Distinguishing Jarisch-Herxheimer Reaction From Septic Shock in Leptospirosis Patients: A Case Study

BACKGROUND The Jarisch-Herxheimer reaction is a transient response that occurs within 24 hours of antibiotic treatment for spirochete infections, such as syphilis, leptospirosis, Lyme disease, and relapsing fever, and can present with nausea, fever, chills, rigors, vomiting, hypotension, and skin lesions. This report describes the case of a 51-year-old woman who was working clearing land, with confirmed leptospirosis, who developed transient fever and hypotension following treatment with ceftriaxone (Jarisch-Herxheimer reaction). CASE REPORT A 51-year-old Japanese woman was admitted with fever and chills for 3 days. Two months prior, she had engaged in land clearance and drinking river water. She reported difficulty moving and joint pain but showed no signs of arthritis or spinal tenderness. Conjunctival injection was observed, and insect bites were absent. Laboratory findings indicated elevated white blood cell count and C-reactive protein level, liver dysfunction, and acute kidney injury. Suspecting leptospirosis and rickettsial infections, ceftriaxone (2 g every 24 hours) was initiated, but 3 hours thereafter, the patient developed chills, fever, and hypotension. Vasopressor administration proved insufficient, necessitating intubation and transfer to the Intensive Care Unit (ICU). Echocardiography findings ruled out cardiogenic shock. Despite a suspicion of septic shock, antibiotics were not escalated owing to a strong clinical suspicion of JHR. The patient's condition improved within 15 hours of antibiotic therapy. Vasopressors were discontinued on hospitalization day 3, and she was extubated. After completing ceftriaxone therapy (7 days), she was discharged on day 9. CONCLUSIONS This report shows the importance of taking a detailed clinical history for patients at risk of exposure to spirochete infections, and highlights the association between antibiotic treatment and the occurrence of transient symptoms that can mimic episodes of parasitemia or sepsis.