Severe Leptospirosis in a Rural Health Centre

The combination of fever, severe calf pain, conjunctival suffusion, jaundice, oliguria, hypotension and thrombocytopenia in a farmer after heavy rain is a classic severe leptospirosis picture until proven otherwise. The creatinine of 220 µmol/L indicates acute kidney injury; the platelets of 85 × 10⁹/L and raised ALT indicate multi-organ involvement. He is not a simple viral illness to send home. The priority problem is severe leptospirosis with developing septic shock and acute kidney injury, with a risk of pulmonary haemorrhage, which can deteriorate quickly in a facility without dialysis or intensive care. The low BP and tachycardia suggest volume depletion and possible sepsis; the reduced urine output means fluid balance and renal function must be monitored closely. The nurse should treat this as a time-critical referral, not await the next ferry without escalation. The differential includes dengue, malaria, typhoid and hepatitis, but the exposure history and calf pain make leptospirosis most likely; regardless, the severity dictates referral.

In the first two hours: assess ABC, give oxygen if SpO2 falls, establish IV access and take blood cultures if available, and start cautious crystalloid resuscitation for hypotension-for example 500 mL boluses with reassessment, because aggressive fluid in leptospirosis can worsen pulmonary haemorrhage. Insert a urinary catheter and measure hourly urine output. Give the first dose of IV ceftriaxone according to protocol after checking allergies and discussing with the medical officer; do not delay transfer for oral antibiotics. Avoid NSAIDs and nephrotoxic drugs. Monitor BP, pulse, respiratory rate, SpO2, conscious state, urine output and bleeding. Arrange the ambulance and ferry priority, prepare a referral letter with observations, creatinine, platelets, ALT, fluids and drugs given, and contact the receiving hospital to confirm acceptance and renal support. Send an escort with oxygen and suction. Obtain informed consent for transfer; if he refuses, escalate to the medical officer and document capacity and advice given.

The nurse should acknowledge that preparing kava for a funeral is a real family and cultural obligation, not an inconvenience. She should explain in plain language that his kidneys are failing and his blood pressure is low; going home could lead to collapse, bleeding in the lungs or death, and the health centre cannot provide dialysis. Involve the family and, if appropriate, a village health worker or church leader to support the decision. Offer practical help: contact relatives to take over the funeral preparation, arrange for him to travel with a family member, and explain that treatment now gives him a better chance of returning to his role. If he still refuses, assess and document his capacity, explain the risks, involve the medical officer, and arrange a safe plan rather than simply discharging him. The aim is shared decision-making, not coercion, but the nurse must not collude with a plan that is clinically unsafe. Document the discussion, the patient’s words and the escalation.