Figure 1
CT brain - axial
Acute on subacute subdural haemorrhage,
Significant mass effect with midline shift and uncal herniation, diffuse cerebral oedema.
Clinical History
A 52-year-old male patient presented with fever and myalgia for the past 9 days, abdominal pain and vomiting for 2 days and decreased urine output for 3 days.
Imaging Findings
Chest X-ray: Right apical pleural thickening with patchy opacity with fibrotic streaks in right upper zone.
CT head: Hyperdense extra-axial collection along the left cerebral convexity suggestive of acute subdural haemorrhage with significant mass effect in the form of midline shift, compression of left lateral ventricle and left uncal herniation. Diffuse cerebral oedema is also noted.
CT head: Hyperdense extra-axial collection along the left cerebral convexity suggestive of acute subdural haemorrhage with significant mass effect in the form of midline shift, compression of left lateral ventricle and left uncal herniation. Diffuse cerebral oedema is also noted.
Discussion
Leptospirosis presenting as a primary neurological disease is highly uncommon. Neurological manifestations of leptospirosis follow a pattern:
First phase: Clouded sensorium and meningism
Second phase: Classical neurological features. As early as 48 hours after inoculation Leptospires reach the CSF and brain. Clinical features are seen due to capillary endothelial damage and vasculitis.
Nervous system involvement is immune-mediated and gross changes include exudates, leptomeningeal oedema, brain and spinal cord congestion and haemorrhage.
Thrombocytopaenia, Hypoprothrombinaemia and vasculitis result in intracranial bleed which commonly manifests as SAH and EDH [1].
Neurological symptoms like headache, vomiting, focal neurological deficits, diminished level of vigilance and seizures are frequently associated with severe leptospirosis. In the recovery phase intracerebral haemorrhage may occur despite normal coagulation state and platelet count [2].
Leptospiral infection presents with a broad range of symptoms. Sub-clinical illness followed by a self-limiting systemic course, as seen in approximately 90% of cases, to a potentially fatal illness like renal and liver failure, pneumonitis and haemorrhagic diathesis. CNS manifestation is aseptic meningitis which may or may not be symptomatic. Lymphocytic pleocytosis, elevated CSF protein and normal CSF glucose are the characteristic CSF findings. Fatal intracranial haemorrhage is rare [3].
Neuritis, polyneuritis, and polyradiculoneuritis are seen in Leptospiral infection involving the peripheral nervous system [4].
Vasculitis accompanied by disseminated endothelial destruction in capillaries may lead to intracerebral haemorrhage. Histological examination shows widespread disseminated small perivasal bleedings found in the brain. Thrombocytopaenia may aggravate the extent of the bleeding area, since thrombocytopaenia per se was not correlated with a higher incidence of haemorrhage in leptospirosis [5].
First phase: Clouded sensorium and meningism
Second phase: Classical neurological features. As early as 48 hours after inoculation Leptospires reach the CSF and brain. Clinical features are seen due to capillary endothelial damage and vasculitis.
Nervous system involvement is immune-mediated and gross changes include exudates, leptomeningeal oedema, brain and spinal cord congestion and haemorrhage.
Thrombocytopaenia, Hypoprothrombinaemia and vasculitis result in intracranial bleed which commonly manifests as SAH and EDH [1].
Neurological symptoms like headache, vomiting, focal neurological deficits, diminished level of vigilance and seizures are frequently associated with severe leptospirosis. In the recovery phase intracerebral haemorrhage may occur despite normal coagulation state and platelet count [2].
Leptospiral infection presents with a broad range of symptoms. Sub-clinical illness followed by a self-limiting systemic course, as seen in approximately 90% of cases, to a potentially fatal illness like renal and liver failure, pneumonitis and haemorrhagic diathesis. CNS manifestation is aseptic meningitis which may or may not be symptomatic. Lymphocytic pleocytosis, elevated CSF protein and normal CSF glucose are the characteristic CSF findings. Fatal intracranial haemorrhage is rare [3].
Neuritis, polyneuritis, and polyradiculoneuritis are seen in Leptospiral infection involving the peripheral nervous system [4].
Vasculitis accompanied by disseminated endothelial destruction in capillaries may lead to intracerebral haemorrhage. Histological examination shows widespread disseminated small perivasal bleedings found in the brain. Thrombocytopaenia may aggravate the extent of the bleeding area, since thrombocytopaenia per se was not correlated with a higher incidence of haemorrhage in leptospirosis [5].
Differential Diagnosis List
Leptospirosis complicated by fatal intracerebral haemorrhage
Viral fever: coxsackie
Hepatitis B
Enteric fever
Rickettsial infection
Malaria
Final Diagnosis
Leptospirosis complicated by fatal intracerebral haemorrhage
References
[1] 1. Panicker JN, Mammachan R, Jayakumar RV (2001) Primary neuroleptospirosis. Postgrad Med J 77(911):589-90 (PMID: 11524519)
[2] Forwell MA, Redding PJ, Brodie MJ, Gentleman DD (1984) Leptospirosis complicated by fatal intracerebral haemorrhage. Br Med J (Clin Res Ed) Dec 8;289(6458):1583 (PMID: 6439329)
[3] Neligan A, Mullins GM, O\'Sullivan SS, Fitzgerald P, Harrington H (2009) A rare cause of fatal intracranial haemorrhage. Ir J Med Sci Sep;178(3):343-5 (PMID: 18813878)
[4] Babamahmoodi F, Babamhmoodi A (2011) Recovery from intracranial hemorrhage due to leptospirosis. Case Rep Med (PMID: 22013452)
[5] Theilen HJ, Lück C, Hanisch U, Ragaller M (2002) Fatal intracerebral hemorrhage due to leptospirosis. Infection Apr;30(2):109-12 (PMID: 12018468)
Case information
| URL: | https://www.eurorad.org/case/11750 |
| DOI: | 10.1594/EURORAD/CASE.11750 |
| ISSN: | 1563-4086 |
Figure 2
CT brain - sagittal
Acute on subacute subdural haemorrhage.
Figure 3
CT brain - coronal
Acute on subacute subdural haemorrhage.
CT brain - axial
Acute on subacute subdural haemorrhage,
Significant mass effect with midline shift and uncal herniation, diffuse cerebral oedema.
FATHER MULLER MEDICAL COLLEGE
FATHER MULLER MEDICAL COLLEGE
CT brain - sagittal
Acute on subacute subdural haemorrhage.
FATHER MULLER MEDICAL COLLEGE
FATHER MULLER MEDICAL COLLEGE
CT brain - coronal
Acute on subacute subdural haemorrhage.
FATHER MULLER MEDICAL COLLEGE
FATHER MULLER MEDICAL COLLEGE