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Kidney Week

Abstract: FR-PO207

Weil Disease as a Cause of Electrolyte Wasting and AKI

Session Information

Category: Acute Kidney Injury

  • 103 AKI: Mechanisms

Authors

  • Mistry, Kavita, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
  • William, Jeffrey H., Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
Introduction

Leptospirosis is a spirochetal illness that can manifest as a severe syndrome of Weil’s disease, characterized by oliguric AKI, liver injury, jaundice, anemia, thrombocytopenia, rhabdomyolysis and pulmonary edema. AKI in Weil’s disease is multifactorial, resulting from direct action of spirochetes on renal tissue, rhabdomyolysis, ATN and AIN.

Case Description

A 67-year-old woman from Haiti residing in the Boston area presented with lower extremity myalgias and weakness. Physical exam revealed scleral icterus and 4/5 muscle strength in the proximal lower extremities. She was found to have oliguric AKI with creatinine of 5.9 mg/dL, potassium of 4.3 mEq/L, phosphorus of 1.3 mg/dL and calcium of 8.2 mg/dL. LFT abnormalities included ALT 187 IU/L, AST 278 IU/L, total bilirubin 10.6 mg/dL and direct bilirubin 9.5 mg/dL. CPK was elevated at 3439 IU/L. CBC was remarkable for white blood cell count 19.8 K/uL, hemoglobin 8.9 g/dL and platelet count 23 K/uL. Reticulocyte count was low at 0.3% with haptoglobin 364 mg/dL and LDH 313 IU/L. INR and PTT were normal. ANA was negative. U/A revealed 1+ glucose, 3+ blood and 3+ protein (quantified at 4.7 g/g) with 10-15 isomorphic RBC/hpf, few granular casts and several renal tubular epithelial cells on microscopy. Infectious Diseases was consulted, and initially had low pre-test probability for infection given that the patient was afebrile and had been living in Massachusetts for 6 months, however recommended testing for leptospirosis, Dengue, chikungunya and tickborne diseases. Leptospira IgM returned positive with high titer of 12,800 for L. interrogans on MAT confirmatory testing. The patient was diagnosed with Weil’s disease and was treated with ceftriaxone with normalization of laboratory parameters and symptoms.

Discussion

This patient’s presentation of oliguric AKI with relatively preserved potassium and hypophosphatemia is characteristic of leptospirosis-associated renal injury, which is often preceded by electrolyte wasting that is thought to result from leptospire-induced changes in expression of tubular transport proteins along the nephron. It is important to maintain a high index of suspicion for leptospirosis in patients who present with AKI and evidence of electrolyte wasting, and in patients who present with direct hyperbilirubinemia out of proportion to other LFT abnormalities, even in the absence of exposure and recent travel history.