Login | Users Online: 857  
Home Print this page Email this page Small font sizeDefault font sizeIncrease font size   
Home | About us | Editorial board | Search | Ahead of print | Current Issue | Archives | Submit article | Instructions | Subscribe | Advertise | Contact us
 


 
Table of Contents
CASE REPORT
Year : 2017  |  Volume : 18  |  Issue : 4  |  Page : 149-151  

Cardiac magnetic resonance of myocardial involvement in leptospirosis


1 Department of Radiology, Narayana Health, Bengaluru, Karnataka, India
2 Department of Cardiology, Narayana Health, Bengaluru, Karnataka, India

Date of Web Publication20-Dec-2017

Correspondence Address:
Dr. Onkar B Auti
Department of Radiology, Narayana Health, Narayana Health City, Bengaluru - 560 099, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HEARTVIEWS.HEARTVIEWS_60_17

Rights and Permissions
   Abstract 


Leptospirosis is a zoonotic infection caused by the Leptospira interrogans. Although it is endemic in tropical countries, global incidence has increased in several temperate and developed regions. Here, we present a cardiac magnetic resonance (CMR) and multidetector computer tomography (MDCT) chest features of active systemic leptospiral infection in a 19-year-old male. The MDCT appearances of lungs and CMR appearances of myocardium in icteric leptospirosis are described. Early diagnosis and prompt treatment is important to manage the cardiothoracic complications.

Keywords: Cardiac magnetic resonance, leptospirosis, multidetector computer tomography, myocardial involvement, myocarditis


How to cite this article:
Auti OB, Kansal K, Shrikanth K V, Raj V. Cardiac magnetic resonance of myocardial involvement in leptospirosis. Heart Views 2017;18:149-51

How to cite this URL:
Auti OB, Kansal K, Shrikanth K V, Raj V. Cardiac magnetic resonance of myocardial involvement in leptospirosis. Heart Views [serial online] 2017 [cited 2019 Sep 20];18:149-51. Available from: http://www.heartviews.org/text.asp?2017/18/4/149/221229




   Introduction Top


Leptospirosis is a widespread and prevalent zoonotic disease.[1],[2] The incidence in the tropical countries like India is almost 10 times higher than in temperate regions.[1],[3] The source of infection in humans is usually either direct or indirect contact with the urine of an infected animal. The disease is seasonal with epidemic outbreaks.


   Case Presentation Top


A 19-year-old male presented to our hospital with a 4-day history of fever, yellowish discoloration of eyes, loss of appetite, and generalized weakness. On examination, vital parameters were stable with icterus and abdominal distension. Blood investigation showed deranged liver function test. Patient was admitted in hospital and treated for viral hepatitis. During the course of disease, patient developed dyspnea and was found to have increased jugular venous pressure, pedal edema, and bilateral crepitations. Echocardiography showed dilated heart chambers with left ventricle (LV) systolic dysfunction and global hypokinesia. Blood investigation revealed IgM antibody positive for leptospirosis.

Cardiac magnetic resonance (CMR) imaging was performed for further assessment. CMR showed biventricular dilatation with LV ejection fraction of 11% and global hypokinesia predominantly affecting anterior and septal wall [Video 1]. Myocardial edema was noted in the basal and mid-anterior segments on Short Tau Inversion Recovery (STIR) imaging [Figure 1]a. There was no evidence of infarction or infiltration on delayed enhancement imaging. Multidetector computed tomography (MDCT) of chest revealed moderate bilateral pleural effusions with ground-glass densities in bilateral lungs and multiple patchy consolidations in bilateral lower lobes. Most of these consolidations were nodular in nature with one showing central ground-glass change [Figure 1]. Subsegmental collapse of anterior segment of right upper lobe was also noted.
Figure 1: (a) Short axis Short Tau Inversion Recovery image at mid cavity level showing myocardial edema in anterior wall (arrows). (b and c) Multidetector computed tomography image of chest showing bilateral pleural effusions, patchy ground-glass densities (short arrows) with nodular peripheral consolidations (block arrows). Note the consolidation in left lower lobe with central ground-glass attenuation (arrowhead)

Click here to view






   Discussion Top


Leptospirosis is a zoonotic infection caused by Leptospira interrogans. Although it is endemic in tropical countries, global incidence has increased in several temperate and developed regions.[4] Icteric leptospirosis is a severe form of disease, in which the clinical course is rapidly progressive. It may involve various systems including lungs and heart. There is increased mortality in severe leptospirosis associated with pulmonary alveolar hemorrhage and myocarditis.[5],[6]

CMR features of leptospiral myocarditis are myocardial hyperintensities on STIR sequence with or without delayed enhancement. MDCT features of pulmonary manifestation of leptospirosis are pleural effusions, ground glass opacities, nodules, and patchy consolidations which represent alveolar hemorrhages.[7] In the present case, the MDCT appearances of lungs and CMR appearances of myocardium in icteric leptospirosis are described.

A mild form of leptospirosis can be treated with doxycycline, ampicillin, or amoxicillin. A Severe form of leptospirosis requires hospital admission and intravenous administration of penicillin G or third-generation cephalosporins.[8] Severe leptospirosis can affect any organ system and results in multiorgan failure. Therefore, careful management of renal, hematological, and hepatic complications is of great importance. Continuous cardiac monitoring is essential in severe form as it can cause arrhythmias, ventricular tachycardia, atrial fibrillation, or flutter. Early treatment has been shown to offer the best clinical outcomes and early recovery of patients.[9],[10]

Leptospirosis affects directly the myocardium causing its inflammation which may proceed to necrosis. Gold standard investigation to diagnose myocarditis is endomyocardial biopsy. However, the procedural complications and sampling errors limit the frequent use of biopsy.[11] ECG can show changes in myocarditis; however, these are very nonspecific.[12],[13] On the other hand, CMR shows promising results in detecting myocarditis due to its high spatial resolution and multiplanar imaging techniques.[14] STIR imaging along with newer sequences such as T2* mapping is very sensitive to detect myocardial inflammation.[15],[16],[17] Early diagnosis of severe leptospiral myocarditis can administer the prompt treatment and early recovery of clinical condition.


   Conclusion Top


Although leptospiral myocarditis is a rare presentation, its prevalence is increasing. Early diagnosis and treatment is important to prevent the lethal outcomes. CMR and MDCT are an excellent tool for early diagnosis of leptospiral myocarditis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Hartskeerl RA, Collares-Pereira M, Ellis WA. Emergence, control and re-emerging leptospirosis: Dynamics of infection in the changing world. Clin Microbiol Infect 2011;17:494-501.  Back to cited text no. 1
    
2.
World Health Organization. Leptospirosis worldwide, 1999. Wkly Epidemiol Rec 1999;74:237-42.  Back to cited text no. 2
    
3.
Ratnam S. Leptospirosis: An Indian perspective. Indian J Med Microbiol 1999;12:228-39.  Back to cited text no. 3
    
4.
Bharti AR, Nally JE, Ricaldi JN, Matthias MA, Diaz MM, Lovett MA, et al. Leptospirosis: A zoonotic disease of global importance. Lancet Infect Dis 2003;3:757-71.  Back to cited text no. 4
    
5.
Yersin C, Bovet P, Mérien F, Clément J, Laille M, Van Ranst M, et al. Pulmonary haemorrhage as a predominant cause of death in leptospirosis in Seychelles. Trans R Soc Trop Med Hyg 2000;94:71-6.  Back to cited text no. 5
    
6.
Levett PN. Leptospirosis. Clin Microbiol Rev 2001;14:296-326.  Back to cited text no. 6
    
7.
Marchiori E, Müller NL. Leptospirosis of the lung: High-resolution computed tomography findings in five patients. J Thorac Imaging 2002;17:151-3.  Back to cited text no. 7
    
8.
Murray CK, Hospenthal DR. Determination of susceptibilities of 26 Leptospira sp. serovars to 24 antimicrobial agents by a broth microdilution technique. Antimicrob Agents Chemother 2004;48:4002-5.  Back to cited text no. 8
    
9.
Watt G, Padre LP, Tuazon ML, Calubaquib C, Santiago E, Ranoa CP, et al. Placebo-controlled trial of intravenous penicillin for severe and late leptospirosis. Lancet 1988;1:433-5.  Back to cited text no. 9
    
10.
Costa E, Lopes AA, Sacramento E, Costa YA, Matos ED, Lopes MB, et al. Penicillin at the late stage of leptospirosis: A randomized controlled trial. Rev Inst Med Trop Sao Paulo 2003;45:141-5.  Back to cited text no. 10
    
11.
Caforio AL, Pankuweit S, Arbustini E, Basso C, Gimeno-Blanes J, Felix SB, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: A position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J 2013;34:2636-48.  Back to cited text no. 11
    
12.
Abgueguen P, Delbos V, Blanvillain J, Chennebault JM, Cottin J, Fanello S, et al. Clinical aspects and prognostic factors of leptospirosis in adults. Retrospective study in France. J Infect 2008;57:171-8.  Back to cited text no. 12
    
13.
Deluigi CC, Ong P, Hill S, Wagner A, Kispert E, Klingel K, et al. ECG findings in comparison to cardiovascular MR imaging in viral myocarditis. Int J Cardiol 2013;165:100-6.  Back to cited text no. 13
    
14.
Baccouche H, Mahrholdt H, Meinhardt G, Merher R, Voehringer M, Hill S, et al. Diagnostic synergy of noninvasive cardiovascular magnetic resonance and invasive endomyocardial biopsy in troponin-positive patients without coronary artery disease. Eur Heart J 2009;30:2869-79.  Back to cited text no. 14
    
15.
Holmvang G, Dec GW. CMR in myocarditis: Valuable tool, room for improvement. JACC Cardiovasc Imaging 2012;5:525-7.  Back to cited text no. 15
    
16.
Roller FC, Harth S, Schneider C, Krombach GA. T1, T2 mapping and extracellular volume fraction (ECV): Application, value and further perspectives in myocardial inflammation and cardiomyopathies. Fortschr Rontgenstr 2015;187:760-70.  Back to cited text no. 16
    
17.
Zhang Y, Corona-Villalobos CP, Kiani AN, Eng J, Kamel IR, Zimmerman SL, et al. Myocardial T2 mapping by cardiovascular magnetic resonance reveals subclinical myocardial inflammation in patients with systemic lupus erythematosus. Int J Cardiovasc Imaging 2015;31:389-97.  Back to cited text no. 17
    


    Figures

  [Figure 1]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   Case Presentation
   Discussion
   Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed1052    
    Printed20    
    Emailed0    
    PDF Downloaded42    
    Comments [Add]    

Recommend this journal