A 12-year-old boy presented to Tangerang district hospital, on 12 February 2015. Tangerang is a suburb in coastal area in the Jakarta metropolitan, consists of both agriculture and business areas. A large river crosses the middle of the town; and some areas are commonly flooded during the rainy season. Dengue and typhoid fever are endemic in this area; whereas sporadic outbreaks of influenza H5N1 have been reported since 2005 [5]. This boy had fever for three days (38.0 °C, on admission to the hospital), headache, fatigue, and muscle pain. The patient was alert and anicteric, with blood pressure of 110/70 mmHg, pulse 100 min, and respiratory rate (RR) of 22 min. Complete blood count showed anemia (7.5 mmol/L), thrombocytopenia (68,000 µL), neutrophilia (84 %), elevated absolute neutrophil count (ANC) (6048 µL), and normal leukocyte count (7200 µL). Based on these findings, a diagnosis of dengue hemorrhagic fever grade I was made; and the patient received supportive treatment with intravenous fluid, acetaminophen, and omeprazole.
On the third day of hospitalization, due to persistent fever, thrombocytopenia (20,000 µL), leukocytosis (15,000 µL), decreasing hemoglobin (5.4 mmol/L), and jaundice (total bilirubin/TB 82 µmol/L); the clinical team conducted additional tests which were blood smear and Coomb’s tests for Evans syndrome, dengue NS1 and IgM antibodies, HAV and HCV antibodies, HBsAg, and serum transaminases. All tests, except increased of AST (371 U/L) and ALT (120 U/L), were negative. On the fifth day of hospitalization, the patient appeared septic with oliguria, continued icterus, and RR of 26/min. The clinicians requested rapid IgM test (SD®) for leptospira which came back positive. Biochemistry showed increased of TB (366 µmol/L), AST (660 U/L), ALT (179 U/L), BUN (11.1 mmol/L), and creatinine (442 µmol/L).
Leukocytosis and thrombocytopenia were persistent; and metamyelocytes were detected in blood smear. Blood cultures were negative. Interview with the family member revealed that the patient played in flood water near his house a week before illness. Treatment with ceftriaxone 70 mg/kg twice a day was commenced and continued for 14 days.
On the eighth day of hospitalization, the patient’s renal function declined (BUN 20.35 mmol/L, creatinine 503.8 µmol/L); and he became anuric with decreased consciousness (Glasgow Coma Scale/GCS = 7). While waiting for the availability of the intensive care unit (ICU) room for intubation, as required by the hospital standard procedure, the GCS improved in the following day. The patient was hemodialysed on the 10th and 12th day of hospitalization.
After hemodialysis, laboratory parameters began to improve; and on the 21st day of hospitalization, the patient was clinically improved and renal function became normal. The patient was discharged although he was still anemic (Hb 5.5 mmol/L), had TB of 82.4 µmol/L and c-reactive protein (CRP) of 1.2 mg/dL. His hemoglobin and bilirubin returned to normal three weeks after discharge.
With the parents’ consent, serial plasma and serum were stored and later tested to confirm leptospira infection. Leptospira IgM rapid test (SD®) was positive in the samples on the first, fifth, and 20th day of hospitalization, and one week after discharge. The micro-agglutination test (MAT) assay was conducted in the leptospira reference center at Kariadi Hospital, Semarang on serum samples from the first, 10th, and 20th day of hospitalization. The titer for Leptospira serogroup bataviae increased from <1:20 (on the first day and 10th day) to 1:640 (on the 20th day).
Retrospective tests on plasma samples during admission were negative for dengue NS1, dengue IgM, and Salmonella typhi IgM. However, several biochemistry parameters were slightly elevated, which were direct bilirubin (13.7 µmol/L), AST (123 U/L), ALT (53 U/L), BUN (4.0 mmol/L), creatinine (123.8 µmol/L), creatinin-kinase (CK) (326 U/L), CRP (30.5 mg/dL), amylase (125 U/L), and lipase (98 U/L). Serial hematology and biochemistry profiles are described in Fig. 1.