A penny for your CSF - An Unexpected consequence of bottle recycling: Meningitis due to Leptospira and Streptococcus – a case report

A penny for your CSF - An Unexpected consequence of bottle recycling: Meningitis due to Leptospira and Streptococcus – a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A penny for your CSF - An Unexpected consequence of bottle recycling: Meningitis due to Leptospira and Streptococcus – a case report Abeer Qasim, Saran Lal Ajai Mokan Dasan, Sri Rameeni Peesapati, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7948869/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Leptospirosis is a preventable zoonotic infection that can present with a wide spectrum of clinical features, ranging from mild flu-like illness to severe multi-organ dysfunction. Meningitis due to Leptospira is rare, and co-infection with Streptococcus pneumoniae has not been reported. Case Presentation We describe here a case of a 50-year-old male with schizophrenia and hypothyroidism who presented with seizures, jaundice, shock, and respiratory failure. Initial evaluation revealed severe metabolic acidosis, renal failure, transaminitis, and thrombocytopenia. Lumbar puncture showed xanthochromic CSF with lymphocytic predominance. Urine Streptococcus antigen was positive, and serum PCR confirmed Leptospira . The patient was treated with broad-spectrum antibiotics, later narrowed to intravenous penicillin G for optimal CNS penetration. He underwent mechanical ventilation, tracheostomy, gastrostomy, and hemodialysis, ultimately achieving a favorable recovery.Epidemiologic history revealed daily collection of discarded bottles in an area with high rodent exposure. Discussion: Leptospirosis, transmitted through contact with rodent urine, is underdiagnosed in the United States. In New York City, most reported cases occur in the Bronx. Our patient’s occupational exposure from bottle collection likely facilitated Leptospira infection. The concurrent pneumococcal infection may have delayed recognition of leptospiral meningitis. Conclusion: This case highlights the importance of thorough exposure history and broad diagnostic testing in atypical meningitis presentations, particularly when occupational or environmental risk factors exist. Leptospirosis Meningitis Bottle recycling Public health concern Introduction Leptospirosis is a globally prevalent disease that affects both humans and animals. Direct contact with infected animals or their urine is a common transmission route, making occupations involving animals or exposure to animal waste a significant risk factor. Leptospirochetes can survive for days to months in urine-contaminated soil and freshwater ​(1)​. Clinical manifestations include mild flu-like symptoms to severe outcomes like Weil's disease and pulmonary hemorrhage syndrome. It impacts multiple systems, leading to conditions such as myocarditis, renal failure, rhabdomyolysis, meningitis, and transaminitis, which can ultimately result in multi-organ failure and even death ​(2,3)​. Efforts to control leptospirosis include surveillance, early diagnosis, and targeted interventions. Improving sanitation, implementing rodent control measures, and promoting public awareness about the disease and preventive measures are crucial. Here we present a case of a 50-year-old male who exhibited severe leptospirosis. Case Details A 50-year-old male with past medical h/o schizophrenia and hypothyroidism from the Bronx, New York, was brought to the emergency department following a witnessed seizure at home. Collateral history from his mother indicated that, two to three days before presentation, he had developed body aches, nausea, vomiting, loss of appetite, and inability to tolerate oral intake. On arrival, he was hemodynamically unstable, with a blood pressure of 75/50 mmHg, temperature of 94.4°F, heart rate of 140 bpm, respiratory rate of 40 breaths per minute, and oxygen saturation of 74% on room air. Physical examination revealed jaundice with icteric sclera, lethargy, and absence of meningeal signs, though he remained responsive to questions and commands. He was intubated for acute respiratory failure in the context of suspected septic shock and admitted to the ICU. Laboratory results at presentation are summarized in Table 1 . Table 1 LABS ON PRESENTATION: HGB 10.7 WBC 20.1 PLATELET 63,000 CREATININE 18 LACTIC ACID 14.5 AST 320 ALT 152 ALP 135 T. BILIRUBIN 13.8 DIRECT BILIRUBIN 14.3 GGT 38 AMMONIA 180 BICARBONATE 5 ANION GAP 48 INR 1.09 FREE THYROXINE 0.66 T3 26.9 TSH 31.3 CREATINE KINASE 4106 URINE TOXICOLOGY POSITIVE FOR CANNABINOIDS URINALYSIS TURBID, 300 + PROTEINURIA, 1 + BLOOD, 500 + LEUKOCYTE ESTERASE, FEW BACTERIA, MANY RBC AND WBC, MODERATE URINE BILIRUBIN Chest X-ray, as well as CT scans of the head, cervical spine, abdomen, and pelvis, revealed no significant abnormalities. Broad-spectrum antibiotics were started. Given the presence of high anion gap metabolic acidosis and renal failure, hemodialysis was initiated. Persistent seizures prompted a lumbar puncture on hospital day four (Table 2 ). Initial cerebrospinal fluid analysis showed elevated protein, xanthochromia, and increased white blood cell count, consistent with possible bacterial meningitis. Infectious workup revealed positive urine streptococcal antigen (Table 3 ) Table 2 CSF ANALYSIS: ON DAY 4 OF ADMISSION TWO WEEKS AFTER ADMISSION Cell count and differential Color: xanthochromia Appearance: clear WBC: 17 RBC: 825 Segmented count: 69 [%] Lymphocyte count: 28 [%] Monocyte: 2 [%] Eosinophil: 1 [%] Macrophage: few Color: xanthochromia Appearance: cloudy WBC: 10 RBC: 3150 Segmented count: 19 [%] Lymphocyte count: 78 [%] Monocyte: 2 [%] Eosinophil: 1 [%] Macrophage: none Glucose 90 [40–70 mg/dL] 42 [40–70 mg/dL] Protein 269 [15–45 mg/dL] 93 [15–45 mg/dL] LDH 126 Unable to obtain Aerobic Culture No growth of organisms No growth of organisms Table 3 INFECTIOUS WORK UP : Urine Legionella Ag Not detected Urine Streptococcal Ag Positive Urine Culture Final, no growth Cryptococcal Antigen Negative Blood culture Staphylococcus hominis, Corynebacterium species Fungal Blood culture Negative Two days later, Leptospira DNA was detected in the patient’s serum. The patient was diagnosed with Weil’s disease and leptospiral meningoencephalitis. He underwent a repeat lumbar puncture two weeks later for persistent neurological manifestations. Antibiotics were deescalated to only IV ceftriaxone after the second CSF study. But later on, due to persistent leukocytosis, ceftriaxone was switched to intravenous penicillin G 2 million units every four hours for optimal central nervous system penetration for 10 days. Subsequently patient underwent a tracheostomy and percutaneous endoscopic gastrostomy placement. Hemodialysis discontinued upon adequate renal recovery. He was discharged to a nursing home for short term rehabilitation. Since discharge, the patient has undergone reversal of tracheostomy and percutaneous endoscopic gastrotomy removal. He later disclosed that he regularly roams the streets collecting bottles from trash cans for money, an activity that brings him into frequent contact with rodents. At follow-up, he was doing well, attending outpatient visits, and had resumed his usual daily activities. DISCUSSION The name "leptospirosis" was coined by Dr. Adolf Weil, a German physician, in the late 19th century. Dr. Weil first described the disease in 1886 and named it "leptospirosis icterohemorrhagica," referring to its ability to cause icterus and scleral hemorrhage or suffusion​(4)​. Leptospirosis is a neglected tropical disease, with an estimated 1 million human cases occurring annually worldwide, including nearly 60,000 deaths​(5,6)​. In the US, the incidence of leptospirosis is 100–150 cases annually ​(1)​, with 14 cases reported in NYC in 2021​(7)​. However, due to underreporting and misdiagnosis, the actual incidence is likely much higher. Ten states in the US, have the Container Deposit Legislation, popularly known as ‘bottle bills’. In New York, the Returnable Container Act (RCA) has been in effect since July 1, 1983. The act requires a deposit of at least 5-cents on carbonated soft drinks, beer and other malt beverages, mineral water, soda water, wine products and water that doesn't contain sugar containers. Glass, metal, and plastic containers that hold less than one gallon are also included in the act​(8)​. Reverse vending machines are operational throughout the country. The return of empty containers into these machines, results in the payment of the 5 cents/ container​(9)​. Our patient used to (and still does) collect empty bottles from trashcans and streets and earn his money by returning them to a reverse vending machine. Daily he earned USD 15 from this activity. He encountered rodents daily as well, which is when, the inoculation of the Leptospira likely occurred. Between 2006 and 2020, New York has seen 57 cases of leptospirosis, with an average of 1–7 cases per year. 90% of these have been male with a median age of 46 years. Majority of the cases were found in the borough of Bronx. Our patient fits the demographic parameters reported ​(10)​. Leptospirosis is a zoonotic disease caused by spiral-shaped bacteria belonging to the Leptospira genus, commonly affecting the tropical countries. It has a global presence in nearly all tropical and temperate regions. It is one of the most widespread zoonotic infections worldwide ​(3)​. These infections occur when individuals come into contact with environmental sources such as animal urine, contaminated water or soil, or infected animal tissue ​(11)​. Leptospira species can infect a wide range of animals, including mammals, birds, reptiles and fish ​(12)​. Infected animals serve as reservoirs for disease, with rodents being the primary reservoir ​(5)​. Leptospira enter the body through openings in the skin like lesions or abrasions, as well as through the lining of the mouth or waterlogged skin after extended periods of immersion [10]. In exceptional cases, the bacteria can be transmitted through inhaling contaminated aerosols or consuming infected tissues. Various risk factors of leptospirosis are listed in Table 4 ​(13,14)​. Table 4 risk factors associated with leptospirosis meningitis. Occupational Farmers and ranchers Veterinarians Loggers Sewage workers Rice field workers Military personnel Recreational Fresh water swimming Canoeing and Kayaking Trail Biking Hunting Walking in the farmland Household Pet dogs Domesticated livestock Rain water catchment systems Rodent infestation The clinical symptoms of leptospirosis resemble those of typical tropical infections like dengue, scrub typhus, viral hepatitis, and malaria ​(15)​. Leptospira meningitis presents as a form of aseptic meningitis, which means that there is no presence of bacteria in the cerebrospinal fluid (CSF). The symptoms of leptospirosis meningitis can vary but often include fever, severe headache, neck stiffness, and photophobia (sensitivity to light). Other symptoms may include nausea, vomiting, muscle aches, joint pain, and rash. If left untreated, leptospirosis meningitis can progress to more severe complications, including neurological damage such as coma, meningoencephalitis, hemiplegia, transverse myelitis, or Guillain-Barré syndrome ​(15)​. On average, the incubation period for leptospirosis is 1–2 weeks, although it can range from 2 days to 30 days. After the acute or septicemic phase, which typically lasts around 1 week, the immune phase begins, characterized by the production of antibodies ​(16)​. A study documented the clinical characteristics and complications of leptospirosis in patients who were treated at nine specialized hospitals between September 28 and November 30, 2009, following a typhoon with heavy rainfall revealed that most of the patients diagnosed with leptospirosis exhibited non-specific symptoms, with fever being the most prevalent (98.5%). Other observed symptoms included myalgia (78.1%), malaise (74.9%), conjunctival suffusion (59.3%), oliguria (56.6%), diarrhea (39%), and jaundice (38%). Most patients were presented with moderate to severe leptospirosis (83%). Renal failure (82%), pulmonary hemorrhage (8%), and myocarditis (4%). Leptospiral meningitis was a rare complication, with only 5% cases​(17)​. Occasionally sudden death may occur from arrhythmias, cardiac failure or adrenal haemorrhage. Massive bleeding from the alimentary and respiratory tract could also lead to death. In those who are not severely ill, recovery takes place in the second week. Diuresis occurs and the blood urea level falls gradually. Fever subsides and general conditions improve, however, jaundice takes a longer time to clear​(18)​. Weil syndrome, a severe form of leptospirosis is marked by kidney and liver dysfunction, abnormal liver enlargement (hepatomegaly), persistent jaundice (yellowing of the skin, mucous membranes, and whites of the eyes), and/or changes in consciousness. Leptospirosis presents in two distinct clinical syndromes: anicteric and icteric​(19)​. Hemorrhagic pulmonitis is another severe form of the disease with higher mortality rates. Rarer manifestations include purely neurological which may present as meningitis/ meningoencephalitis​(11,20)​. Early diagnosis is crucial for timely treatment, as leptospirosis meningitis can be a severe and potentially life-threatening condition. Various methods for diagnosing the organism directly or detecting its components, such as culture, microscopy, and molecular techniques, are available, alongside serological tests like microagglutination test (MAT), enzyme-linked immunosorbent assay (ELISA), and rapid diagnostic tests (RDTs). The gold standard for diagnosis is culture from clinical specimens (urine, blood, or cerebrospinal fluid) or MAT, which is considered the reference test​(21)​. Other imaging studies such as MRI or CT scans may be utilized to assess the brain and spinal cord for any abnormalities caused by the infection. PCR has become a widely used diagnostic technique for swiftly and accurately detecting microbial infections in clinical specimens at an early stage ​(22,23)​. As soon as symptoms manifest, PCR has the capability to identify leptospiral DNA in cerebrospinal fluid (CSF). In an observation study conducted in Brazil, involving 103 patients with meningitis of unknown origin, it was found that 40% of them tested positive for PCR, while only 4% and 9% showed positive results for ELISA-IgM and MAT, respectively​(21)​. This signifies either underreporting of leptospiral meningitis with traditional serological tests and the improved sensitivity of the PCR based testing. Therefore, PCR offers benefits compared to MAT and ELISA-IgM in promptly diagnosing leptospiral meningitis, especially when antibodies are either absent or present in low levels in cerebrospinal fluid ​(24)​. Similarly, in a flood related outbreak in Sri Lanka, Quantitative PCR assay has been shown to be much sensitive than other serological tests​(25)​. The cerebrospinal fluid (CSF) analysis on our patient revealed the following results: protein level of 296, glucose level of 90, and a cell count with 17 white blood cells (WBC) and 825 red blood cells (RBC). The differential count indicated 69% segmented cells, 28% lymphocytes, 2% monocytes, and 1% eosinophils. However, serum Leptospira PCR was detected along with urine streptococcal antigen. The streptococcal coinfection in the meninges explains the lymphocytic preponderance in CSF studies. Treatment guidelines for leptospirosis suggest the use of penicillin, cephalosporins, doxycycline, and chloramphenicol​(26)​. Leptospira exhibits a surface architecture that resembles Gram- negative and Gram- positive bacteria. Double membrane constitution supports Gram-negative bacteria whereas attachment of peptidoglycan to the inner membrane resembles gram positive nature. Hence it is susceptible to the antibiotics which are used for both Gram-negative as well as gram positive bacteria. The bacteria are sensitive to wide range of antibiotics except chloromphenical, as some of the serovars were found to be resistant. For early-stage leptospirosis treatment and chemoprophylaxis, Doxycycline is the standard therapy, effectively combating infection and preventing its progression. In cases of late and severe disease, while intravenous penicillin was once the preferred drug of choice, ceftriaxone is now increasingly utilized due to its easier administration​(27)​. Initially, our patient received vancomycin and Piperacillin/ Tazobactam for unclear sepsis. Later, Caspofungin and doxycycline were added, but Caspofungin was discontinued as fungal cultures were negative. Leptospira DNA was detected in the patient's blood, leading to a diagnosis of Weil's disease and leptospiral meningoencephalitis. However, ceftriaxone was later switched to penicillin G for better CSF penetration. The use of steroids in handling severe complications caused by leptospirosis is a matter of debate and lacks sufficient evidence from adequately conducted studies​(28)​. Supportive care may include management of symptoms like fever, pain, and dehydration. Patients with severe cases may require hospitalization for close monitoring and intravenous fluids. Early diagnosis and timely initiation of appropriate treatment are crucial for a positive outcome in cases of leptospirosis meningitis. Despite receiving optimal treatment, the mortality rate remains elevated in cases of severe leptospirosis​(29)​. The case fatality rate was reported to be 15% in some studies​(18)​. The CFR is 6.7% when presented with hepatic or renal involvement with mortality raising as high as 50–70% when presented with Hemorrhagic pneumonitis​(18)​. Other predictors with a high mortality rate, include age ≥ 70, breathlessness, positive lung findings, oliguria, use of vasopressors, administration of steroids, the need for ventilator support, and blood transfusion.​(30)​ Although the basic principles of prevention such as source reduction, environmental sanitation, more hygienic work-related and personal practices etc., are same everywhere, there is no universal control method applicable to all epidemiological settings. Comprehensive understanding of the eco-epidemiological and cultural characteristics of a community that faces the problem of leptospirosis is an essential prerequisite for evolving an effective and acceptable control measure​(18)​. Conclusion While leptospira coinfection with salmonella has been reported as case reports from different parts of world​(31)​, the coinfection of streptococcus with leptospira is hitherto never reported. This mixed pattern meningitis is an incidental co-infection and though doesnot affect the prognosis individually, can delay the diagnosis of the more fulminant leptospiral meningitis. As such initiating a broad serological testing should be a norm. Abbreviations ALP Alkaline Phosphatase ALT Alanine Aminotransferase AST Aspartate Aminotransferase CNS Central Nervous System CSF Cerebrospinal Fluid CT Computed Tomography DNA Deoxyribonucleic Acid ELISA Enzyme-Linked Immunosorbent Assay GGT Gamma-Glutamyl Transferase ICU Intensive Care Unit INR International Normalized Ratio IV Intravenous MAT Microagglutination Test MRI Magnetic Resonance Imaging PCR Polymerase Chain Reaction RCA Returnable Container Act RBC Red Blood Cells RDT Rapid Diagnostic Test TSH Thyroid Stimulating Hormone WBC White Blood Cells Declarations Ethics approval and Consent to participate: Informed consent was obtained from the patient for participation in scientific research. Consent for publication: Written informed consent was obtained from the patient for the publication of personal and clinical details, including identifying images, in this study. Data availability statement: Data sharing is not applicable to this article as no datasets were generated or analyzed. For further information, please contact the corresponding author, Dr. Saran Lal Ajai Mokan Dasan ( [email protected] ). Competing interests: No competing interests is reported by any of the authors Funding: No external funding reported by any of the authors Author Contributions: Abeer Qasim, MD conceptualized the case report and prepared the first draft of the manuscript. Saran Lal Ajai Mokan Dasan, MD was responsible for literature review and performed the final critical revision of the manuscript for intellectual content. Sri Ramani Peesapati, MD , Abhishrut Jog, MD , Hammad Ashraf, MD , and Khaja Misbahuddin, MD provided editorial input and assisted with literature search and formatting. All authors reviewed and approved the final version of the manuscript. Acknowledgements: None References CDC. LEPTOSPIROSIS Fact Sheet for Clinicians Background [Internet]. 2018. Available from: http://www.cdc.gov/ncezid/dhcpp/ Daher EDF, Zanetta DMT, Abdulkader RCRM. Pattern of renal function recovery after leptospirosis acute renal failure. Nephron Clin Pract. 2004;98(1):c8-14. Kaushal A. Recent advances in the diagnosis of leptospirosis. Frontiers in Bioscience. 2020;25(9):4872. Weil A. Ueber eine eigenthümliche, mit Milztumor, Icterus und Nephritis einhergehende, acute Infectionskrankheit [Internet]. 1886. Available from: https://books.google.com/books?id=hQy8jwEACAAJ Adler B, de la Peña Moctezuma A. Leptospira and leptospirosis. Vet Microbiol. 2010 Jan;140(3–4):287–96. Costa F, Hagan JE, Calcagno J, Kane M, Torgerson P, Martinez-Silveira MS, et al. Global Morbidity and Mortality of Leptospirosis: A Systematic Review. PLoS Negl Trop Dis. 2015 Sep 17;9(9):e0003898. Chokshi DA. 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Cureus. 2024 Feb 21; Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7948869","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":548303315,"identity":"c2b9d879-c78f-48ae-9db2-a1bd643e3c66","order_by":0,"name":"Abeer Qasim","email":"","orcid":"","institution":"Bronxcare Health System","correspondingAuthor":false,"prefix":"","firstName":"Abeer","middleName":"","lastName":"Qasim","suffix":""},{"id":548303316,"identity":"217e07f9-b7de-4c67-99bc-9d0964e18dc4","order_by":1,"name":"Saran Lal Ajai Mokan 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10:08:34","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":7705,"visible":true,"origin":"","legend":"","description":"","filename":"6cfd006c3d10482494f99a0493446647.json","url":"https://assets-eu.researchsquare.com/files/rs-7948869/v1/5f10895ddab2823dafdb6940.json"},{"id":96623338,"identity":"b5b4dc80-5156-4c6a-9b41-0c43f70b7779","added_by":"auto","created_at":"2025-11-24 11:10:48","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":75554,"visible":true,"origin":"","legend":"","description":"","filename":"6cfd006c3d10482494f99a04934466471enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7948869/v1/e58debdd480bbbd32a3b49b9.xml"},{"id":96623340,"identity":"38ea1bfb-e3c2-47e3-bdf2-7bffab75dbdf","added_by":"auto","created_at":"2025-11-24 11:10:48","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":69952,"visible":true,"origin":"","legend":"","description":"","filename":"6cfd006c3d10482494f99a04934466471structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7948869/v1/371d492879e68dbe1ed13ed5.xml"},{"id":96623341,"identity":"8e49d6a1-9b7d-4d0c-91e0-daf0a9c44c39","added_by":"auto","created_at":"2025-11-24 11:10:48","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":81632,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7948869/v1/f4e21ced8cdac752ae8b4811.html"},{"id":102739744,"identity":"7e7114d6-5833-449d-ba48-57043fc60071","added_by":"auto","created_at":"2026-02-16 07:11:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":715061,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7948869/v1/ef8b59d0-1a5a-418a-8c83-d27a7f24837c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A penny for your CSF - An Unexpected consequence of bottle recycling: Meningitis due to Leptospira and Streptococcus – a case report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLeptospirosis is a globally prevalent disease that affects both humans and animals. Direct contact with infected animals or their urine is a common transmission route, making occupations involving animals or exposure to animal waste a significant risk factor. Leptospirochetes can survive for days to months in urine-contaminated soil and freshwater ​(1)​. Clinical manifestations include mild flu-like symptoms to severe outcomes like Weil's disease and pulmonary hemorrhage syndrome. It impacts multiple systems, leading to conditions such as myocarditis, renal failure, rhabdomyolysis, meningitis, and transaminitis, which can ultimately result in multi-organ failure and even death ​(2,3)​. Efforts to control leptospirosis include surveillance, early diagnosis, and targeted interventions. Improving sanitation, implementing rodent control measures, and promoting public awareness about the disease and preventive measures are crucial. Here we present a case of a 50-year-old male who exhibited severe leptospirosis.\u003c/p\u003e"},{"header":"Case Details","content":"\u003cp\u003eA 50-year-old male with past medical h/o schizophrenia and hypothyroidism from the Bronx, New York, was brought to the emergency department following a witnessed seizure at home. Collateral history from his mother indicated that, two to three days before presentation, he had developed body aches, nausea, vomiting, loss of appetite, and inability to tolerate oral intake.\u003c/p\u003e\u003cp\u003eOn arrival, he was hemodynamically unstable, with a blood pressure of 75/50 mmHg, temperature of 94.4\u0026deg;F, heart rate of 140 bpm, respiratory rate of 40 breaths per minute, and oxygen saturation of 74% on room air. Physical examination revealed jaundice with icteric sclera, lethargy, and absence of meningeal signs, though he remained responsive to questions and commands. He was intubated for acute respiratory failure in the context of suspected septic shock and admitted to the ICU. Laboratory results at presentation are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eLABS ON PRESENTATION:\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHGB\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10.7\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWBC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePLATELET\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e63,000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCREATININE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLACTIC ACID\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAST\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e320\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eALT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e152\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eALP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e135\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eT. BILIRUBIN\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDIRECT BILIRUBIN\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGGT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAMMONIA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e180\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBICARBONATE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eANION GAP\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eINR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFREE THYROXINE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.66\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eT3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTSH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCREATINE KINASE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4106\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eURINE TOXICOLOGY\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePOSITIVE FOR CANNABINOIDS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eURINALYSIS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTURBID, 300\u0026thinsp;+\u0026thinsp;PROTEINURIA, 1\u0026thinsp;+\u0026thinsp;BLOOD, 500\u0026thinsp;+\u0026thinsp;LEUKOCYTE ESTERASE, FEW BACTERIA, MANY RBC AND WBC, MODERATE URINE BILIRUBIN\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e\u003c/h2\u003e\u003cp\u003eChest X-ray, as well as CT scans of the head, cervical spine, abdomen, and pelvis, revealed no significant abnormalities. Broad-spectrum antibiotics were started. Given the presence of high anion gap metabolic acidosis and renal failure, hemodialysis was initiated. Persistent seizures prompted a lumbar puncture on hospital day four (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Initial cerebrospinal fluid analysis showed elevated protein, xanthochromia, and increased white blood cell count, consistent with possible bacterial meningitis. Infectious workup revealed positive urine streptococcal antigen (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCSF ANALYSIS:\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eON DAY 4 OF ADMISSION\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTWO WEEKS AFTER ADMISSION\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCell count and differential\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eColor: xanthochromia\u003c/p\u003e\u003cp\u003eAppearance: clear\u003c/p\u003e\u003cp\u003eWBC: 17\u003c/p\u003e\u003cp\u003eRBC: 825\u003c/p\u003e\u003cp\u003eSegmented count: 69 [%]\u003c/p\u003e\u003cp\u003eLymphocyte count: 28 [%]\u003c/p\u003e\u003cp\u003eMonocyte: 2 [%]\u003c/p\u003e\u003cp\u003eEosinophil: 1 [%]\u003c/p\u003e\u003cp\u003eMacrophage: few\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eColor: xanthochromia\u003c/p\u003e\u003cp\u003eAppearance: cloudy\u003c/p\u003e\u003cp\u003eWBC: 10\u003c/p\u003e\u003cp\u003eRBC: 3150\u003c/p\u003e\u003cp\u003eSegmented count: 19 [%]\u003c/p\u003e\u003cp\u003eLymphocyte count: 78 [%]\u003c/p\u003e\u003cp\u003eMonocyte: 2 [%]\u003c/p\u003e\u003cp\u003eEosinophil: 1 [%]\u003c/p\u003e\u003cp\u003eMacrophage: none\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGlucose\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90 [40\u0026ndash;70 mg/dL]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42 [40\u0026ndash;70 mg/dL]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eProtein\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e269 [15\u0026ndash;45 mg/dL]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e93 [15\u0026ndash;45 mg/dL]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLDH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e126\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnable to obtain\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAerobic Culture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo growth of organisms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo growth of organisms\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eINFECTIOUS WORK UP\u003c/b\u003e:\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrine Legionella Ag\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot detected\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUrine Streptococcal Ag\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ePositive\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUrine Culture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFinal, no growth\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCryptococcal Antigen\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNegative\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBlood culture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStaphylococcus hominis, Corynebacterium species\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFungal Blood culture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNegative\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003cp\u003eTwo days later, Leptospira DNA was detected in the patient\u0026rsquo;s serum. The patient was diagnosed with Weil\u0026rsquo;s disease and leptospiral meningoencephalitis. He underwent a repeat lumbar puncture two weeks later for persistent neurological manifestations. Antibiotics were deescalated to only IV ceftriaxone after the second CSF study. But later on, due to persistent leukocytosis, ceftriaxone was switched to intravenous penicillin G 2\u0026nbsp;million units every four hours for optimal central nervous system penetration for 10 days. Subsequently patient underwent a tracheostomy and percutaneous endoscopic gastrostomy placement. Hemodialysis discontinued upon adequate renal recovery. He was discharged to a nursing home for short term rehabilitation. Since discharge, the patient has undergone reversal of tracheostomy and percutaneous endoscopic gastrotomy removal. He later disclosed that he regularly roams the streets collecting bottles from trash cans for money, an activity that brings him into frequent contact with rodents. At follow-up, he was doing well, attending outpatient visits, and had resumed his usual daily activities.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe name \"leptospirosis\" was coined by Dr. Adolf Weil, a German physician, in the late 19th century. Dr. Weil first described the disease in 1886 and named it \"leptospirosis icterohemorrhagica,\" referring to its ability to cause icterus and scleral hemorrhage or suffusion​(4)​. Leptospirosis is a neglected tropical disease, with an estimated 1\u0026nbsp;million human cases occurring annually worldwide, including nearly 60,000 deaths​(5,6)​. In the US, the incidence of leptospirosis is 100\u0026ndash;150 cases annually ​(1)​, with 14 cases reported in NYC in 2021​(7)​. However, due to underreporting and misdiagnosis, the actual incidence is likely much higher.\u003c/p\u003e\u003cp\u003eTen states in the US, have the Container Deposit Legislation, popularly known as \u0026lsquo;bottle bills\u0026rsquo;. In New York, the Returnable Container Act (RCA) has been in effect since July 1, 1983. The act requires a deposit of at least 5-cents on carbonated soft drinks, beer and other malt beverages, mineral water, soda water, wine products and water that doesn't contain sugar containers. Glass, metal, and plastic containers that hold less than one gallon are also included in the act​(8)​. Reverse vending machines are operational throughout the country. The return of empty containers into these machines, results in the payment of the 5 cents/ container​(9)​.\u003c/p\u003e\u003cp\u003eOur patient used to (and still does) collect empty bottles from trashcans and streets and earn his money by returning them to a reverse vending machine. Daily he earned USD 15 from this activity. He encountered rodents daily as well, which is when, the inoculation of the Leptospira likely occurred. Between 2006 and 2020, New York has seen 57 cases of leptospirosis, with an average of 1\u0026ndash;7 cases per year. 90% of these have been male with a median age of 46 years. Majority of the cases were found in the borough of Bronx. Our patient fits the demographic parameters reported ​(10)​.\u003c/p\u003e\u003cp\u003eLeptospirosis is a zoonotic disease caused by spiral-shaped bacteria belonging to the Leptospira genus, commonly affecting the tropical countries. It has a global presence in nearly all tropical and temperate regions. It is one of the most widespread zoonotic infections worldwide ​(3)​. These infections occur when individuals come into contact with environmental sources such as animal urine, contaminated water or soil, or infected animal tissue ​(11)​. Leptospira species can infect a wide range of animals, including mammals, birds, reptiles and fish ​(12)​. Infected animals serve as reservoirs for disease, with rodents being the primary reservoir ​(5)​. Leptospira enter the body through openings in the skin like lesions or abrasions, as well as through the lining of the mouth or waterlogged skin after extended periods of immersion [10]. In exceptional cases, the bacteria can be transmitted through inhaling contaminated aerosols or consuming infected tissues. Various risk factors of leptospirosis are listed in Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e​(13,14)​.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003erisk factors associated with leptospirosis meningitis.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOccupational\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFarmers and ranchers\u003c/p\u003e\u003cp\u003eVeterinarians\u003c/p\u003e\u003cp\u003eLoggers\u003c/p\u003e\u003cp\u003eSewage workers\u003c/p\u003e\u003cp\u003eRice field workers\u003c/p\u003e\u003cp\u003eMilitary personnel\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRecreational\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFresh water swimming\u003c/p\u003e\u003cp\u003eCanoeing and Kayaking\u003c/p\u003e\u003cp\u003eTrail Biking\u003c/p\u003e\u003cp\u003eHunting\u003c/p\u003e\u003cp\u003eWalking in the farmland\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHousehold\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePet dogs\u003c/p\u003e\u003cp\u003eDomesticated livestock\u003c/p\u003e\u003cp\u003eRain water catchment systems\u003c/p\u003e\u003cp\u003eRodent infestation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003e\u003c/h3\u003e\n\u003cp\u003eThe clinical symptoms of leptospirosis resemble those of typical tropical infections like dengue, scrub typhus, viral hepatitis, and malaria ​(15)​. Leptospira meningitis presents as a form of aseptic meningitis, which means that there is no presence of bacteria in the cerebrospinal fluid (CSF). The symptoms of leptospirosis meningitis can vary but often include fever, severe headache, neck stiffness, and photophobia (sensitivity to light). Other symptoms may include nausea, vomiting, muscle aches, joint pain, and rash. If left untreated, leptospirosis meningitis can progress to more severe complications, including neurological damage such as coma, meningoencephalitis, hemiplegia, transverse myelitis, or Guillain-Barr\u0026eacute; syndrome ​(15)​.\u003c/p\u003e\u003cp\u003eOn average, the incubation period for leptospirosis is 1\u0026ndash;2 weeks, although it can range from 2 days to 30 days. After the acute or septicemic phase, which typically lasts around 1 week, the immune phase begins, characterized by the production of antibodies ​(16)​. A study documented the clinical characteristics and complications of leptospirosis in patients who were treated at nine specialized hospitals between September 28 and November 30, 2009, following a typhoon with heavy rainfall revealed that most of the patients diagnosed with leptospirosis exhibited non-specific symptoms, with fever being the most prevalent (98.5%). Other observed symptoms included myalgia (78.1%), malaise (74.9%), conjunctival suffusion (59.3%), oliguria (56.6%), diarrhea (39%), and jaundice (38%). Most patients were presented with moderate to severe leptospirosis (83%). Renal failure (82%), pulmonary hemorrhage (8%), and myocarditis (4%). Leptospiral meningitis was a rare complication, with only 5% cases​(17)​.\u003c/p\u003e\u003cp\u003eOccasionally sudden death may occur from arrhythmias, cardiac failure or adrenal haemorrhage. Massive bleeding from the alimentary and respiratory tract could also lead to death. In those who are not severely ill, recovery takes place in the second week. Diuresis occurs and the blood urea level falls gradually. Fever subsides and general conditions improve, however, jaundice takes a longer time to clear​(18)​.\u003c/p\u003e\u003cp\u003eWeil syndrome, a severe form of leptospirosis is marked by kidney and liver dysfunction, abnormal liver enlargement (hepatomegaly), persistent jaundice (yellowing of the skin, mucous membranes, and whites of the eyes), and/or changes in consciousness. Leptospirosis presents in two distinct clinical syndromes: anicteric and icteric​(19)​. Hemorrhagic pulmonitis is another severe form of the disease with higher mortality rates. Rarer manifestations include purely neurological which may present as meningitis/ meningoencephalitis​(11,20)​.\u003c/p\u003e\u003cp\u003eEarly diagnosis is crucial for timely treatment, as leptospirosis meningitis can be a severe and potentially life-threatening condition. Various methods for diagnosing the organism directly or detecting its components, such as culture, microscopy, and molecular techniques, are available, alongside serological tests like microagglutination test (MAT), enzyme-linked immunosorbent assay (ELISA), and rapid diagnostic tests (RDTs). The gold standard for diagnosis is culture from clinical specimens (urine, blood, or cerebrospinal fluid) or MAT, which is considered the reference test​(21)​. Other imaging studies such as MRI or CT scans may be utilized to assess the brain and spinal cord for any abnormalities caused by the infection. PCR has become a widely used diagnostic technique for swiftly and accurately detecting microbial infections in clinical specimens at an early stage ​(22,23)​. As soon as symptoms manifest, PCR has the capability to identify leptospiral DNA in cerebrospinal fluid (CSF). In an observation study conducted in Brazil, involving 103 patients with meningitis of unknown origin, it was found that 40% of them tested positive for PCR, while only 4% and 9% showed positive results for ELISA-IgM and MAT, respectively​(21)​. This signifies either underreporting of leptospiral meningitis with traditional serological tests and the improved sensitivity of the PCR based testing. Therefore, PCR offers benefits compared to MAT and ELISA-IgM in promptly diagnosing leptospiral meningitis, especially when antibodies are either absent or present in low levels in cerebrospinal fluid ​(24)​. Similarly, in a flood related outbreak in Sri Lanka, Quantitative PCR assay has been shown to be much sensitive than other serological tests​(25)​.\u003c/p\u003e\u003cp\u003eThe cerebrospinal fluid (CSF) analysis on our patient revealed the following results: protein level of 296, glucose level of 90, and a cell count with 17 white blood cells (WBC) and 825 red blood cells (RBC). The differential count indicated 69% segmented cells, 28% lymphocytes, 2% monocytes, and 1% eosinophils. However, serum Leptospira PCR was detected along with urine streptococcal antigen. The streptococcal coinfection in the meninges explains the lymphocytic preponderance in CSF studies.\u003c/p\u003e\u003cp\u003eTreatment guidelines for leptospirosis suggest the use of penicillin, cephalosporins, doxycycline, and chloramphenicol​(26)​.\u003c/p\u003e\u003cp\u003eLeptospira exhibits a surface architecture that resembles Gram- negative and Gram-\u003c/p\u003e\u003cp\u003epositive bacteria. Double membrane constitution supports Gram-negative bacteria whereas attachment of peptidoglycan to the inner membrane resembles gram\u003c/p\u003e\u003cp\u003epositive nature. Hence it is susceptible to the antibiotics which are used for both Gram-negative as well as gram positive bacteria. The bacteria are sensitive to wide\u003c/p\u003e\u003cp\u003erange of antibiotics except chloromphenical, as some of the serovars were found to be resistant. For early-stage leptospirosis treatment and chemoprophylaxis, Doxycycline is the standard therapy, effectively combating infection and preventing its progression. In cases of late and severe disease, while intravenous penicillin was once the preferred drug of choice, ceftriaxone is now increasingly utilized due to its easier administration​(27)​. Initially, our patient received vancomycin and Piperacillin/ Tazobactam for unclear sepsis. Later, Caspofungin and doxycycline were added, but Caspofungin was discontinued as fungal cultures were negative. Leptospira DNA was detected in the patient's blood, leading to a diagnosis of Weil's disease and leptospiral meningoencephalitis. However, ceftriaxone was later switched to penicillin G for better CSF penetration.\u003c/p\u003e\u003cp\u003eThe use of steroids in handling severe complications caused by leptospirosis is a matter of debate and lacks sufficient evidence from adequately conducted studies​(28)​. Supportive care may include management of symptoms like fever, pain, and dehydration. Patients with severe cases may require hospitalization for close monitoring and intravenous fluids. Early diagnosis and timely initiation of appropriate treatment are crucial for a positive outcome in cases of leptospirosis meningitis. Despite receiving optimal treatment, the mortality rate remains elevated in cases of severe leptospirosis​(29)​. The case fatality rate was reported to be 15% in some studies​(18)​. The CFR is 6.7% when presented with hepatic or renal involvement with mortality raising as high as 50\u0026ndash;70% when presented with Hemorrhagic pneumonitis​(18)​. Other predictors with a high mortality rate, include age\u0026thinsp;\u0026ge;\u0026thinsp;70, breathlessness, positive lung findings, oliguria, use of vasopressors, administration of steroids, the need for ventilator support, and blood transfusion.​(30)​\u003c/p\u003e\u003cp\u003eAlthough the basic principles of prevention such as source reduction, environmental sanitation, more hygienic work-related and personal practices etc., are same everywhere, there is no universal control method applicable to all epidemiological settings. Comprehensive understanding of the eco-epidemiological and cultural characteristics of a community that faces the problem of leptospirosis is an essential\u003c/p\u003e\u003cp\u003eprerequisite for evolving an effective and acceptable control measure​(18)​.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWhile leptospira coinfection with salmonella has been reported as case reports from different parts of world​(31)​, the coinfection of streptococcus with leptospira is hitherto never reported. This mixed pattern meningitis is an incidental co-infection and though doesnot affect the prognosis individually, can delay the diagnosis of the more fulminant leptospiral meningitis. As such initiating a broad serological testing should be a norm.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eALP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAlkaline Phosphatase\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eALT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAlanine Aminotransferase\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAST\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAspartate Aminotransferase\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCNS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCentral Nervous System\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCSF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCerebrospinal Fluid\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eComputed Tomography\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDNA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDeoxyribonucleic Acid\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eELISA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEnzyme-Linked Immunosorbent Assay\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGGT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGamma-Glutamyl Transferase\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eICU\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntensive Care Unit\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eINR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInternational Normalized Ratio\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntravenous\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMAT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMicroagglutination Test\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMagnetic Resonance Imaging\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePCR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePolymerase Chain Reaction\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRCA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eReturnable Container Act\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRBC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRed Blood Cells\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRDT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRapid Diagnostic Test\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTSH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eThyroid Stimulating Hormone\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWBC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWhite Blood Cells\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and Consent to participate:\u003c/strong\u003e Informed consent was obtained from the patient for participation in scientific research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eWritten informed consent was obtained from the patient for the publication of personal and clinical details, including identifying images, in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement:\u0026nbsp;\u003c/strong\u003eData sharing is not applicable to this article as no datasets were generated or analyzed. For further information, please contact the corresponding author, Dr. Saran Lal Ajai Mokan Dasan ([email protected]).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e No competing interests is reported by any of the authors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e No external funding reported by any of the authors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbeer Qasim, MD\u003c/strong\u003e conceptualized the case report and prepared the first draft of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSaran Lal Ajai Mokan Dasan, MD\u003c/strong\u003e was responsible for literature review and performed the final critical revision of the manuscript for intellectual content.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSri Ramani Peesapati, MD\u003c/strong\u003e,\u0026nbsp;\u003cstrong\u003eAbhishrut Jog, MD\u003c/strong\u003e,\u0026nbsp;\u003cstrong\u003eHammad Ashraf, MD\u003c/strong\u003e, and\u0026nbsp;\u003cstrong\u003eKhaja Misbahuddin, MD\u003c/strong\u003e provided editorial input and assisted with literature search and formatting.\u003c/p\u003e\n\u003cp\u003eAll authors reviewed and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCDC. LEPTOSPIROSIS Fact Sheet for Clinicians Background [Internet]. 2018. Available from: http://www.cdc.gov/ncezid/dhcpp/ \u003c/li\u003e\n\u003cli\u003eDaher EDF, Zanetta DMT, Abdulkader RCRM. Pattern of renal function recovery after leptospirosis acute renal failure. Nephron Clin Pract. 2004;98(1):c8-14.\u003c/li\u003e\n\u003cli\u003eKaushal A. Recent advances in the diagnosis of leptospirosis. Frontiers in Bioscience. 2020;25(9):4872.\u003c/li\u003e\n\u003cli\u003eWeil A. Ueber eine eigenth\u0026uuml;mliche, mit Milztumor, Icterus und Nephritis einhergehende, acute Infectionskrankheit [Internet]. 1886. Available from: https://books.google.com/books?id=hQy8jwEACAAJ \u003c/li\u003e\n\u003cli\u003eAdler B, de la Pe\u0026ntilde;a Moctezuma A. Leptospira and leptospirosis. Vet Microbiol. 2010 Jan;140(3\u0026ndash;4):287\u0026ndash;96.\u003c/li\u003e\n\u003cli\u003eCosta F, Hagan JE, Calcagno J, Kane M, Torgerson P, Martinez-Silveira MS, et al. Global Morbidity and Mortality of Leptospirosis: A Systematic Review. PLoS Negl Trop Dis. 2015 Sep 17;9(9):e0003898.\u003c/li\u003e\n\u003cli\u003eChokshi DA. NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE [Internet]. 2021. Available from: https://www.cdc.gov/leptospirosis/pdf/fs-leptospirosis-clinicians-eng-508.pdf \u003c/li\u003e\n\u003cli\u003eNysdec. NEW YORK STATE ENVIRONMENTAL CONSERVATION LAW * [Internet]. [cited 2025 Aug 10]. Available from: https://dec.ny.gov/environmental-protection/recycling-composting/bottle-bill \u003c/li\u003e\n\u003cli\u003eReverse vending machine [Internet]. [cited 2025 Aug 10]. Available from: https://en.wikipedia.org/wiki/Reverse_vending_machine#cite_note-:63-7 \u003c/li\u003e\n\u003cli\u003eChokshi DA. NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE [Internet]. 2021. Available from: https://www.cdc.gov/leptospirosis/pdf/fs-leptospirosis-clinicians-eng-508.pdf \u003c/li\u003e\n\u003cli\u003eBhatt M, Rastogi N, Soneja M, Biswas A. Uncommon manifestation of leptospirosis: a diagnostic challenge. BMJ Case Rep. 2018 Oct 7;2018.\u003c/li\u003e\n\u003cli\u003eGomes-Solecki M, Santecchia I, Werts C. Animal Models of Leptospirosis: Of Mice and Hamsters. Front Immunol. 2017 Feb 21;8.\u003c/li\u003e\n\u003cli\u003eFarr RW. Leptospirosis. Clinical Infectious Diseases. 1995 Jul 1;21(1):1\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eTangkanakul W, Tharmaphornpil P, Plikaytis BD, Bragg S, Poonsuksombat D, Choomkasien P, et al. Risk factors associated with leptospirosis in northeastern Thailand, 1998. Am J Trop Med Hyg. 2000;63(3\u0026ndash;4):204\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eLevett PN. Leptospirosis. Clin Microbiol Rev. 2001 Apr;14(2):296\u0026ndash;326.\u003c/li\u003e\n\u003cli\u003eMusso D, La Scola B. Laboratory diagnosis of leptospirosis: A challenge. Journal of Microbiology, Immunology and Infection. 2013 Aug;46(4):245\u0026ndash;52.\u003c/li\u003e\n\u003cli\u003eMendoza MT, Roxas EA, Ginete JK, Alejandria MM, Roman ADE, Leyritana KT, et al. Clinical profile of patients diagnosed with leptospirosis after a typhoon: a multicenter study. Southeast Asian J Trop Med Public Health. 2013 Nov;44(6):1021\u0026ndash;35.\u003c/li\u003e\n\u003cli\u003eLeptospirosis-emerging public health problem [Internet]. Available from: http://www.ias.ac.in/jbiosci \u003c/li\u003e\n\u003cli\u003eWang S, Dunn N. Leptospirosis. 2025.\u003c/li\u003e\n\u003cli\u003eJha S, Ansari MK. Leptospirosis presenting as acute meningoencephalitis. Vol. 4, J Infect Dev Ctries. 2010.\u003c/li\u003e\n\u003cli\u003eFischer RSB, Flores Somarriba B. Challenges to Diagnosing Leptospirosis in Endemic Regions Require Urgent Attention. Curr Trop Med Rep. 2017 Apr 21;4(2):57\u0026ndash;61.\u003c/li\u003e\n\u003cli\u003eAvery RA, Frank G, Eppes SC. Diagnostic Utility of Borrelia burgdorferi Cerebrospinal Fluid Polymerase Chain Reaction in Children with Lyme Meningitis. Pediatric Infectious Disease Journal. 2005 Aug;24(8):705\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eRomero EC, Blanco RM, Yasuda PH. Aseptic meningitis caused by Leptospira spp diagnosed by polymerase chain reaction. Mem Inst Oswaldo Cruz. 2010 Dec;105(8):988\u0026ndash;92.\u003c/li\u003e\n\u003cli\u003eAbdelrahim NA, Fadl-Elmula IM, Hartskeerl RA, Ahmed A, Goris M. Are Pathogenic Leptospira a Possible Cause of Aseptic Meningitis in Suspected Children in Sudan? Res Rep Trop Med. 2021;12:267\u0026ndash;74.\u003c/li\u003e\n\u003cli\u003eAgampodi SB, Dahanayaka NJ, N\u0026ouml;ckler K, Mayer-Scholl A, Vinetz JM. Redefining Gold Standard Testing for Diagnosing Leptospirosis: Further Evidence from a Well-Characterized, Flood-Related Outbreak in Sri Lanka. Am J Trop Med Hyg. 2016 Sep 7;95(3):531\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eBandara AGNMK, Kalaivarny G, Perera N, Indrakumar J. Aseptic meningitis as the initial presentation of Leptospira borgpetersenii serovar Tarassovi: two case reports and a literature review. BMC Infect Dis. 2021 Dec 27;21(1):488.\u003c/li\u003e\n\u003cli\u003eFaucher JF, Hoen B, Estavoyer JM. The management of leptospirosis. Expert Opin Pharmacother. 2004 Apr;5(4):819\u0026ndash;27.\u003c/li\u003e\n\u003cli\u003ePanicker JN, Mammachan R, Jayakumar R V. Primary neuroleptospirosis. Postgrad Med J. 2001 Sep 1;77(911):589\u0026ndash;90.\u003c/li\u003e\n\u003cli\u003eMarchiori E, Louren\u0026ccedil;o S, Set\u0026uacute;bal S, Zanetti G, Gasparetto TD, Hochhegger B. Clinical and imaging manifestations of hemorrhagic pulmonary leptospirosis: a state-of-the-art review. Lung. 2011 Feb;189(1):1\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eLiu YH, Chen YH, Chen CM. Fulminant Leptospirosis Presenting with Rapidly Developing Acute Renal Failure and Multiorgan Failure. Biomedicines. 2024 Feb 1;12(2).\u003c/li\u003e\n\u003cli\u003eUllah R, Ahmad A, Salcedo YE, Hassan A, Khanal A, Chaulagain A. Concomitant Salmonella and Leptospira Meningitis: A Rare Case Report. Cureus. 2024 Feb 21;\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Leptospirosis, Meningitis, Bottle recycling, Public health concern","lastPublishedDoi":"10.21203/rs.3.rs-7948869/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7948869/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLeptospirosis is a preventable zoonotic infection that can present with a wide spectrum of clinical features, ranging from mild flu-like illness to severe multi-organ dysfunction. Meningitis due to \u003cem\u003eLeptospira\u003c/em\u003e is rare, and co-infection with \u003cem\u003eStreptococcus pneumoniae\u003c/em\u003e has not been reported.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe describe here a case of a \u0026nbsp;50-year-old male with schizophrenia and hypothyroidism who presented with seizures, jaundice, shock, and respiratory failure. Initial evaluation revealed severe metabolic acidosis, renal failure, transaminitis, and thrombocytopenia. Lumbar puncture showed xanthochromic CSF with lymphocytic predominance. Urine \u003cem\u003eStreptococcus\u003c/em\u003eantigen was positive, and serum PCR confirmed \u003cem\u003eLeptospira\u003c/em\u003e. The patient was treated with broad-spectrum antibiotics, later narrowed to intravenous penicillin G for optimal CNS penetration. He underwent mechanical ventilation, tracheostomy, gastrostomy, and hemodialysis, ultimately achieving a favorable recovery.Epidemiologic history revealed daily collection of discarded bottles in an area with high rodent exposure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion:\u003c/strong\u003e Leptospirosis, transmitted through contact with rodent urine, is underdiagnosed in the United States. In New York City, most reported cases occur in the Bronx. Our patient’s occupational exposure from bottle collection likely facilitated \u003cem\u003eLeptospira\u003c/em\u003e infection. The concurrent pneumococcal infection may have delayed recognition of leptospiral meningitis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e This case highlights the importance of thorough exposure history and broad diagnostic testing in atypical meningitis presentations, particularly when occupational or environmental risk factors exist.\u003c/p\u003e","manuscriptTitle":"A penny for your CSF - An Unexpected consequence of bottle recycling: Meningitis due to Leptospira and Streptococcus – a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-24 11:10:43","doi":"10.21203/rs.3.rs-7948869/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9d5e275e-ef95-4368-858f-2efc81533ade","owner":[],"postedDate":"November 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-16T07:10:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-24 11:10:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7948869","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7948869","identity":"rs-7948869","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}