Leptospirosis with an Unusually High Bilirubin Level—a Probable Case of Ceftriaxone-Induced Hyperbilirubinemia

Jaundice in an adult patient has got myriad reasons ranging from benign to life-threatening causes; in tropical countries, the causes may be skewed in favor of tropical infections. From the province of Kerala in India, we report a case of leptospirosis with an unusually high level of serum bilirubin. A 23-year old male with an occupational risk for leptospirosis was admitted with fever and myalgia. His liver function tests were markedly deranged, with bilirubin levels being significantly elevated (direct hyperbilirubinemia): total bilirubin 15.4 mg/dL and direct bilirubin 13.2 mg/dL. He also had anemia, thrombycytopenia, and mildly altered renal function. Owing to the clinical suspicion of leptospirosis, he was started on ceftriaxone at the time of admission itself. Though the platelet count and renal function started improving, surprisingly, bilirubin levels were on an upward trend. On day 4 (from initiation of antibiotics), the total bilirubin level was 45.5 mg% and the direct bilirubin level was 42.8 mg%. At this juncture, ceftriaxone was stopped, and the patient was started on ciprofloxacin injection. In the subsequent days, there was a rapid fall in the bilirubin levels. Ceftriaxone was suspected as the cause of the unusually high bilirubin level. Several reasons are attributed to jaundice in leptospirosis. In the case of obstinate jaundice in leptospirosis, one more reason to be considered is ceftriaxone-induced hyperbilirubinemia.