A 25-year-old sewage worker presents with fever lasting a week, followed by sudden weakness. He has scleral congestion, jaundice, and oliguria. Lab findings show raised bilirubin. What is the most likely diagnosis?

Explanation

## Correct Answer: D. Weil's disease Weil's disease is the severe, icteric form of leptospirosis caused by *Leptospira interrogans* serovars (especially Icterohaemorrhagiae). The clinical presentation is pathognomonic: biphasic fever (leptospiraemic phase 4–7 days, then immune phase), followed by sudden onset of jaundice, renal failure (oliguria), and hemorrhagic manifestations. The occupational exposure (sewage worker) is a critical clue—leptospirosis is transmitted via contact with contaminated water/urine from infected rodents, making it an occupational hazard in India's sanitation workers. The triad of **jaundice + acute renal failure + hemorrhage** in a febrile patient with water/sewage exposure is diagnostic. Lab findings of hyperbilirubinemia (predominantly direct), elevated creatinine, and thrombocytopenia support this. Mortality in Weil's disease reaches 5–15% if untreated. Early recognition and doxycycline or penicillin therapy (as per Indian guidelines) are life-saving. The sudden transition from fever to organ dysfunction (renal, hepatic) distinguishes this from other febrile illnesses in India. ## Why the other options are wrong **A. Brucellosis** — Brucellosis presents with undulating fever, arthralgia, and hepatosplenomegaly but does NOT cause acute jaundice, oliguria, or hemorrhagic manifestations. Occupational exposure in India is more common in dairy/livestock workers, not sewage workers. Renal failure is not a feature of brucellosis. **B. DHF** — Dengue hemorrhagic fever presents with biphasic fever and hemorrhage but typically occurs in urban/mosquito-endemic areas with a clear history of mosquito exposure. Jaundice is not prominent in DHF; instead, thrombocytopenia and plasma leakage dominate. Oliguria from acute kidney injury is less common than in Weil's disease. Sewage exposure is not a risk factor. **C. Enteric fever** — Enteric fever (typhoid) presents with prolonged fever, rose spots, and hepatosplenomegaly but does NOT cause acute jaundice with oliguria in the first week. Renal failure is a late complication, not an early feature. Scleral congestion and hemorrhagic manifestations are absent. Sewage exposure is epidemiologically less specific than for leptospirosis. ## High-Yield Facts - **Weil's disease** = severe icteric leptospirosis with jaundice + acute kidney injury + hemorrhage; mortality 5–15% if untreated. - **Biphasic fever pattern**: leptospiraemic phase (4–7 days) → immune phase with sudden organ dysfunction (jaundice, renal failure, bleeding). - **Occupational risk**: sewage workers, farmers, slaughterhouse workers in India exposed via contaminated water/rodent urine. - **Diagnostic triad**: jaundice + oliguria + scleral congestion in a febrile patient with water exposure = Weil's disease until proven otherwise. - **DOC in India**: doxycycline 100 mg BD × 7 days (leptospiraemic phase) or IV penicillin G 1.5 MU 6-hourly (severe disease); supportive care for renal failure. - **Lab findings**: direct hyperbilirubinemia, elevated creatinine (>2 mg/dL), thrombocytopenia, elevated transaminases; urine culture positive in immune phase. ## Mnemonics **WEIL'S = Water + Occupational + Icteric + Leptospira + Sudden organ failure** Water exposure (sewage/flooding) + occupational risk + Icteric (jaundice) + Leptospira interrogans + Sudden renal/hepatic failure. Use this when you see a sewage/water worker with jaundice + AKI. **Biphasic Fever → Sudden Jaundice + AKI = LEPTOSPIROSIS** If fever resolves briefly then returns with jaundice/renal failure, think leptospirosis. The immune phase (week 2) brings organ dysfunction, not the initial fever phase. ## NBE Trap NBE may pair "fever + jaundice" with enteric fever (a common Indian diagnosis) to distract from the occupational exposure (sewage worker) and acute renal failure, which are hallmarks of Weil's disease, not typhoid. The sudden transition from fever to multi-organ failure is the discriminator. ## Clinical Pearl In India's monsoon season, sewage workers presenting with fever → jaundice → oliguria within 7–10 days should trigger immediate leptospirosis workup and empiric doxycycline, as delayed treatment in Weil's disease rapidly progresses to renal failure and death. A single negative blood culture does not exclude leptospirosis; PCR or MAT (microscopic agglutination test) confirms diagnosis. _Reference: Jawetz, Melnick & Adelberg's Medical Microbiology (Leptospirosis chapter); Harrison's Principles of Internal Medicine Ch. 159 (Leptospirosis); Park's Textbook of Preventive and Social Medicine (Occupational health & leptospirosis in India)_