Leptospirosis : update on management

LEPTOSPIROSIS UPDATEDr Vasif MCGMKMCH

• Zoonotic disease

• Caused by the spirochete Leptospira

• Historically known as Weil’s disease

• Described in 1885 by Adolf Weil with clinical hallmarks of

splenomegaly jaundice nephritis

INTRODUCTION

SYNONYMS

THE CAUSATIVE BACTERIUMOrder Spirochaetales – Treponema, Borrelia, Leptospira

Family – Leptospiraceae, susceptible to heat, acid

Genus – Leptospira, 26 serogroups, 250 serovars

Pathogenic: Interrogans, Nonpathogenic: biflex

Corkscrew shaped, delicate, flexible spirochete, Gram -ve

thick, coiled, flagellate, actively motile

EPIDEMIOLOGY

• Incidence of Leptospirosis in developing countries is 10 - 100/1,00,000 cases/year• Only four states (Kerala,Gujarat, Tamilnadu & Maharashtra) report more

than 500 cases per year• Incidence of Leptospirosis is 50 – 65 cases /100,000 per year in Andaman

and Nicobar Islands • Prevalence rate of Leptospirosis reported

• 38.1% from Calicut• 52.7% from Andaman and Nicobar Islands• 32.9% from Chennai (data from asymptomatic persons detected during sero surveys)

• Leptospirosis is grossly under reported because of lack of awareness of the disease and non availability of diagnostic tests• Last outbreak reported in Mumbai during 2015

LIFE CYCLE

PATHOGENESIS

•Clinical expression can beSubclinical infectionUndifferentiated febrile illnessWeil’s disease

• Incubation period 2-30 days (average 5-14 days)

CLINICAL FEATURES

• The most severe form of leptospirosis• Monophasic and fulminant• Variable combinations of jaundice, acute kidney

injury, hypotension and hemorrhage

• Pulmonary hemorrhage is the most common• Multisystem involvement occurs

WEIL’S DISEASE

•High index of suspicion is critical in a setting ofAn appropriate exposure historyInfection’s protean manifestations

• Biochemical, hematological and urinalysis may suggest but are not specific for diagnosis

DIAGNOSIS

LABORATORY TESTS

• TC / DC / ESR / Hb / Platelet count LEUCOCYTOSIS/THROMBOCYTOPENIA• Serum Bilirubin / SGOT/ SGPT / SAP• Blood Urea, Creatinine & Electrolytes HYPOKALEMIA/HYPOMAGNESEMIA• Chest X-Ray; ECG• Tests for diagnosis of Leptospirosis

• Culture for Leptospira• MAT; Sero conversion or 4 fold rise/ high titer• ELISA / MSAT• PCR

• MAT: Microscopic agglutination test• (M)SAT: Microscopic slide agglutination Test

Dark field microscopy showing Leptospira spp.

MAT INTERPRETATION• Titres peak late (2nd or 3rd week) but persist longer ( 5 to 10

years)• Less sensitive,Repeat samples needed• Single titre 1:100 significant criteria

• Endemic area 1:400• Non endemic area 1:100, 1:200• Serosurvey 1:50

• Repeat titre four fold rise / seroconversion

• Leptospires can be cultured from blood and CSF during first 7-10 days

•Urine culture useful beginning in the 2nd week

•May take 2-4 weeks to be positive

•Urine cultures can remain positive for many months/years despite therapy

ISOLATION

GUIDELINES TO DIAGNOSE

LEPTOSPIROSIS

•INDIAN GUIDELINES•WHO GUIDELINES

• Malaria• Enteric fever• Dengue/ chikungunya• Hanta virus infection• Viral hepatitis• Influenza• Rickettsial diseases

DIFFERENTIAL DIAGNOSIS

TREATMENT

SUPORTIVE TREATMENT

• Methyl Prednisolone at 1 gm daily IV for 3 days, followed by oral prednisolone at 1 mg/kg for 7 days offered benefit if given within 12 h of the onset of pulmonary manifestations

COMPLICATIONS

• Jaundice

• AKI

• Pulmonary hemorrhage

• ARDS

• Neuroleptospirosis

• Hypotension

• Thrombocytopenia

• Myocarditis

• Ocular complications

• Hypokalemic paralysis

LEPTOSPIROSIS IN PREGNANCY

• Fetal loss high in 1st trimester and near term mothers

• Congenital infections are rare and long-term serious effects have not been documented.• Hence, leptospirosis acquired in pregnancy is not an indication for its

termination• AMPICILLIN 500mg 6th hourly should be given

LEPTOSPIROSIS IN HIV• recovery slower than is usual for leptospirosis• residual renal impairment likely

LEPTOSPIROSIS WITH CONCOMITANT ILLNESS

• It is important to look for alternative infections in an appropriate setting particularly if the patient does not show clinical signs of improvement despite pathogen-directed therapy for leptospirosis as dual infections like

• DENGUE• HEPATITIS E• SCRUB TYPHUS• MALARIACan coexist concurrently

PREVENTION

CHEMOPROPHYLAXIS

VACCINE ???

•No vaccine is yet available for use in humans with proven benefit..

TAKE HOME MESSAGES

• Leptospirosis has a spectrum of clinical presentations, with a biphasic natural history.• Major systemic complications occur during the immune phase of the disease, which is

usually 5–10 days after infection.

• 2 major symptoms : fever and myalgia +/- Jaundice• 2 major signs : conjunctival suffusion and muscle tenderness

• Choice of diagnostic testing relies on accurate prediction of the infection. Acute disease is best detected by culture or PCR, and immune phase disease by serology.

• reducing the incidence of leptospirosis can be achieved by promoting the ‘cover-wash-clean up’ strategies to at risk individuals to reduce contact with infected animals or materials