Correspondence

Clinical Problem-Solving: Leptospirosis

N Engl J Med 1993; 329:2040-2041December 30, 1993

Article

To the Editor:

Dr. Kreisberg's cogent assessment and coherent comments on clinical problem-solving (Aug. 5 issue)1 emphasize the need for a probing history taking in every patient. The first reported instance of leptospirosis in Connecticut was recognized by establishing that the patient had swum to a stagnant bay frequented by dogs to retrieve a beach ball five days before the onset of his serious illness and that he had sustained a traumatic puncture of the left eardrum two weeks before the event2. Nine members of one family contracted Leptospira canicola infection from a communal water dipper contaminated by a sick bulldog3.

Alertness to the subtle hazards of water immersion or seafood ingestion may aid in a prompt recognition of toxic shock syndrome or massive rhabdomyolysis caused by the virulent toxins of Vibrio vulnificus, V. damsela,4 or Plesiomonas shigelloides. Schistosomal cercariae and acanthamoeba trophozoites may await a hapless recreational swimmer in a warm polluted lake or near a hydroelectric-plant outlet, resulting in perplexing and serious neurologic conditions. Toddlers being taught swimming skills before bowel training have contaminated even chlorinated pools with Giardia lamblia and cryptosporidia.

Prior ingestants often also guide our diagnostic investigation. Few recognize that unpasteurized, canned goat's milk in Oceania may transmit brucellosis. Excruciating abdominal pain after the ingestion of raw fish (e.g., in sushi) with infected anisakis may be related to larval penetration of gastric mucosa, which may simulate a tumor5,6. Eating inadequately cooked beef or rabbit meat infected with Toxoplasma gondii or trichina-infected pork sausage, cold or smoked hors d'oeuvres, or bear meat may result in cardiomyopathy of “obscure origin.” Puzzling tachyarrhythmia and digestive motor dysfunctions may be correlated with contact with the reduviid insect (kissing bug) lurking in an upholstered seat in a Latin American train and transmitting Trypanosoma cruzi.

The effort to resolve diagnostic puzzles calls for detailed assessments of our patients' prior activities and possible exposure to endemic diseases during travel. This effort also requires that we tap into the gigabytes of our own cerebral hard drives.

Martin E. Gordon, M.D.
Yale School of Medicine, New Haven, CT 06531-0548

6 References

1. 1

   Kreisberg RA. An abundance of options. N Engl J Med 1993;329:413-416
   Full Text | Web of Science | Medline

2. 2

   Gordon ME. Canicola fever: report of first case in Connecticut and review of the literature. N Engl J Med 1952;247:708-714
   Full Text | Web of Science | Medline

3. 3

   Haunz EA, Cardy JD. Canicola fever: report of nine cases in one family, with abstract of the world literature. Arch Intern Med 1952;89:978-993
   

4. 4

   Perez-Tirse J, Levine JF, Mocca M. Vibrio damsela: a cause of fulminant septicemia. Arch Intern Med 1993;153:1838-1840
   CrossRef | Web of Science | Medline

5. 5

   Ikeda K, Kumashiro R, Kifune T. Nine cases of acute gastric anisakiasis. Gastrointest Endosc 1989;35:304-308
   CrossRef | Web of Science | Medline

6. 6

   Sakai K, Ohtani A, Muta H, et al. Endoscopic ultrasonography findings in acute gastric anisakiasis. Am J Gastroenterol 1992;87:1618-1623
   Web of Science | Medline

To the Editor:

During my residency in Wisconsin, I saw a patient with leptospirosis whose history was exceptionally instructive.

The patient was a 42-year-old computer programmer who had been ill for six months with fever, chills, night sweats, and headaches. Her husband and three teenage children had had similar, but briefer and less severe, symptoms. Her family physician had made a presumptive diagnosis of Lyme disease because of a positive antibody test for that disease. As part of an exhaustive history taking, I learned that the family kept 28 pet mice, which were permitted to roam the entire house, including the kitchen, where the mice were fed from the family's plates and where they often urinated. The titer of antibody to leptospira was elevated, and the patient was treated successfully with ciprofloxacin. The elevated antibody titer for Lyme disease was probably a cross-reaction between the Lyme spirochete and spirochetes of the genus leptospira. The patient and her family did not accept our recommendation that they remove the mice from their home.

A diagnosis of leptospirosis should be considered in patients who are exposed to animal waste products at work or in the home.

Brian J. Bohlmann, M.D.
Dean Medical Center, Madison, WI 53715-1992