What is the treatment for a patient with leptospirosis who develops myocarditis?

Treatment of Leptospirosis-Associated Myocarditis

The treatment of leptospirosis-associated myocarditis requires prompt antibiotic therapy with penicillin or tetracycline antibiotics during the bacteremic phase, along with supportive care including hospitalization at an advanced heart failure center for patients with hemodynamic compromise, and consideration of corticosteroids for severe cases with myocardial inflammation. 1

Diagnosis and Initial Assessment

Clinical Presentation

• Leptospirosis classically follows a biphasic course:
  • Initial bacteremic phase (4-7 days): Flu-like symptoms
  • Immune phase (1-3 days later): Characterized by fever, myalgia (especially calves), hepatorenal syndrome, and hemorrhage
  • Conjunctival suffusion is a suggestive clinical finding 1
  • Cardiac involvement may present with:
    • Chest pain
    • Arrhythmias (particularly atrial fibrillation)
    • Tachycardia
    • ECG changes (ST segment depression, T wave changes)
    • Hemodynamic instability/shock 2, 3

Diagnostic Workup

1. Initial cardiac evaluation:

   • ECG
   • Cardiac troponin (preferably high-sensitivity assay)
   • 2D echocardiography 1

2. Laboratory investigations:

   • Urinalysis (may show proteinuria and hematuria)
   • Complete blood count (may show polymorphonuclear leukocytosis)
   • Renal and liver function tests
   • Serology for leptospirosis (IgM ELISA, microscopic agglutination test) 1

3. Additional cardiac testing if myocarditis is suspected:

   • Cardiac MRI (if hemodynamically stable) 1
   • Consider endomyocardial biopsy in deteriorating patients 1

Treatment Algorithm

1. Antimicrobial Therapy

• Start antibiotics immediately upon suspicion of leptospirosis, without waiting for confirmation 1
• First-line options:
  • Penicillin antibiotics (effective during bacteremic phase)
  • Tetracycline antibiotics (alternative option) 1

2. Cardiac Management

• Hospitalization:

  • All patients with suspected or confirmed myocarditis should be hospitalized 1
  • Patients with fulminant myocarditis should be managed at centers with expertise in advanced heart failure and mechanical circulatory support 1

• Cardiac monitoring:

  • Continuous ECG monitoring for arrhythmias
  • Temporary pacemaker insertion for symptomatic bradycardia or heart block 1

• Hemodynamic support:

  • Inotropic/vasopressor support for patients with shock 2
  • Consider mechanical circulatory support in severe cases 1

3. Immunomodulatory Therapy

• Corticosteroids:
  • Consider IV corticosteroids in patients with hemodynamic compromise or severe myocardial inflammation 1
  • The decision should be balanced against infection risk

4. Management of Heart Failure

• Guideline-directed medical therapy for heart failure should be initiated as appropriate and continued after discharge 1

5. Management of Arrhythmias

• Antiarrhythmic therapy can be useful in patients with symptomatic NSVT or sustained VT during the acute phase of myocarditis 1

Special Considerations

Predictors of Complications

Be vigilant for early signs of complications. The following clinical features are predictors of myocarditis or acute renal failure in leptospirosis:

• Oliguria
• Jaundice
• Arrhythmias 4

Timing of Device Therapy

• ICD implantation is contraindicated during the acute phase of myocarditis 1
• Consider ICD implantation only after recovery from the acute phase in patients with life-threatening ventricular arrhythmias who are receiving optimal medical therapy 1

Exercise Restriction

• Patients with clinical myocarditis should have 3-6 months of complete exercise abstinence 1
• Return to physical activity should be based on:
  1. Absence of cardiopulmonary symptoms
  2. Resolution of laboratory evidence of myocardial injury
  3. Normalization of LV systolic function
  4. Absence of arrhythmias on ECG monitoring and stress testing 1

Pitfalls and Caveats

1. Delayed recognition: Cardiac involvement in leptospirosis may be overlooked due to non-specific findings and co-existing multi-organ dysfunction 2

2. Co-infections: Consider co-infection with other endemic diseases (e.g., dengue) in patients with atypical presentations 2

3. Rapid deterioration: Leptospirosis-associated myocarditis can progress rapidly to cardiogenic shock and death, even early in the disease course (as early as the second day of illness) 3

4. Multiorgan involvement: Be vigilant for other complications including acute kidney injury, hepatitis, thrombocytopenia, and pulmonary involvement 5, 6

5. Reliance on serology: Serological confirmation may not be available in the acute setting, so treatment should be initiated based on clinical suspicion 1