). Leptospirosis in humans. Current Topics in Microbiology and Immunology, 387, 65. https://doi.org/10.1007/978-3-662-45059-8_5
  12. Ibanez, B., James, S., Agewall, S., Antunes, M. J., Bucciarelli-Ducci, C., Bueno, H., Caforio, A. L. P., Crea, F., Goudevenos, J. A., Halvorsen, S., Hindricks, G., Kastrati, A., Lenzen, M. J., Prescott, E., Roffi, M., Valgimigli, M., Varenhorst, C., Vranckx, P., Widimský, P., … Gale, C. P. (2018). 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal, 39(2), 119-177. https://doi.org/10.1093/eurheartj/ehx393
  13. Mathew, A., Shanks, M., Punnoose, E., Fischer, L., Koshy, G., Potluri, R., & Bainey, K. R. (2020). Cardiac involvement in critically ill patients with leptospirosis: A prospective study using myocardial deformation imaging. European Heart Journal. Acute Cardiovascular Care, 9(8), 975-983. https://doi.org/10.1177/2048872618809319
  14. Misra, D. P., & Shenoy, S. N. (2017). Cardiac involvement in primary systemic vasculitis and potential drug therapies to reduce cardiovascular risk. Rheumatology International, 37(1), 151-167. https://doi.org/10.1007/s00296-016-3435-1
  15. Monteiro, M. B., Sousa, I. E. de, Piteira, M., Coelho, S., & Freitas, P. (2021). Leptospirosis, a re-emerging threat. Cureus, 13(4). https://doi.org/10.7759/CUREUS.14295
  16. Navinan, M. R., & Rajapakse, S. (2012). Cardiac involvement in leptospirosis. Transactions of the Royal Society of Tropical Medicine and Hygiene, 106(9), 515-520. https://doi.org/10.1016/J.TRSTMH.2012.06.007
  17. Rajapakse, S. (2022). Leptospirosis: Clinical aspects. Clinical Medicine, 22(1), 14. https://doi.org/10.7861/CLINMED.2021-0784
  18. Satiya, J., Gupta, N. M., & Parikh, M. P. (2020). Weil’s disease: A rare cause of jaundice. Cureus, 12(6), e8428. https://doi.org/10.7759/cureus.8428
  19. Shah, A. H., Puri, R., & Kalra, A. (2019). Management of cardiogenic shock complicating acute myocardial infarction: A review. Clinical Cardiology, 42(4), 484-493. https://doi.org/10.1002/clc.23168
  20. Warnasekara, J., Srimantha, S., Kappagoda, C., Jayasundara, D., Senevirathna, I., Matthias, M., Agampodi, S., & Vinetz, J. M. (2022). Diagnostic method-based underestimation of leptospirosis in clinical and research settings; An experience from a large prospective study in a high endemic setting. PLOS Neglected Tropical Diseases, 16(4), e0010331. https://doi.org/10.1371/journal.pntd.0010331