Leptospirosis in pregnancy: A lesson in subtlety

Leptospirosis is a zoonotic disease caused by spirochaete of the genus Leptospira. Human infection occurs after exposure to water or soil contaminated by urine from an infected animal. Most patients manifest as self-limited systemic illness. However 10% of patients manifest as severe disease associated with high fatality. The disease affects mostly men, cases involving pregnant women are uncommon. We presented a case of leptospirosis in a pregnant woman leading to mortality of both mother and foetus. A 28-year-old woman at 18 weeks of gestation, had shortness of breath and collapsed. She was brought unconscious to the emergency department and died shortly after arrival. A week prior to this, she had presented to the same hospital with pain on both thighs. Examination of the patient and ultrasound of the foetus revealed normal findings. Post mortem examination revealed hepatosplenomegaly and congested lungs; no jaundice, meningeal inflammation or cardiac abnormalities was evident. Histopathology examination of the lungs revealed pulmonary haemorrhages and oedema. Multiple infarcts were seen in the spleen and the kidneys showed foci of acute tubular necrosis. Laboratory investigations revealed Leptospira IgM antibody and PCR for leptospira were positive. This case illustrates the subtleness of clinical presentation of leptospirosis. The diagnosis was obscure even at post-mortem and was only suspected following histopathological examination, leading to further investigations. Leptospirosis may have a subtle presentation and a high index of suspicion for this infection is required for early identification of the disease.