Haemophagocytic Lymphohistiocytosis with Leptospirosis: A Rare but Devastating Complication

Table 1

Sequential investigation results during intensive care stay.

Investigation	D 01	D 02	D 03	D 04	D 05	D 06	Reference range
Hb	9.5	8.3	8.7	7.8	7.8	8.0	10–14 g/dl
PCV	27.5	25.2	25.7	24.7	23.8	24.1	34–45
Platelet	15	5	15	41	38	20	150–450 × 10^3/mm^3
WBC	4.9	14.8	11.6	7.6	5.8	0.9	4–11 × 10^3/mm^3
Neutrophils	3.5	13.2	10.6	6.9	5.3	0.74	2–8 × 10^3/mm^3
Lymphocytes	1.1	0.8	0.26	0.29	0.2	0.16	1–5 × 10^3/mm^3
ESR	60	—	50	—	—	—	0–20 mm/h
PT	25.5	22.2	19.6	19.8	16.8	21	11–12.5 s
INR	2.23	2.33	1.62	1.63	1.3	1.73	08–1.1
APTT	—	45.1	41.7	24.9	42.2	32.8	30–40 s
Na^+	145	144	138	136	185	132	135–145 mmol/l
K^+	4.3	4.6	7.06	6.58	6.02	6.04	3.5–4.5 mmol/l
Ca^2+	1.2	1.3	1.1	1.4	0.8	1.2	1.1–1.3 mmol/l
B. urea	311	268	294	329	381	384	18–55 mg/dl
S. creatinine	10.8	10.7	11.2	11.2	12.8	12.4	0.7–1.3 mg/dl
ALT	615	780	550	262	127	124	0–45 IU/L
AST	1780	2754	1039	515	365	352	0-35 IU/L
ALP	178	—	—	—	—	—	80–300 U/L
Gamma GT	180	—	—	—	—	—	9–48 U/L
Total bilirubin	6.6	6.4	6.8	5.4	5.5	6.7	0–1.4 mg/dl
Direct bilirubin	0.3	6.0	6.2	4.8	4.9	6.2	0–0.3 mg/dl
Indirect bilirubin	6.3	0.4	0.6	0.6	0.6	0.5	—
Serum amylase	234	—	—	—	—	—	30–110 U/L
CRP	141	—	165	—	228	—	<6 mg/L
S. ferritin	—	60685	—	—	—	—	20–250 ng/ml
LDH	—	450	—	—	—	—	150–300 u/L
Total cholesterol	—	168	—	—	—	—	<200 mg/dl
Triglycerides	—	358	—	—	—	—	<150 mg/dl
LDL	—	82	—	—	—	—	<100 mg/dl
Troponin T	Negative	—	—	—	—	—	—
UFR	—	—	—	—	—	—	—
Albumin	2+	—	—	—	—	—	—
Pus cells	12–18/HPF	—	—	—	—	—	—
Red cells	Nil	—	—	—	—	—	—
Urine ketone bodies	Negative	—	—	—	—	—	—
Urine culture	—	No growth	—	—	—	—	—
Blood culture	—	No growth	—	—	—	—	—
Serological studies
Malaria screening	—	Negative	—	—	—	—	—
Hanta antibodies	—	Negative	—	—	—	—	—
Mycoplasma antibodies	—	Negative	—	—	—	—	—
CMV antibodies	—	Negative	—	—	—	—	—
EBV antibodies	—	Negative	—	—	—	—	—
TB PCR	—	Negative	—	—	—	—	—
COVID-19 PCR	—	Negative	—	—	—	—	—
Leptospira antibody test (MAT with the pathogenic Leptospira panel)	—	1 : 640 (significant result)	—	—	—	—	—
Blood picture	Initial: marked thrombocytopenia and rouleaux formation, no features of haemolysis, exclude DIC
	Later: suggestive features of DIC
Bone marrow trephine biopsy	Haemophagocytes present, suggestive of HLH, no additional abnormalities in the main cell lineages
USS abdomen	Mild hepatosplenomegaly, bilaterally increased renal echogenicity suggestive of acute kidney injury, no intra-abdominal collections or other organomegaly

Hb: haemoglobin; PCV: packed cell volume; WBC: white blood cells; ESR: erythrocyte sedimentation rate; PT: prothrombin time; INR: international normalized ratio; APTT: activated partial thromboplastin time; ALT: alanine aminotransferase; AST: aspartate aminotransferase; ALP: alkaline phosphatase; CRP: C-reactive protein; UFR: urine full report; HPF: high-power field; CMV: cytomegalovirus; EBV: Epstein–Barr virus; TB PCR: tuberculosis polymerase chain reaction; MAT: microscopic agglutination test; LDH: lactate dehydrogenase.