Leptospirosis, an infectious zoonosis, is common to tropical areas. The clinical presentation varies from flu-like symptoms to a serious presentation called Weil’s syndrome. Fever and conjunctival suffusion are present in the majority of patients. This case report describes a resident of New York City who presented initially with gastroenteritis symptoms without fever or conjunctival suffusion to develop septic shock before being diagnosed with leptospirosis.

The median busulfan AUC following PK-directed dosing was 1100 μM-min (998-1280). We did not find an association between busulfan AUC and 5-year overall survival (OS) [HR 1.001 (.999, 1.004), P = .68] or progression-free survival (PFS) [cause-specific HR .998 (.994, 1), P = .34].Toxicities were assessed per CTCAE v4.03 and grade 3-4 mucositis occurred in 63/86 patients (73.3%) and grade 3-4 hepatotoxicity in 19/86 patients (22%). Neither toxicity was correlated with busulfan AUC [Spearman's ρ .18 (-.04, .37), P = .11 and-.06 (-.27, .16), P = .6 respectively]. No patients developed sinusoidal obstruction syndrome. Results are summarized in Table 1. Notably we found an association with higher busulfan AUC and utilization of TPN (Table 2). In this cohort of patients with relapsed MM undergoing a busulfan-based conditioning regimen results validate our target busulfan AUC of 1025-1315 μM-min. Higher busulfan exposure as determined by AUC does not appear to convey improved OS or PFS within this therapeutic range. There was not a significant difference in grade 3-4 mucositis or liver toxicity, with a slight increase in the utilization of TPN when the bu-AUC was > 1100 μM-min.

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