# A Rare Case of Triple Infection with Leptospira, Hepatitis A Virus, and Hepatitis E Virus

## TL;DR

A 34-year-old woman in a non-endemic area was diagnosed with a rare triple infection involving Leptospira, Hepatitis A Virus, and Hepatitis E Virus, highlighting the need for broad diagnostic testing.

## Contribution

This is the first reported case of triple infection with Leptospira, Hepatitis A, and Hepatitis E in a non-endemic area without tropical travel history.

## Key findings

- The patient showed symptoms like fever, jaundice, and liver dysfunction, confirmed by serology and PCR.
- Triple infection was managed with antibiotics and fluids, leading to clinical improvement and normalized liver tests.
- The case emphasizes the importance of considering coinfections in non-endemic regions based on patient history.

## Abstract

Background and Clinical Significance: Simultaneous, multiple infections coinfections caused by zoonotic or fecal-orally transmitted diseases are common in tropical and subtropical regions. Published data report that leptospirosis may coexist with other infections, complicating the clinical presentation and trajectory due to overlapping symptoms and leading to more severe clinical progress. Case Presentation: We describe a clinical case of a 34-year-old female diagnosed with a triple infection caused by Leptospira, Hepatitis A Virus, and Hepatitis E Virus. To our knowledge, this is the first case described in the literature in a non-endemic area without travel history to tropical or subtropical regions. The patient presented with one-week history of influenced clinical status, myalgia, headaches, nausea, high fever, bloody diarrheas, and abdominal pain. During the last two days, she also developed jaundice. Swimming in the rock pools of the island where she lives was indicated as the source of the infection. The laboratory tests revealed increased values of inflammatory markers, thrombocytopenia, and severe abnormalities of liver function. Serological and PCR tests for a wide range of pathogens proved an acute infection caused by Leptospira interogans, Hepatitis A virus, and Hepatitis E Virus. The patient received intravenous fluids and antibiotic treatment with ceftriaxone for seven days leading to gradual clinical improvement and normalization of liver function tests with subsequent reduction in jaundice within 30 days. Conclusions: This case report suggests that clinical suspicion and laboratory investigation should include the probability of coinfections even in non-endemic areas based on medical history of the patients. An early diagnosis of a zoonotic disease and other infective agents of acute hepatitis are vital in order to choose the appropriate treatment option and avoid severe complications.