A 60 YEAR OLD MALE WITH Leptospirosis!!?

 60/M presented with a 1 week history of malaise, diffuse muscle aches, distention of abdomen, loss of appetite and increased urine output. 

An agile farmer whose work involves tilling lands and working barefooted in muddy waters (infested with rats), the patient recalls being well until a week ago, when he developed fever with loss of appetite. His fever was low grade, with a mild evening rise and associated with loss of appetite. At this point he consulted a doctor who prescribed symptomatic treatment which provided quick relief. However, he continue to have loss of appetite and since the last 4 days he has been having fatigue and muscle aches. He denies having involuntary weight loss, vomiting, altered bowel habits, jaundice or altered taste. His past history is significant for Chronic Diabetes and Hypertension for which he uses Telmisartan 40 mg + Hydrochlorothiazide 12.5 mg. He has been using Glibenclamide 5mg and Metformin 500mg. His dietary adherence to salt and sugar restriction is poor. He has a fairly well balanced diet. He reports having unrefreshing sleep since the last few years and his wife confides that the patient snores during his sleep. He however does not have daytime somnolence. He occasionally has nocturia but denies having nocturnal diarrhoea, increased frequency, urgency or hesitancy. 

Vitals - PR - 93 BPM

BP - 110/80 mm Hg

Temp - 98.3 F

RR - 22 com

Spo2 - 97% on Room air

RBS - 664

General Examination:

 Tiny bilateral subconjuntival hemorrhages with marked conjunctival suffusion and icterus present

Tongue and mucous membranes are moist

 Mallampati Class 3. 

Nails ___ Terry nails. 

No cervical or supraclavicular lymphadenopathy. 

He also has bilateral pitting type pedal edema with the pits resolving in about 40 seconds.

Per abdomen:

 Abdomen is distended and the umbilicus central and inverted. There are no obvious dilated veins or pulsations. 

On palpation soft ,non tender,no organomegaly.

Bowel sounds heard

No specific tender points on muscle exam. 

RS_ B/L air entry present,no added sounds

CVS: S1S2 heard ,no murmurs

CNS: NFND

Investigations:

Diagnosis - A 60/M presented with a 1 week history of fever and loss of appetite. Labs revealed an RBS of 664 with no metabolic acidosis or ketonuria. His TB is 3.2 ad DB is 2.5 with ALP at 550 and TP 5.9 and Alb at 2.9. Blood urea 150 and Serum Creatinine 3.5. Na - 129, K - 4.3 andCl - 90

1. Leptospirosis

2. Diabetic Nephropathy (Hypoalbuminemia) (Diabetes since 10 years)

3. Hypertension

4. Hyponatremia and Hypochloremia due to Interstitial Nephritis (8 to 10 pus cells in urine) or Thiazide use.