Title of Case(s)

Spontanous resolution, and setback thereafter, of fever and severe headaches - a "typical" presentation of a not-so-rare disease with an unusual complication.

Background

This case highlights important findings of leptospirosis:

1. Leptospirosis often presents with two phases, a complete remission of symptoms in between phases is possible.

2. Leptospirosis-induced acute kidney injury usually shows low potassium levels.

3. Meningitis can lead to intracranial hypertension.

Case Presentation Summary

A 15 year old girl presented to the ER late at night with 5 days of fever (40°C), neck pain, back pain and severe headaches (9/10 VNRS), no meningism, no pathologic neurological findings. Two days before presentation she came back from a summercamp in northern italy. Laboratory workup showed a highly elevated CRP, elevated creatinine, hyponatriemia, hypopotassemia, thrombocytpenia, lymphopenia. The main suspicion was a viral infection, but due to the severe symptoms we planned for a cMRI and LP.

However, for rounds before the tests (8 hours after admission) she presented with completely resolved symptoms. We deceided to cancel the diagnostics, but to keep her in the hospital for observation. 24 hours later she complained of a sudden severe headache and showed a clear meningism as well as papilledema. MRI showed flattened bulbi but no other pathological findings. LP opening pressure was 60cmH2O, and CSF showed pleocytosis, elevated lactate, low glucose, elevated protein. She was started on cefotaxime.

Our standard meningitis-workup includes culture, borrellia and TBE. Due to the two-phasic course of the illness, the AKI with low potassium levels, the meningitis and the camping holiday we performed leptospirosis-PCR of the urine, wich came back positive. With treatment her symptoms resolved quickly and had no squellae in her follow-up.

Key Learning Points

1. Leptospirosis is a two-phasic, often underdiagnosed zoonotic disease, can affect all organs while often leading to meningitis (with possible intracranial hypertension being rare); a peculiarity being the low potassium levels following kidney-involvement.

2. Travelhistory and exact analysis of all test-results are equally important for infectious diagnostic reasoning.