The association between Leptospirosis and hepatitis A has not been frequently referred to in medical literature, despite being one of the most prevalent diseases in the Amazon region, consequent to the region’s poor health conditions.[1,2]

We report 2 cases of leptospirosis and hepatitis A coinfection in patients admitted to the department of infectious diseases of a local public hospital in Belém, Brazil.

Case 1

A 38 year old man was admitted with fever since 9 days along with nausea and epistaxis. The patient also reported pain in his lower limbs, and contact with flood water 11 days before admission. Physical examination revealed jaundice with no other significant systemic finding.

Laboratory tests showed urine containing red blood cells, leukocytes, proteins and casts. ELISA based serological investigations revealed the presence of anti-HAV (hepatitis A virus) IgM and anti-HAV IgG antibodies and anti-leptospiral IgM antibodies.

The patient received 4,000,000 IU of crystalline penicillin G for 9 days. After 16 days of admission, the patient was discharged without complaints. The patient was still icteric, but his jaundice had much improved since his arrival at the hospital.

Case 2

A 33-year-old woman was admitted with complaints of jaundice and fever since 3 days. The patient gave past history of experiencing similar episodes of fever, jaundice and abdominal pain two months prior to the current illness, when she was diagnosed with hepatitis A. On physical examination she was found to have fever (38.5oC), jaundice and mild dehydration. Serological investigations using ELISA revealed the presence of anti-HAV IgM and anti-HAV IgG antibodies and antileptospiral IgM antibodies.

Twelve hours after hospitalization for clinical investigations, the patient developed abrupt onset of mental confusion, impaired awareness and psychomotor agitation that later evolved to coma, compatible with grade IV encephalopathy. The patient was admitted to the intensive care unit and maintained on clinical support.

The patient had acute liver failure with refractory shock and multiple organ failure and expired six says later

Discussion

The association between infection with hepatitis A and leptospirosis has not been reported frequently in medical literature, despite the high prevalence of these diseases in tropical regions with poor sanitary conditions[1,2] as observed in the Amazon region.

The presence of hepatitis A in adulthood is not common in regions like the Amazon.[3,4] Our cases have drawn attention to this changing epidemiology of this disease, usually with more complicated evolution in this age group.[4,5]

Hepatitis A and leptospirosis may reveal nonspecific laboratory findings such as increased levels of AST and ALT[3,6,7] which were found in both the cases in this study. Pereira and Goncalves[3] found no association between these laboratory tests and prognosis. Higher levels of AST and ALT are associated with a more unfavorable outcome.[8,9] Normally, bilirubin levels do not exceed 10 mg/dL in patients diagnosed with hepatitis A3,6 which was not observed in the cases presented here, where co-infection of leptospirosis and hepatitis A may have been responsible for increased liver damage explaining this result.[7,8]

Among the risk factors for poor prognosis[10,12] case 1 showed increased level of total bilirubin[11,12] and case 2 showed increased bilirubin, oliguria, tachycardia, pulmonary complications requiring mechanical ventilation, hypotension refractory to administration of epinephrine and delay in administering antibiotic therapy for leptospirosis.[8,11,12] This study highlights the importance of timely diagnosis of leptospirosis and hepatitis A co-infection which act as synergistic factors of liver damage. It is necessary that health professionals be alert to this type of co-infection especially in endemic areas with socio-economically disadvantaged
communities.

References