Probable Leptospirosis in the Adventure Traveler with Freshwater Exposure: Narrative Review and Case Series.

Leptospirosis is an emerging zoonotic infectious disease in the adventure traveler with recreational freshwater exposure. We describe three cases of probable leptospirosis acquired during whitewater rafting trips in rural Ecuador. Rafting took place following periods of heavy rainfall and flooding of rivers, which are well documented risk factors for leptospirosis. Two of our patients presented to our rapid assessment clinic with acute febrile illness after travel to a region with a confirmed leptospirosis outbreak, while the third patient presented four weeks after a convalescent episode of acute febrile jaundice during a dramatic rise in reported leptospirosis cases in Ecuador. Delayed turnaround times for confirmatory microbiologic diagnostics in leptospirosis challenge its management and necessitate provisional clinical diagnosis and empiric antimicrobials based on compatible clinical symptoms, biochemical abnormalities, exposure history, and known outbreak epidemiology. We herein situate the presentations of our patients within the broader literature by reviewing the clinical, diagnostic, therapeutic, and prognostic considerations when caring for leptospirosis patients. Leptospirosis should be considered in the differential diagnosis of all patients presenting with acute febrile illness following adventure travel with freshwater exposure, and empiric treatment should be considered given the absence of readily available confirmatory microbiologic testing.