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leptospirosis high total bilirubin normal transaminases neutrophilic leukocytosis thrombocytopenia diagnosis treatment
Lab Report Summary — Mr. Hasim Seikh, 26Y/Male (Casualty, Dhanwantari Diagnostics, 17/08/2026)
Key abnormal findings
| Test | Result | Normal | Interpretation |
|---|---|---|---|
| Total WBC count | 14,100/cumm | 4,000-11,000 | Leukocytosis |
| Neutrophils | 90% | 40-75% | Marked neutrophilia (bacterial/severe infective pattern) |
| Lymphocytes | 10% | 20-40% | Relative lymphopenia |
| Platelet count | 1.0 lakh/cumm (rechecked manually) | 1.5-4.5 lakh | Mild thrombocytopenia |
| Total bilirubin | 1.66 mg/dl | 0.1-1.2 | Mild hyperbilirubinemia |
| Direct bilirubin | 0.36 mg/dl | 0-0.3 | Slightly elevated |
| Indirect bilirubin | 1.30 mg/dl | - | Elevated |
| SGPT/SGOT | 25 / 24 IU/L | 5-40 | Normal (liver enzymes not raised despite raised bilirubin — important pattern) |
| Alkaline phosphatase | 286 U/L | 80-306 | Upper-normal |
| Uric acid | 9.55 mg/dl | 3.5-7.0 (male) | Raised |
| RBS, urea, creatinine, Na, K | All normal | - | Kidney function currently preserved |
| Urine ketone bodies | Present (+) | Nil | Suggests dehydration/poor intake |
| Urine pus cells | 3-4/HPF | 0-5 | Mild pyuria (borderline) |
| Malaria (MP-ICT) | Negative | - | Malaria excluded |
| Dengue NS1/IgG/IgM | All non-reactive | - | Dengue excluded (at time of testing) |
Interpretation
This is an acute febrile illness picture (patient was brought to Casualty) with:
- Neutrophil-predominant leukocytosis + mild thrombocytopenia
- Disproportionately raised bilirubin with normal transaminases — a hallmark biochemical dissociation
- Raised uric acid and ketonuria (dehydration/reduced intake)
- Malaria and dengue both ruled out
This specific combination — neutrophilia, thrombocytopenia, and elevated bilirubin with near-normal liver enzymes, in a young adult with dengue/malaria excluded — is the classic laboratory profile of leptospirosis, a common cause of acute febrile illness in India, especially with any recent exposure to flood water, paddy fields, or contact with rodent/cattle urine-contaminated water or soil. Harrison's and Goldman-Cecil textbooks both note that in leptospirosis "serum bilirubin levels may be high, whereas rises in aminotransferase and alkaline phosphatase levels are usually moderate," together with neutrophilic leukocytosis and thrombocytopenia - exactly this pattern.
Other differentials that must be kept in mind and cannot be excluded from labs alone:
- Urosepsis/UTI (supported by mild pyuria, ketonuria from poor intake, neutrophilic leukocytosis) — needs urine culture
- Enteric (typhoid) fever — usually shows leukopenia/normal counts rather than neutrophilic leukocytosis, so less likely but not excluded without blood culture/Widal
- Early dengue (NS1/IgM can still be negative in the very first 24-48 hours) — repeat serology in 48-72h if fever persists
- Viral hepatitis with reactive systemic changes (less likely given normal transaminases)
This is an interpretation of the lab data only — it cannot substitute for clinical examination (fever duration/pattern, myalgia especially calf tenderness, conjunctival suffusion, jaundice, urine output, water/animal exposure history, abdominal exam) which the treating casualty doctor should already be correlating with.
Suggested next steps (for the treating physician)
Confirmatory work-up:
- Leptospira IgM ELISA / rapid card test (and repeat after 5-7 days if early and negative); MAT if available
- Blood culture and urine culture/routine microscopy repeat
- Peripheral blood smear, CPK (if myalgia, to check for rhabdomyolysis), coagulation profile (PT/INR, aPTT) given thrombocytopenia
- Repeat CBC (platelet trend) in 12-24h
- Chest X-ray if respiratory symptoms (pulmonary hemorrhage is a leptospirosis complication)
- Widal/blood culture for typhoid if fever persists and leptospira workup is negative
Empirical management (pending confirmation), to be started/continued by the attending doctor:
- IV fluids for hydration (ketonuria + normal but borderline creatinine suggest early volume depletion) - monitor urine output closely
- Antibiotics: for suspected leptospirosis, doxycycline 100 mg PO BID for mild disease, or IV ceftriaxone 1 g OD / IV crystalline penicillin if more unwell/hospitalized - these also cover most bacterial causes of undifferentiated febrile illness including possible UTI
- Antipyretics: paracetamol only — avoid NSAIDs/aspirin because of thrombocytopenia and bleeding risk
- Monitor: platelet count, renal function (urea/creatinine), liver function, and urine output daily — leptospirosis can progress to AKI and hemorrhagic complications over the next 48-72 hours even when initial renal parameters are normal
- Avoid nephrotoxic drugs until leptospirosis/AKI risk is clarified
Recent evidence check
A 2024-2025 PMC review on early leptospirosis diagnosis (used above) validated a clinical-lab scoring system using exactly these cutoffs — neutrophilia >80%, platelets <85,000-100,000, and elevated bilirubin — to differentiate leptospirosis from other febrile illnesses, supporting this interpretation. No systematic review in the last 2 years contradicts standard doxycycline/ceftriaxone treatment for leptospirosis.
Bottom line: Malaria and dengue are excluded. The pattern (neutrophilic leukocytosis + thrombocytopenia + isolated hyperbilirubinemia with normal transaminases) is most suggestive of leptospirosis, with urosepsis/UTI as a reasonable alternative given the mild pyuria. Confirmatory serology, blood/urine cultures, and close monitoring of platelets and renal function over the next 24-48 hours are essential, and treatment should be guided by the physician physically examining the patient in casualty, not by labs alone.
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