Case Series of Fatal Leptospira spp./Dengue Virus Co-Infections—Puerto Rico, 2010–2012

Nicole M. Pérez Rodríguez Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico; Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia; Medicolegal and Toxicological Investigation Division, Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico; San Lucas Episcopal Hospital, Ponce, Puerto Rico; Division of Epidemiology, Puerto Rico Department of Health, San Juan, Puerto Rico

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Renee Galloway Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico; Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia; Medicolegal and Toxicological Investigation Division, Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico; San Lucas Episcopal Hospital, Ponce, Puerto Rico; Division of Epidemiology, Puerto Rico Department of Health, San Juan, Puerto Rico

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Dianna M. Blau Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico; Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia; Medicolegal and Toxicological Investigation Division, Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico; San Lucas Episcopal Hospital, Ponce, Puerto Rico; Division of Epidemiology, Puerto Rico Department of Health, San Juan, Puerto Rico

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Rita Traxler Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico; Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia; Medicolegal and Toxicological Investigation Division, Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico; San Lucas Episcopal Hospital, Ponce, Puerto Rico; Division of Epidemiology, Puerto Rico Department of Health, San Juan, Puerto Rico

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Julu Bhatnagar Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico; Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia; Medicolegal and Toxicological Investigation Division, Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico; San Lucas Episcopal Hospital, Ponce, Puerto Rico; Division of Epidemiology, Puerto Rico Department of Health, San Juan, Puerto Rico

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Sherif R. Zaki Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico; Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia; Medicolegal and Toxicological Investigation Division, Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico; San Lucas Episcopal Hospital, Ponce, Puerto Rico; Division of Epidemiology, Puerto Rico Department of Health, San Juan, Puerto Rico

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Aidsa Rivera Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico; Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia; Medicolegal and Toxicological Investigation Division, Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico; San Lucas Episcopal Hospital, Ponce, Puerto Rico; Division of Epidemiology, Puerto Rico Department of Health, San Juan, Puerto Rico

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Jose V. Torres Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico; Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia; Medicolegal and Toxicological Investigation Division, Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico; San Lucas Episcopal Hospital, Ponce, Puerto Rico; Division of Epidemiology, Puerto Rico Department of Health, San Juan, Puerto Rico

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David Noyd Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico; Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia; Medicolegal and Toxicological Investigation Division, Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico; San Lucas Episcopal Hospital, Ponce, Puerto Rico; Division of Epidemiology, Puerto Rico Department of Health, San Juan, Puerto Rico

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Xavier E. Santiago-Albizu Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico; Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia; Medicolegal and Toxicological Investigation Division, Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico; San Lucas Episcopal Hospital, Ponce, Puerto Rico; Division of Epidemiology, Puerto Rico Department of Health, San Juan, Puerto Rico

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Brenda Rivera García Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico; Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia; Medicolegal and Toxicological Investigation Division, Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico; San Lucas Episcopal Hospital, Ponce, Puerto Rico; Division of Epidemiology, Puerto Rico Department of Health, San Juan, Puerto Rico

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Kay M. Tomashek Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico; Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia; Medicolegal and Toxicological Investigation Division, Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico; San Lucas Episcopal Hospital, Ponce, Puerto Rico; Division of Epidemiology, Puerto Rico Department of Health, San Juan, Puerto Rico

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William A. Bower Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico; Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia; Medicolegal and Toxicological Investigation Division, Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico; San Lucas Episcopal Hospital, Ponce, Puerto Rico; Division of Epidemiology, Puerto Rico Department of Health, San Juan, Puerto Rico

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Tyler M. Sharp Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico; Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia; Medicolegal and Toxicological Investigation Division, Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico; San Lucas Episcopal Hospital, Ponce, Puerto Rico; Division of Epidemiology, Puerto Rico Department of Health, San Juan, Puerto Rico

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Co-infection with pathogens that cause acute febrile illness creates a diagnostic challenge as a result of overlapping clinical manifestations. Here, we describe four fatal cases of Leptospira species/dengue virus co-infection in Puerto Rico. Although all patients sought care early, antibiotic administration was delayed for most. Steroids were administered to all patients, in most cases before antibiotics. These cases show the need for clinicians evaluating patients in or recently returned from the tropics with acute febrile illness to consider both dengue and leptospirosis. Furthermore, they illustrate the need for nucleic acid- or antigen-based rapid diagnostic tests to enable timely patient diagnosis and management. In particular, antibiotic therapy should be initiated early for patients with suspected leptospirosis, and steroids should not be administered to patients with suspected dengue.

Author Notes

* Address correspondence to Tyler M. Sharp, Centers for Disease Control and Prevention, Dengue Branch, 1324 Calle Cañada San Juan, PR 00920. E-mail: tsharp@cdc.gov

Authors' addresses: Nicole M. Pérez Rodríguez, Aidsa Rivera, David Noyd, Kay M. Tomashek, and Tyler M. Sharp, Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, PR, E-mails: xhp4@cdc.gov, erj2@cdc.gov, wyf1@cdc.gov, kct9@cdc.gov, and tsharp@cdc.gov. Renee Galloway, Rita Traxler, and William A. Bower, Bacterial Special Pathogens Branch, Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, GA., E-mails: zul0@cdc.gov, gna9@cdc.gov, and wab4@cdc.gov. Dianna M. Blau, Julu Bhatnagar, and Sherif R. Zaki, Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, GA., E-mails: bvv1@cdc.gov, zrn1@cdc.gov, and sxz1@cdc.gov. Xavier E. Santiago-Albizu, San Lucas Episcopal Hospital, Ponce, PR., E-mail: xsantiagoal@yahoo.com. Jose V. Torres, Medicolegal and Toxicological Investigation Division, Puerto Rico Institute of Forensic Sciences, Carparra Heights Station, San Juan, PR., E-mail: JVTorres@icf.gobierno.pr. Brenda Rivera-García, Epidemiology and Research Office, Puerto Rico Department of Health, Medical Center Area, San Juan, PR., E-mail: brendarivera@salud.pr.gov.

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