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A 24 year old factory worker male was admitted to Emergency Department Hasan Sadikin Hospital/Padjadjaran University, Bandung, Indonesia because of syncope approximately 10 minutes duration. There was no residual neurological deficit at presentation. History taking after the patient regained consciousness revealed that he complained of high fever over the last 7 days, accompanied by nausea, vomiting, severe muscle pain. There was no icterus and urination abnormalities. Two weeks prior to admission, he cleaned sewer in front of his house on bare foot.
Vital signs were normal except for pulses of 25-30 bpm. Physical exams demonstrated no cardiac abnormality, but marked hepatomegaly. Laboratory revealed leukocytosis 21.600/mm3, SGOT/SGPT 248/352 U/l, Ureum/Creatinin 67/1,72 mg/dl, Troponin T >2,0 ng/ml. Chest X-ray showed no cardiomegaly or pulmonary disease. Total atrioventricular block was noted at the ECG. Further laboratorium results were as follows: IgM anti Dengue negative, IgM anti Leptospira 13,3 units. Normal cardiac chambers and normal ejection fraction was found on Echocardiogram. The patient was put on TPM (apex RV, treshold 0,75mA, output 1 mA, 70 bpm), and antibiotic course of Azithromycin 1x500mg po and Cefotaxime 3x1 gr IV. On 5th day of hospitalization, the rhythm became sinus with HR 75 bpm, thus TPM was turned off, subsequently removed, and the patient was discharged. At follow up outpatient visit, the microscopic agglutination test was 1:1400, but blood culture was negative. Therapy was continued with Doxycycline 2x200mg po. Leptospirosis is a bacterial infection caused by Leptospira genus, usually transmitted by animal urine or by water or soil containing animal urine coming into contact with breaks in the skin. Prior observational studies described cardiac involvement was discovered in 52% patients with serologically-positive leptospirosis and myocarditis was demonstrated in 8.1% of patients. In other studies, ECG abnormalities was found in 59% of patients, with first-degree AV block and atrial fibrillation were the most frequent findings. This was a rare case of myocarditis due to leptospirosis complicated by total atrioventricular block.