Subconjunctival Hemorrhage in Leptospirosis
A previously healthy 18-year-old man presented to the emergency department with a 2-day history of fever, vomiting, and diarrhea. Three weeks before presentation, he had fallen into a canal. His heart rate was 110 beats per minute, and the temperature was 38.4°C. The physical examination was notable for scleral icterus and subconjunctival hemorrhage in both eyes (Panels A and B) as well as mild abdominal tenderness without hepatosplenomegaly. Laboratory studies showed acute kidney injury and elevations in aminotransferase and total bilirubin levels. A severe form of leptospirosis that manifests as fever, jaundice, renal failure, and hemorrhage was suspected on the basis of the patient’s classic presentation (including the subconjunctival bleeding) and exposure to water with probable contamination by rodent urine. Empirical treatment with intravenous penicillin was initiated. Analysis for IgM antibodies against leptospira species revealed a titer of 1:320 (reference value, negative). Serum nucleic acid amplification testing was positive for leptospira species, and microscopic agglutination testing later identified Icterohaemorrhagiae as the infecting serogroup. The patient was discharged after a 1-week hospital stay. At follow-up 3 weeks later, his symptoms, subconjunctival hemorrhage, and liver and kidney injury had resolved.