dr.

Limdawati FK UKM / RSI 2012

OUTLINE

Etiology Epidemiology Pathogenesis Clinical manifestations Laboratory and radiologic findings Diagnosis Differential diagnosis Treatment Complications Prognosis Prevention

ETIOLOGY
Most common zoonosis Spirochete disease Family : Leptospiraceae Genus : Leptospira Species : L. interrogans and L. biflexa >> 250 serovars

ETIOLOGY
Coiled Thin Highly motile Hooked ends Two periplasmic flagella 620 m x 0.1 m

ETIOLOGY
Gram negative, aerobic

Can be seen microscopically by dark-field examination and after silver impregnation staining (1907)
Require special media and conditions for growth

EPIDEMIOLOGY

EPIDEMIOLOGY
Larrey (1812) Adolph Weil (1900) US (CDC) : 40 120 cases / year

RISK FACTORS

RISK FACTORS

RISK FACTORS

RISK FACTORS

PATHOGENESIS
abrasion Intact mucous membrane Leptospiremia Skeletal muscle
Skin

Blood

Kidney

Lung

Eye

Liver

Interstitial Pulmonary Uveitis Centrilobular Focal nephritis hemorrhage necrosis necrosis Fluid leakage Tubular necrosis Renal failure Dehydration

Vasculitis

CLINICAL MANIFESTATIONS
Anicteric leptospirosis Icterohemorhagica leptospirosis (Weils disease)

CLINICAL MANIFESTATIONS

Anicteric leptospirosis
Symptoms
Acute

influenza-like illness Muscle pain (calves, back, abdomen) Sore throat and rash Intense headache (frontal, retroorbital, photophobia) Cough, chest pain, hemoptysis

CLINICAL MANIFESTATIONS

Anicteric leptospirosis

Signs
Fever Conjunctival

suffusion Muscle tenderness Pharyngeal injection Lymphadenopathy Hepato splenomegaly Mild jaundice Rashes macular, maculopapular, erythematous, urticaria, hemorrhagic

Conjunctival suffusion

CLINICAL MANIFESTATIONS

1st stage (leptospiremic phase)

Mild

flu-like syndrome Self limited disease

2nd stage (immune phase)

Less

severe Variable symptoms Coincide with antibody development Complication : aseptic meningitis Persists for several days to weeks

CLINICAL MANIFESTATIONS

Severe leptospirosis / icteric leptospirosis (Weils syndrome)

Jaundice,

renal dysfunction, hemorrhagic

diathesis Pulmonary involvement Mortality rates : 5 15% No biphasic pattern Rhabdomyolisis, hemolysis, myocarditis, pericarditis, CHF, cardiogenic shock, ARDS, necrotizing pancreatitis, multiorgan failure

LABORATORY FINDINGS

Blood
Elevated

ESR Leukocytosis, shift to the left Mild thrombocytopenia Elevated SGPT, SGOT, ALP, bilirubin, prolonged PT Elevated CK Elevated BUN, Creatinine

LABORATORY FINDINGS

Urine
Urine

sediment (leukocytes, erythrocytes, hyalin, granular casts) Mild proteinuria

RADIOLOGIC FINDINGS
Common in 3 9 days after onset of illness Patchy alveolar pattern alveolar hemorrhage Predilection : lower lobe in the periphery of lung fields

DIAGNOSIS

Definitive diagnosis
Isolation

of organisms Seroconversion or a rise in antibody titer in the serologic test Standard serologic test
MAT

: uses a battery of live Leptospiral strain ELISA : uses a broadly reacting antigen PCR : not widely available

DIAGNOSIS

Isolation of organism
Blood
Urine Culture

and CSF
:
(EMJH)

Ellinghausen-McCullough-Johnson-Harris

medium Fletcher medium and Korthof medium Positive in range 1 week 6 months (usually 2 4 weeks)

DIAGNOSIS

Dark field microscope exam of Leptospira

Do not use this exam only for definitive diagnosis

DIAGNOSIS
Serologic
Fourfold

test :

or greater rise between acute and convalescence phase serum specimen Serum antibody titer is 1/200 1/800 with strong clinical evidence Detected after 2nd week of illness False negative

DIFFERENTIAL DIAGNOSIS
Dengue Influenza Malaria Enteric fever Viral hepatitis Hantavirus infections Rickettsial diseases

TREATMENT
Indication
Mild leptospirosis

Regimen Treatment
Doxycycline 100 mg orally bid Ampicillin 500750 mg orally qid Amoxicillin, 500 mg orally qid Penicillin G, 1.5 million units IV qid Ampicillin, 1 g IV qid Amoxicillin, 1 g IV qid Ceftriaxone, 1 g IV once daily Cefotaxime, 1 g IV qid Erythromycin, 500 mg IV qid Doxycycline, 200 mg orally once a week

Moderate/severe leptospirosis

Chemoprophylaxis

All treatments above should be given for 7 days

TREATMENT

Jarisch Herxheimer reaction

Develops

within hours after the antibiotic is

started Rare event Supportive management TNF antibody role ???

TREATMENT

Weils syndrome
ICU

admission Transfusion of blood and/or platelet Dialysis may be required

COMPLICATIONS
DIC HUS TTP Vasculitis ARDS ARF

PROGNOSIS
Good prognosis Carrier (in immunologically privileged sites : brain, anterior chamber of eyes, renal tubule) Mortality rate increased ( 5 40%) in :

Elderly Weils

syndrome Immunocompromised host Pregnancy fetal death

PREVENTION

PREVENTION

PREVENTION

PREVENTION

PREVENTION

PREVENTION