대한흉부영상의학회 Weekly Chest Cases

Case No : 375 Date 2005-01-01

Courtesy of Jeong-Hee Sohn, M.D., Kyung Hyun Do, M.D., Joon Beom Seo, M.D. / University of Ulsan, Asan Medical Cneter, Seoul, Korea
Age/Sex 66 / F
Chief ComplaintFever, dry cough for 7 hours

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Diagnosis With Brief Discussion

Diagnosis: Leptospirosis
Radiologic Findings: This patient is farmer. He complained of fever and dry cough.
Laboratory findings included mild leukocytosis (WBC: 10300), thrombocytopenia (platelat: 79000) and anemia (Hb: 7.8). Blood chemistry revealed decreased protein, decreased albumin and increased aminotransferase (AST and ALT) indicating decreased hepatic function. But, he had no definite renal dysfunction.
On bronchoscopy, there was large amount of blood in distal trachea.
Antibody for Hantanvirus, rickettsia and leptospirosis were all negative. Antibody for leptospirosis became positive four days later after admission.
After antibiotic treatment with penicillin was given, follow-up chest radiograph 20 days later showed improvement of lung opacities.

Initial chest PA with lateral view showed mild cardiomegaly with diffuse increased opacities in both lungs. Chest CT showed multifocal consolidation with patchy ground-glass opacity in both lungs without lobar predominancy. There are also diffuse interlobular septal thickening in both lungs and cardiomegaly.

Follow up of the chest film showed interval aggravation of multifocal consolidations in both lungs with cardiomegaly until September 15, 2004. Follw up chest radiograph obtained 4 days later showed mild improvement of parenchymal lesion and that of 20 days later showed marked improvement of parenchymal lesion.
Brief Review: Leptospirosis is an acute, febrile, systemic disease caused by spirochetes of the Leptospira interrogans in rodent and wild animals. The typical clinical symptom of leptospiremic phase include fever, headache, conjunctivitis, myalgia, and jaundice, which last 4-9 days. Leptospirosis can be complicated by ARDS, which needs the treatment of underlying disease and adequate supportive care with artificial mechanical ventilation. The main suspicious causes of the disease are heavy rain and water flooding during the summer, which leads to wide propagation of Leptospira.

Leptospirosis can occur as two clinical manifestations: a self-limiting anicteric systemic illness, which occurs in 85-90 % of the disease, and a septicemic leptospirosis, 10-15 % of patients. Weil's disease (hepatic involvement), icteric leptospirosis, is the severest form of the disease and characterized by the presence of impaired renal and hepatic function, multi-organ internal hemorrhage, vascular collapse, and severe alteration in consciousness.

The radiologic findings of the lung are reported as three forms: (1) multiple nodular opacities (air-space nodules) ranging from 1 to 7 mm in diameter with or without associated focal areas of consolidation (57%); (2) large confluent areas of consolidation (16%); and (3) diffuse, ill-defined areas of ground-glass opacity (27%).

In all patients, the abnormalities were bilateral and nonlobar in distribution; in approximately 50%, they involved mainly the peripheral lung regions. Other findings included small pleural effusions (19%) and cardiomegaly (27%).

Differential diagnosis should include ARDS, pulmonary edema and/or pneumonia, acute infection such as viral pneumonia or Pneumocystis cainii pneumonia, diffuse pulmonary hemorrhage, etc. However, the clinical setting suggests the diagnosis of leptospirosis, which was confirmed by the increased level of antibody titer.
Please refer to
References: 1. Fraser and Pare's Diagnosis of diseases of the chest. 4th ed. 776-777.
2. Im JG, Yeon KM, Han MC, et al. Leptospirosis of the lung: radiographic findings in 58 patients. AJR 1989 152;955.
Keywords: Lung, Infection, Bacterial infection,

No. of Applicants : 42

▶ Correct Answer : 16/42, 38.1%

- Aditya Imaging Centre, Baroda, India Vivek Patel
- Annecy Hospital, France Gilles Genin
- Asan Medical Center, Korea Eun Jin Chae
- Boomin Hospital, Korea Sangwoo Lee
- Chungnam National University Hospital, Korea Mi Hyun Park
- CIM Saint Dizier, France JC Leclerc
- Clinic 1, Moscow, Russia Lepikhina Dasha
- Ev. Krkhs. Hubertus, Berlin, Germany Michael Weber
- Govt. Medical College, Vadodara , India Vijay Vaidya
- Hanyang University Hospital, Seoul, Korea Yo Won Choi
- Hanyang university Guri Hospital, Korea Hyunji Kim
- Homs National Hospital, Homs, Syria Rami Abou Zalaf
- Incheon Sarang Hospital, Korea Jung Hee Kim
- Korea University Hospital, Korea Kyoung-Rae Kim
- Marien Hospital, Hamm, Germany Davis Chiramel
- Social Security Hospital, Ankara, Turkey Meric Tuzun

▶ Semi-Correct Answer : 11/42, 26.2%

- Annemasse Polyclinique De Savoie, France Gay-Depassier Philippe
- Apollo Firstmed Hospitals, Chennai, India RG Gopinath
- ASL BOLOGNA Maggiore Hospital, Bologna, Italy Marcellino Burzi
- Centre d'imagerie Jacques Callot, Nancy, France Lionel Cannard
- Busan Veterans Hospital, Korea Suhku Huh
- Dong-A University Hospital, Korea Ki-Nam Lee
- Hangang SacredHeart Hospital, Korea Eil Seong Lee
- Hospital Monaldi, Naples, Italy Gaetano Rea
- Max Hospital, Delhi, India Vickrant Malhotra
- Sharma Clinic, Jaipur, India Dinesh Sharma
- University of Colorado, USA Brian Petersen

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 375 Date 2005-01-01

Discussion

No. of Applicants : 42