Abstract: PUB017
From Jaundice to Dialysis: Severe Leptospirosis Presenting as Hyperbilirubinemia-Driven Pigment Nephropathy
Session Information
Category: Acute Kidney Injury
- 102 AKI: Clinical, Outcomes, and Trials
Authors
- Ghimire, Kalpana, University of Illinois Chicago, Chicago, Illinois, United States
- Ghimire, Manoj, Baylor College of Medicine, Houston, Texas, United States
Introduction
Severe leptospirosis (Weil disease) is a life-threatening zoonosis characterized by jaundice, multiorgan dysfunction, and acute kidney injury (AKI). Dialysis-requiring AKI in the setting of profound hyperbilirubinemia is uncommon and may reflect underrecognized mechanisms such as pigment nephropathy. Early diagnosis is challenging due to nonspecific presentation and overlapping infectious and hepatonephropathic differentials.
Case Description
A 58-year-old man with no significant medical history presented with generalized weakness, mild hypotension, and low-grade fever. He had not engaged in routine medical care and denied medication, alcohol, or substance use. Possible occupational rodent exposure was identified.
Initial evaluation revealed severe hyperbilirubinemia (total bilirubin >20 mg/dL), acute kidney injury with metabolic acidosis, thrombocytopenia, leukocytosis with left shift, normocytic anemia, and mild rhabdomyolysis. Liver enzymes demonstrated a mixed hepatocellular pattern. Urinalysis was bland, and imaging showed no biliary obstruction or intra-abdominal pathology.
Despite broad infectious and autoimmune evaluation and empiric ceftriaxone, renal function progressively worsened, complicated by uremic encephalopathy requiring temporary hemodialysis (three sessions). Hospital course included transient atrial fibrillation with rapid ventricular response, which resolved with rate control.
Leptospirosis was suspected and confirmed by serologic testing. With supportive care and targeted antimicrobial therapy, the patient achieved full renal recovery and was successfully liberated from dialysis prior to discharge.
Discussion
This case highlights severe leptospirosis as a reversible cause of dialysis-requiring AKI with extreme hyperbilirubinemia. Proposed mechanisms include tubular injury, interstitial nephritis, and bile pigment–mediated nephrotoxicity (bile cast nephropathy). Recognition is critical, as early empiric therapy and supportive care can result in complete renal recovery even in severe presentations.