title: Case series of fatal Leptospira spp./dengue virus co-infections-Puerto Rico, 2010-2012.
abstract: 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.
authors.affiliation: 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.
authors.forename: Nicole M
authors.initials: NM
authors.lastname: Pérez Rodríguez
authors.affiliation: 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.
authors.forename: Renee
authors.initials: R
authors.lastname: Galloway
authors.affiliation: 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.
authors.forename: Dianna M
authors.initials: DM
authors.lastname: Blau
authors.affiliation: 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.
authors.forename: Rita
authors.initials: R
authors.lastname: Traxler
authors.affiliation: 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.
authors.forename: Julu
authors.initials: J
authors.lastname: Bhatnagar
authors.affiliation: 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.
authors.forename: Sherif R
authors.initials: SR
authors.lastname: Zaki
authors.affiliation: 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.
authors.forename: Aidsa
authors.initials: A
authors.lastname: Rivera
authors.affiliation: 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.
authors.forename: Jose V
authors.initials: JV
authors.lastname: Torres
authors.affiliation: 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.
authors.forename: David
authors.initials: D
authors.lastname: Noyd
authors.affiliation: 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.
authors.forename: Xavier E
authors.initials: XE
authors.lastname: Santiago-Albizu
authors.affiliation: 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.
authors.forename: Brenda
authors.initials: B
authors.lastname: Rivera García
authors.affiliation: 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.
authors.forename: Kay M
authors.initials: KM
authors.lastname: Tomashek
authors.affiliation: 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.
authors.forename: William A
authors.initials: WA
authors.lastname: Bower
authors.affiliation: 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 tsharp@cdc.gov.
authors.forename: Tyler M
authors.initials: TM
authors.lastname: Sharp
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D060085:Coinfection; D003715:Dengue / Q000175:diagnosis* / Q000188:drug therapy / Q000821:virology; D003716:Dengue Virus / Q000302:isolation & purification*; D017809:Fatal Outcome; D006801:Humans; D007919:Leptospira / Q000302:isolation & purification*; D007922:Leptospirosis / Q000175:diagnosis* / Q000188:drug therapy / Q000382:microbiology; D008297:Male; D008875:Middle Aged; D011647:Puerto Rico; D013256:Steroids / Q000008:administration & dosage; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents; D013256:Steroids
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