Co-existent facial palsy and myocarditis in a 50-year old farmer diagnosed with probable leptospirosis: a case report

BACKGROUND: Leptospirosis is a worldwide zoonotic disease caused by spirochetes belonging to the genus Leptospira. This is a case report on a patient with probable leptospirosis, who developed lower motor neuron facial nerve palsy during the recovery phase of this illness. Leptospirosis is endemic in Sri Lanka and this complication has been reported earlier in other countries but not in Sri Lanka to the best of our knowledge. CASE PRESENTATION: A previously well 50 year old Sinhalese farmer in Sri Lanka was admitted to a tertiary care hospital with five day history of fever, headache, prostration, severe myalgia especially in the calves and yellowish discoloration of the eyes. He was febrile, icteric and had suffusion of both conjunctivae. His pulse rate and blood pressure was 98/min and 90/50 mmHg respectively. The initial laboratory examinations showed neutrophil leukocytosis and thrombocytopenia. Antibodies test for leptospirosis was done and IgM was positive. Because of this evidence the probable diagnosis of leptospirosis was made and antibiotic therapy initialed with intravenous cefotaxime 1 g 8 hrly and crystalline penicillin 2 mu 6 hrly. On the eighth day he developed chest pain associated with shortness of breath with a heart rate of 120/min. Electrocardiograpic and echocardiograpic evidence suggested myocarditis, and trponin I titer was positive. Supportive care was provided and antibiotics were continued. On the 13(th) day of illness he developed lower motor type facial nerve palsy of the left side with positive Bell’s phenomenon. But rest of the neurological examination was normal. He was discharged on a step-down course of prednisolone and physiotherapy. He fully recovered from cardiac involvement before discharge but recovery from facial nerve palsy took place only six months later. CONCLUSION: Our case emphasizes cardiac and facial nerve involvement in leptospirosis. This is the first published report in Sri Lanka of facial nerve palsy occurring in leptospirosis possibly due to immunological damage. Further literature survey revealed that this is the first case in the world with simultaneous occurrence of myocarditis and facial nerve palsy in leptospirosis. The pathogenesis of this occurrence is yet to be fully understood.