Case of Leptospirosis
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Transcript of Case of Leptospirosis
FeverFeverWeaknessWeaknessVomitingVomitingAnorexiaAnorexiaCough/coldCough/cold
EpistaxisEpistaxisJaundiceJaundicedyspnea dyspnea Abdominal painAbdominal painDiarrheaDiarrheaTea colored urineTea colored urine
Symptoms
Physical Physical examinationexamination
Weak lookingWeak lookingGasping respirationGasping respirationHypotensionHypotensionBradycardiaBradycardiaGeneralized JaundiceGeneralized JaundiceCool, blotchy,congested Cool, blotchy,congested
skinskinPale palpebral conjunctivaePale palpebral conjunctivaeIcteric ScleraeIcteric ScleraeCircumoral cyanosisCircumoral cyanosisPalpable Cervical lymph Palpable Cervical lymph
nodenode
Decreased vocal and Decreased vocal and tactile fremitustactile fremitus
HepatosplenomegalyHepatosplenomegalyPale nailbedsPale nailbedsRapid and weak pulsesRapid and weak pulsesProlonged CRTProlonged CRT
LethargicLethargicanisocoriaanisocoria(+) left lateral gaze(+) left lateral gaze(+) weak gag reflex(+) weak gag reflexSluggish reaction toSluggish reaction topainful stimuluspainful stimulus
No clonusNo clonusNo nuchal rigidityNo nuchal rigidity
Neurologic examinationNeurologic examination
LeukopeniaLeukopeniaThrombocytopeniaThrombocytopeniaProlonged APTT, PTProlonged APTT, PTHyperkalamiaHyperkalamiaMetabolic AcidosisMetabolic Acidosis
Laboratory resultsLaboratory results
Social HistorySocial History
Salient FeaturesSalient Features
Weak lookingWeak lookingGasping respirationGasping respirationHypotensionHypotensionBradycardiaBradycardiaCool, blotchy,congested skinCool, blotchy,congested skinPale palpebral conjunctivaePale palpebral conjunctivaeCircumoral cyanosisCircumoral cyanosis
DIC
FEVER +JAUNDICE+ HEPATOMEGALY
Acute Chronic
Hepatitis A
Hemolytic Uremic Syndrome
Dengue Hemorrhagic Fever
Malaria
Typhoid Fever
Leptospirosis
Incubation Period 28 days
Range2 weeks- 6 months
FeverNausea
VomitingAnorexia
Abdominal PainDiarrhea
Direct Cell Injury
Cholestasis Jaundice
InadequateLiver function
Prolonged Coagulation Parameters
LIVER NECROSIS
FEVER +JAUNDICE+ HEPATOMEGALY
Acute
Hepatitis A
Hemolytic Uremic Syndrome
Dengue Hemorrhagic Fever
Malaria
Typhoid Fever
Leptospirosis
Ingestion of bacteria
Inflammation/ulceration of colon
Endothelial cell injury HemolysisFlu-like symptoms
Platelet aggregationThrombocytopenia Anemia Pallor
Hepatosplenomegaly Thrombosis/ischemia
BLOODY DIARRHEA
LEUKOCYTOSIS
NOMAL COAGULATION PARAMETERS
FEVER +JAUNDICE+ HEPATOMEGALY
Acute
Hemolytic Uremic Syndrome
Dengue Hemorrhagic Fever
Malaria
Typhoid Fever
Leptospirosis
Fever
Abdominal Pain
AnorexiaWeakness
Cough & Cold
Anemia
Thrombocytopenia
Leukopenia
HepatosplenomegalyGeneralized Jaundice
NO SEVERE ANEMIA
FEVER +JAUNDICE+ HEPATOMEGALY
Acute
Dengue Hemorrhagic Fever
Malaria
Typhoid Fever
Leptospirosis
Incubation Period 2-7 days
Fever
AnorexiaWeakness
Vomiting
Abdominal PainCough
Disorder in Hemostasis
Platelet Dysfunction
Coagulopathy
Bleeding
Thrombocytopenia
Leukopenia
DURATION
NO HEMOCONCENTRATION
Liver Injury
FEVER +JAUNDICE+ HEPATOMEGALY
Acute
Dengue Hemorrhagic Fever
Typhoid Fever
Leptospirosis
10-14 Days
Fever
MalaiseAnorexiaCough
Abdominal Pain
Cholestasis & Hepatitis
Nephritis Renal Failure
Genealized Jaundice
Hepatomegaly
Tea colored Urine
Hyperkalemia Splenomegaly
Respiratory Distress
1st Week
2nd Week
FEVER +JAUNDICE+ HEPATOMEGALY
Acute
Typhoid Fever
Leptospirosis
LEPTOSPIROSIS
Icteric Form
Septicemic Phase Immune
PhaseImmune Phase
Septicemic Phase
(3 - 7 Days) (0 - 1 Month)(3 - 7 Days) (10 - 30 Days)
Anicteric Form* 5-10%
*18th Ed Nelson Textbook of Pediatrics
Part A ,
Part A + Part B together Score26 or more
or
PART A + B + C
25 or more
or
score between score between 20 and 2520 and 25
Fever?Fever? Yes=2Yes=2No= 0No= 0
22
If “Yes” is the temp 39C or moreIf “Yes” is the temp 39C or more Yes=2Yes=2No= 0No= 0
22
Jaundice?Jaundice? Yes=1Yes=1No= 0No= 0
11
Total ScoreTotal Score 55
Part APart A ScoreScore
Part BPart B ScoreScoreEpidemilogigal Factors: contact with Epidemilogigal Factors: contact with animals at home,work travel or contact animals at home,work travel or contact with known contaminated waterwith known contaminated water
Yes=10Yes=10 1010
TotalScore A+BTotalScore A+B 1515
Has the patient Headache of sudden onset Has the patient Headache of sudden onset Yes=2Yes=2No= 0No= 0
22
Fever?Fever? Yes=2Yes=2No= 0No= 0
22
If “Yes” is the temp 39C or moreIf “Yes” is the temp 39C or more Yes=2Yes=2No= 0No= 0
22
Conjuntival Suffusion?Conjuntival Suffusion? Yes=4Yes=4No= 0No= 0
44
MeningismMeningism Yes=4Yes=4No= 0No= 0
00
Are all three features (conjuntival Are all three features (conjuntival suffusion,muscle pains and meningism suffusion,muscle pains and meningism present together?present together?
Yes=10Yes=10 00
Jaundice?Jaundice? Yes=1Yes=1No= 0No= 0
11
Albuminuria or Nitrogen retentionAlbuminuria or Nitrogen retention Yes=2Yes=2No= 0No= 0
22
Total ScoreTotal Score 1313
Part APart A ScoreScore
Part BPart B ScoreScoreEpidemilogigal Factors: contact with Epidemilogigal Factors: contact with animals at home,work travel or contact animals at home,work travel or contact with known contaminated waterwith known contaminated water
Yes=10Yes=10 1010
TotalScore A+BTotalScore A+B 2323
Part CPart CBacteriologicallaboratory findings?Bacteriologicallaboratory findings? DiagnosisCriteriaDiagnosisCriteriaPositive serology-leptospirosis endemicPositive serology-leptospirosis endemic Single positive, low titer Single positive, low titer Yes=2Yes=2
No=0No=0 Single positive, high titer Single positive, high titer Yes=10Yes=10
No=0No=0 Paired Sera,rising TiterPaired Sera,rising Titer Yes=25Yes=25
No=0No=0Positive serology,leptospirosis not Positive serology,leptospirosis not endemicendemic Single positive, low titer Single positive, low titer Yes=5Yes=5
No=0No=0 Single positive, high titer Single positive, high titer Yes=15Yes=15
No=0No=0 Paired Sera,rising TiterPaired Sera,rising Titer Yes=25Yes=25
No=0No=0Total ScoreTotal ScoreA+B+CA+B+C
Infected Urine & Excreta
PATHOGENESIS
Endotoxin
Flu-like symptoms(fever,cough &colds,diarrhea
leukopenia thrombocytopenia)
Hemorrhagic Diasthesis
Septicemic Phase
Endothelial damage to the different
organ system of the body
Multiorgan Dysfunction
Immune Phase
Pulmonary Liver CardiacRenal
RENAL FAILURE
HEPATICFAILURE
HEMORRHAGIC DIASTHESIS+ +
Hypovolemia
Circulatory CollapseCirculatory Collapse
Multiple Organ FailureMultiple Organ Failure
DEATHDEATH
Hypotension&
Dehydration
MULTIPLE ORGAN FAILURE MULTIPLE ORGAN FAILURE SECONDARY TO WEIL’S DISEASESECONDARY TO WEIL’S DISEASE
THANK YOU !THANK YOU !
PULMONARY20-70%
Endothelial damage to capillaries
Interstitial and Alveolar Hemorrhage
Parenchymal Cells
Necrosis
Decreased Vocal & Tactile Fremitus
Respiratory Distress
Acute Inflammation
Pneumonia
5th edition Textbook of Infectious Diseases by Feigin
LIVER
Centrilobular Necrosis with Kupffer Proliferation
Hepatic Dysfunction
HEPATOCELLULARHEPATOCELLULAR INJURYINJURY
Jaundice AnemiaHemoglobin 104
Prolonged APTT (62.5 sec)&PT(56.5 sec)
Thrombocytopenia
Hepatomegaly
HEMOLYSISHEMOLYSIS
Cardiac Dysfunction
Hypoperfusion
Prolonged Capillary Time
HypotensionTachycardia
Rapid & Weak Pulses
Hypovolemia Electrolyte Imbalance
Hyperkalemia
RENAL
TubularTubularnecrosisnecrosis
Interstitial Interstitial NephritisNephritis
tea colored tea colored urineurine
Renal FailureRenal Failure
DehydrationDehydration
HyperkalemiaHyperkalemia
Widespread damage of capillary endotheliumWidespread damage of capillary endothelium
Hemorrhagic DiasthesisHemorrhagic Diasthesis
GI BleedingGI Bleeding
Blood streaked Vomitus
PulmonaryPulmonaryHemorrhageHemorrhage
IntracranialIntracranial BleedBleed
Uncal Uncal herniationherniation
anisocoriaanisocoria
lethargylethargylateral lateral gazegaze
DyspneaDyspnea
Cough
Primary Hemostasis Secondary Hemostasis
Thrombocytopenia
Prolonged APTT/PT
FibrinolysisBone marrow supression
INCIDENCE Leptospirosis is a worldwide zoonotic infection and now identified as
one of the emerging infectious diseases
Endemic with estimated incidence of 25 clinical infection per 100,000 population
Significant outbreaks in Nicaragua, Brazil, India, Malaysia & USA
Large clusters of cases were noted following flooding as a result of excessive rainfall
Human infection is either direct or indirect contact with the urine of an infected animal, higher in warm-climate countries
Chain of TransmissionAnimal Species :
Rodents Cattles
Domestic animals
Human Infections: Occupational
Direct Contact• farmers• veterinarians• abattoir workers• meat inspectors Indirect• sewers • miners • soldiers• septic tank cleaners• canal workers
Recreational water sports, swimming,
canoeing, water rafting, potholing, caving
Avocational exposures barefoot walking ,
flood swimming
Serological Classification & Groupings Hosts Serogroups
RATS L. Icterohaemorrhagiae MICE L. Ballum
DAIRY CATTLES L. Hardjo, Pomona DOGS L. Canicola
SHEEP L. Hardjo PIGS L. Pomona, Tarassovi
HUMANS L. Icterohaemorrhagiae
PORTOF
ENTRY
LEPTOSPIRES
ConjunctivaMucous MembraneMouthAbraded SkinOpen wounds
Adhesion to Cell Surfacesand Cellular Toxicity
Small Blood Vessel –vasculitis
Kidney – interstitial nephritis&
tubular necrosis
Liver – centrilubular necrosis
Skeletal Muscles – swelling ,
focal necrosis
CLINICAL FEATURES
Incubation Period - 2 – 25 days after initial direct exposure
to the urine or tissue of an infected animal
Biphasic stages Anicteric Leptospirosis
1 .Acute leptospiremic phase - - Non-specific flu-like symptoms as fever and chills ,
severe headache usually frontal and retrobulbar w/photophobia nausea and vomiting
muscle pain affecting the calves, back and abdomen mental confusion pulmonary involvement as cough with some hemoptysis - Signs of conjunctival suffusion is evident less common are myalgias, lymphadenoathy, hepatosplenomegaly, rashes in any form
CLINICAL FEATURES
2. Immune leptospiremic phase
- asymptomatic for a week, and illness recur within a few days in some
- aseptic meningitis may develop in some patient for certain duration
- however, in a few cases complication such iritis, iridocyclitis and
chorioretinitis may occur.
CLINICAL FEATURESSevere Leptospirosis (Weil’s Syndrome)
1. Jaundice
2. Renal dysfunction
3. Hemorrhagic diasthesis
-Infection is associated with serovars L. icterohemorrhagiae and copenhagen
-Within 4 – 9 days, jaundice and vascular dysfunction generally develop.
-Renal failure within 2-3 weeks after, however, reversible if attended
-Pulmonary involvement with cough, dyspnea, chest pain and blood- stain sputum
-Hemorrhagic manifestations e.g. epistaxis, petechiae, purpura and eechymoses
GI bleeding, adrenal and subarachnoid hemorrhage are seen
-Rhabdomyolysis, myocarditis, CHF, cardiogenic shock, ARDS, and multi-organ failure are seen
LABORATORY & RADIOLOGIC FINDINGS
URINALYSIS - urine sediments changes leokocytes, erythrocytes, hyaline or granular
casts, with mild proteinuria
ESR - elevated (anicteric leptospirosis) peripheral leukocyte count range from 3,000 to
26,000/Ul with left shift; (Weil’s Syndrome) marked leukocytosis
THROMBOCYTOPENIA - in about 50% of patients implying renal failure
LIVER ENZYMES - are noted to be elevated up to up to 200U/L (alkaline phosphatase
and aminotransferase)
PROTHROMBINE TIME - is prolonged in Weil’s however can be corrected by Vit K
CSF - slightly elevated protein, normal glucose level but there is increase of polymorphs
followed by mononuclear cell increases
RADIOGRAPHIC FINDINGS - the affected lower lobes shows patchy alveolar pattern
that corresponds to alveolar hemorrhages
DIAGNOSIS
Definitive Diagnosis Isolation of the organism from the patient
Seroconversion or rise in antibody titer in MAT
Presumptive MAT with antibody titer of >1:100
Positive macroscopic slide agglutination test Presence of compatible clinical illness
DIAGNOSIS
ANTIGEN DETECTION
MICROSCOPIC AGGLUTINATION TEST ( MAT )
- reference method for serological diagnosis of leptospirosis
- patient sera is mixed with live antigen suspensions of leptospiral serovars
- after incubation, the serum-antigen mixture are examined microscopically for
agglutination and titers are determined
CDC case definition, a titer of >200 = probable case w/clinically compatible illness
Endemic Countries: a single titer of >800 in symptomatic patients is indicative of Lep
Acute Infection: may go as high as >25,600
DIAGNOSIS
ENZYME-LINK IMMUNOASSAY ( ELISA )
- use to detect IgM antibodies for diagnosis of human leptospira infection
- useful towards detection of serovar-specific antibodies for detection of infection
in food animals, detection of serovar pomona and hardjo infection in cattle
- IgM-specific dot-ELISA was developed and use to detect IgG and IgA anibodies
and shown to be sensitive
MACROSCOPIC SLIDE AGGLUTINATION TEST
-used for detection of 12 serovars for rapid screening of sera from humans & animals
- a new commercial slide agglutination assay was found to be as sensitive and
specific as an IgM-ELISA while remaining reactive for a shorter time after recovery
DIAGNOSIS
INDIRECT HEMAGGLUTINATION ASSAY ( IHA )
- use to detect both IgM and IgG antibodies
- it was developed at CDC and shown to have a sensitivity of 92% and a specificity
of 95% for serological diagnosis of leptospirosis
MICROCAPSULE AGGLUTINATION TEST (MCAT)
-using a synthetic polymer in place of RBC and has been extensively evaluated in
Japan and China
- more sensitive than MAT and IgM-ELISA in acute phase samples
- this is a direct agglutination method
POLYMERASE CHAIN REACTION ( PCR )
- use for detection of Leptospiral DNA, more sensitive than culture
- has been used to distinguish pathogenic from non-pathogenic serovars
DIAGNOSIS
CULTURE OF THE ORGANISM
- leptospire can be detected from blood and CSF during the first 10 days of illness
- while in urine for several weeks beginning within the 1st week
- cultures may become positive after 2 to 4 weeks ranging from 2 weeks to 4 months
- sometimes urine culture remain positive for months or years from the start of illness
-
TREATMENT
Mild Cases of Leptospirosis - Oral Tetracycline, Doxycycline, Ampicillin and Amoxycillin
Severe Leptospirosis - Intravenous Penicillin-G, Amoxycillin, Ampicillin or Erythromycin
- Weil’s syndrome may require dialysis for renal failure, may need
transfusion of whole blood/or platelets
Hepa AHepa A