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Weekly Chest CasesArchive of Old Cases

Case No : 650 Date 2010-04-11

  • Courtesy of Jae-Yeon Hwang, Hyun Joo Lee, Eun Jin Chae, Jae-Woo Song / University of Ulsan College of Medicine, Asan Medical Center.
  • Age/Sex 57 / M
  • Chief ComplaintVisited ER for fever, cough, and blood-tinged sputum.
  • Figure 1
  • Figure 2

Initial chest radiograph

Diagnosis With Brief Discussion

Diagnosis
Pulmonary leptospirosis
Radiologic Findings
A 57-year-old male complained of fever, cough, and blood-tinged sputum for one day. On a chest radiograph, there were areas of increased opacity in both upper lung zones. On the same day, he had an episode of hemoptysis (approximately 300 cc) and required intubation for hypoxemia. His chest radiograph obtained at 15 hours later demonstrated extensive, ill-defined consolidation involving both lungs. The patient was diagnosed as having leptospirosis by positive serologic test.
A CT image (Figure 1) shows areas of consolidation mixed with ground-glass opacities in both upper lobes. These findings may be attributed to diffuse alveolar hemorrhage related to leptospirosis. On a bronchoscopy, large amount of fresh blood appeared without demonstrable endobronchial lesion (Figure 2).

Fig 1. Chest CT

Fig 2. Bronchoscopy

Brief Review
Leptospirosis, a zoonosis caused by spirochetes from the species Leptospira interrogans, occurs worldwide, but is more common in tropical regions. Humans become infected from direct contact with the urine of infected animals or from exposure to soil, water, or other matter contaminated with it. The spirochetes enter the host through abraded skin or intact mucous membranes and travel to the liver where they reproduce. After an incubation period of 2 to 30 days, leptospiremia occurs, spreading organisms to all parts of the body.
Pulmonary symptoms occur in both the non-icteric and icteric forms, including chest pain secondary to myositis or with a pleuritic character. Many case reports, clinical series, and descriptions of outbreak document the frequent occurrence of hemoptysis and diffuse pulmonary hemorrhage. The primary mechanism of pulmonary hemorrhage in leptospirosis is vasculitis.
Radiographic findings commonly accompany pulmonary symptoms but may occur without them. In on series, 82% of patients with hemoptysis had abnormal chest radiography. Abnormal findings appear as early as 24h after symptoms begin, although more commonly 3 to 9 days later. Three radiographic patterns occur: (1) Small “snowflake-like” nodular densities corresponding to areas of alveolar hemorrhage, (2) large confluent consolidations, and (3) a diffuse, ill-defined ground-glass pattern that may represent resolving hemorrhage. Serial radiographs may show progression from a nodular pattern to confluent consolidation.
References
1. Luks AM, Lakshminarayanan S, Hirschmann JV. Leptospirosis presenting as diffuse alveolar hemorrhage: Case report and literature review. Chest 2003;123:639-643.
Keywords
Lung, Infection, Bacterial infection,

No. of Applicants : 91

▶ Correct Answer : 18/91,  19.8%
  • - radiologist, aditya imaging centre , India vivek patel
  • - Institute of Chest Diseases,Calicut , India sijith raghavan
  • - Hangang sacred heart hospital , Korea (South) You Mie Han
  • - Youngdong Hospital , Korea (South) Sang Min Lee
  • - Konkuk university hospital , Korea (South) Jeong Geun Yi
  • - Hangang Sacred Heart Hospital , Korea (South) Eil Seong Lee
  • - ROK air force aerospacemedical center , Korea (South) Daekeon Lim
  • - CHRU lille , France manuel toledano
  • - Hospital Moinhos de Ventos , Brazil Felipe Hertz
  • - Osaka University , Japan Hiromitsu Sumikawa
  • - Uzunkopru Devlet Hastanesi , Turkey Armagan Sarac
  • - Bundang CHA hospital , Korea (South) Jung Jin Young
  • - Homs National Hospital , Syria Rami Abou Zalaf
  • - Beaulieu clinic Geneva , Switzerland gilles GENIN
  • - Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
  • - NASA SCANS , India RAKESH BHATIA
  • - Hospital Sotiria, Athens, Greece , Greece Vasilios Tzilas
  • - Armed Forces Chun-Cheon Hospital , Korea (South) Chae Lim
▶ Correct Answer as Differential Diagnosis : 21/91,  23.1%
  • - care hospital , India Chary D
  • - University of British Columbia , Canada Amr Ajlan
  • - Vitalife Clinics , Pune , India. , India Rahul Deshmukh
  • - McGill University , Canada Ben Smith
  • - Nirman hitech diagnostic centre , India minal seth
  • - chungbuk uni. hospital , Korea (South) Ahn ypung
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - University of Montreal , Canada Laurent Letourneau-G.
  • - MEDISURGE HOSPITAL AHEMDABAD , India jignesh dubal
  • - Yonsei University college of medicine Severance Hospital , Korea (South) Hua Sun Kim
  • - universidad de chile , Chile enrique aguilera
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - Toyama University Hospital, Laboratory of Pathology , Japan TOMONORI TANAKA
  • - HOSPITAL SOTIRIA , Greece AIKATERINI DELAVERI
  • - CHU NANCY , France, Metropolitan GREGORY LESANNE
  • - PingTung Christian Hospital ,China Medical University ,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - Hotel-Dieu Montreal , Canada nicolas gautier
  • - IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
  • - IRSA La Rochelle France , France Denis Chabassiere
  • - Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
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