What is the appropriate management for a patient with hypotension, tachycardia, impaired renal function, jaundice, bipedal edema, and dyspnea, with a history of exposure to contaminated waters and an abdominal mass?

Management of Suspected Leptospirosis with Multi-Organ Failure and Shock

This patient requires immediate ICU admission with aggressive resuscitation for septic shock, urgent broad-spectrum antibiotics covering leptospirosis, and simultaneous evaluation for the abdominal mass which may represent hepatic involvement or an unrelated pathology requiring urgent intervention. 1

Immediate Stabilization (First Hour)

Airway and Breathing

• Intubate immediately given hypotension (BP 70/50), tachycardia (HR 105), and dyspnea with decreased bilateral breath sounds, as altered perfusion and respiratory distress indicate impending respiratory failure 1
• Target oxygen saturation 88-92% initially, avoiding excessive oxygen which can worsen outcomes 1
• Mechanical ventilation redirects up to 40% of cardiac output consumed by work of breathing in sepsis, potentially reversing shock 1

Vascular Access and Fluid Resuscitation

• Establish large-bore IV access immediately; if unable to obtain reliable venous access within minutes, use intraosseous access 1
• Begin aggressive crystalloid resuscitation with 500-1000 mL boluses over 5-10 minutes, targeting initial 30 mL/kg (approximately 2-3 liters for average adult) 2, 1, 3
• Monitor closely for fluid overload: watch for hepatomegaly progression, new pulmonary rales, and worsening dyspnea, as this patient already has bipedal edema and may have cardiac involvement 2, 3
• Titrate to clinical endpoints: improved mental status, capillary refill <2 seconds, urine output >1 mL/kg/h, warming of extremities, and normalization of heart rate 1, 3

Vasopressor Support

• Initiate norepinephrine immediately if hypotension persists after initial 30 mL/kg fluid bolus, targeting MAP ≥65 mmHg 1
• Norepinephrine is first-line vasopressor; add epinephrine if additional agent needed to maintain adequate blood pressure 1
• Peripheral vasopressor administration is acceptable while obtaining central access 3

Antibiotic Administration

• Administer broad-spectrum antibiotics within 1 hour covering leptospirosis and other causes of septic shock 1
• For severe leptospirosis: IV penicillin G 1.5 million units every 6 hours OR ceftriaxone 1-2g daily OR doxycycline 100mg IV every 12 hours 2
• Obtain blood cultures before antibiotics when possible, but never delay antibiotics to obtain cultures 1
• Given exposure to contaminated water, jaundice, renal failure, and thrombocytopenia (platelets 23,000), leptospirosis is highly likely and requires immediate empiric coverage 2

Diagnostic Workup (Parallel to Resuscitation)

Essential Laboratory Tests

• Arterial blood gas with lactate to assess tissue perfusion and acidosis 2, 1
• Complete metabolic panel including electrolytes, liver function tests (already showing jaundice), and repeat creatinine 2, 4
• Complete blood count (already showing severe thrombocytopenia at 23,000) 2
• Coagulation studies (PT/INR, PTT) given thrombocytopenia and risk of DIC 2
• Leptospirosis serology and blood cultures for confirmation 2

Imaging Studies

• Urgent abdominal CT with contrast (once hemodynamically stable) to characterize the 8x10cm epigastric mass, assess for hepatomegaly, and evaluate for complications 2
• Chest X-ray to assess for pulmonary edema, ARDS, or pulmonary hemorrhage (complications of severe leptospirosis) 2
• Bedside ultrasound for cardiac function assessment and IVC diameter to guide fluid management 2

Echocardiography

• Urgent bedside echocardiography to assess cardiac function, exclude mechanical complications, and guide fluid/inotrope management given hypotension and edema 2, 4
• Not required before initial resuscitation but should be performed within first few hours 2

Specific Management Considerations

Severe Leptospirosis Management

• This presentation meets criteria for severe malaria/leptospirosis: hypotension (shock), jaundice with parasitemia equivalent, acute renal failure (elevated creatinine), and thrombocytopenia 2
• Pulmonary involvement suggested by dyspnea and decreased breath sounds bilaterally requires monitoring for pulmonary hemorrhage, a life-threatening complication 2
• Renal replacement therapy may be required given acute renal failure; prepare for urgent dialysis if oliguria persists despite resuscitation 2

Abdominal Mass Evaluation

• The 8x10cm epigastric mass with prominent veins requires urgent characterization as it may represent:
  • Hepatomegaly from leptospirosis-induced hepatitis
  • Hepatic abscess requiring drainage
  • Malignancy with superimposed infection
  • Other surgical pathology requiring intervention 2
• Surgical consultation should be obtained early given the mass characteristics and patient instability 2

Thrombocytopenia Management

• Platelet count of 23,000 places patient at high bleeding risk 2
• Avoid unnecessary invasive procedures until platelets improved 2
• Platelet transfusion indicated if active bleeding or before essential invasive procedures 2

Monitoring Parameters

Continuous Monitoring (Until Stabilized)

• Heart rate, rhythm, blood pressure, SpO2, respiratory rate and effort 1, 4
• Mental status and peripheral perfusion (capillary refill, extremity temperature) 1, 3
• Urine output (target >0.5-1 mL/kg/h) 1, 3

Serial Laboratory Monitoring

• Lactate levels every 2-4 hours until normalizing, as marker of resuscitation adequacy 3
• Electrolytes and renal function every 6-12 hours during acute phase 4
• Platelet count daily or more frequently if bleeding 2
• Liver function tests daily given jaundice 2

Critical Pitfalls to Avoid

• Do not delay antibiotics for diagnostic workup; leptospirosis mortality increases significantly with delayed treatment 1
• Avoid excessive fluid administration without clinical reassessment, as patient already has bipedal edema and may develop pulmonary edema 2, 3
• Do not assume heart failure as primary diagnosis without excluding septic shock and evaluating the abdominal mass 4
• Monitor for pulmonary hemorrhage, a rapidly fatal complication of severe leptospirosis that can occur suddenly 2
• Recognize that hypotension may worsen transiently with intubation; ensure adequate preload and consider vasopressor support before induction 1

Disposition and Ongoing Care

• ICU admission mandatory for patients with persistent hypotension, respiratory distress, and multi-organ dysfunction 2, 1
• Source control must be pursued once stabilized, including evaluation and potential drainage of abdominal mass if infectious 1
• Hydrocortisone may be considered if catecholamine-resistant shock develops, though not routine 1