When Steroids Backfire: A Case of Hyperosmolar Hyperglycemic State, Pneumocystis Pneumonia, and Cauda Equina Syndrome.

Leptospirosis is a bacterial zoonosis caused by spirochetes of the genus , with global distribution but predominance in tropical and subtropical regions, especially in contexts of heavy rainfall, flooding, or poor sanitary conditions. Transmission to humans usually occurs through direct contact with the urine of infected animals, typically rodents, or indirectly through contaminated water. Although traditionally associated with rural settings, outbreaks have also been documented in urban areas and developed countries, often linked to recreational water activities [,]. From a clinical perspective, leptospirosis presents with great variability, ranging from subclinical infections to severe forms with renal failure, pulmonary hemorrhages, or meningitis. In its classic form, it follows a biphasic course: an acute phase followed by an immune phase, during which systemic complications may arise, including ocular involvement [,]. Ophthalmological manifestations, although described over a century ago, remain underdiagnosed. In the acute phase, mild signs such as non-purulent conjunctivitis, episcleral hyperemia, or subconjunctival hemorrhages may be observed. However, in the immune-mediated phase — typically between the second and sixth week after infection — more severe forms may appear, such as anterior uveitis, panuveitis, retinitis, papillitis, retinal vasculitis, choroiditis, or even neuroretinitis [-]. These ocular manifestations may be the sole clinical expression of a subclinical leptospirosis, making recognition even more difficult. Diagnosis in these cases relies on a high index of clinical suspicion. It is usually supported by serology (IgM and IgG), whereas direct tests such as PCR in urine or aqueous humor tend to become negative in later phases [].