Case series of fatal Leptospira spp./dengue virus co-infections-Puerto Rico, 2010-2012

Abstract

Co-infection with pathogens that cause acute febrile illness creates a diagnostic challenge as a result of overlapping clinical manifestations. Here, we describe four fatal cases of Leptospira species/dengue virus co-infection in Puerto Rico. Although all patients sought care early, antibiotic administration was delayed for most. Steroids were administered to all patients, in most cases before antibiotics. These cases show the need for clinicians evaluating patients in or recently returned from the tropics with acute febrile illness to consider both dengue and leptospirosis. Furthermore, they illustrate the need for nucleic acid- or antigen-based rapid diagnostic tests to enable timely patient diagnosis and management. In particular, antibiotic therapy should be initiated early for patients with suspected leptospirosis, and steroids should not be administered to patients with suspected dengue.

Figure 1.

Histopathologic evaluation of tissue specimens collected post-mortem from an individual (Case 2) that died in Puerto Rico in 2010 following co-infection with Leptospira species and dengue virus-type 4. Tissue specimens were taken from the lung (A) and kidney (B and C) and stained with hemotoxylin-eosin (A and B; original magnification 10× and 20×, respectively) or probed with polyclonal anti-Leptospira antibody for immunohistochemical detection of Leptospira antigen (C; arrowheads indicate antigen; original magnification 63×).

Figure 2.

Chest radiographs from an individual (Case 3) that died in Puerto Rico in 2011 following co-infection with Leptospira species and dengue virus-type 1. Posteroanterior (A and C) and lateral (B) chest radiographs were taken on Day 1 (A and B) and Day 2 (C) of hospitalization. The patient died on hospital Day 2.