Leptospirosis Treatment- Cause, Symptoms, Signs, Investigations, Treatment, Prevention.
Cause:
Clinical illness from asymptomatic to fatal kidney & liver failure.
Acute & Occasional severe treponemal infection.
Caused by- 21 species within the genus Leptospira (pathogenic species like L. Interrogans).
Organism enter through small skin lesions & may be conjunctiva.
Cases seen after swimming or rafting in contaminated water, & rice planters, sewer workers, abattoir workers, & farmers.
Other- Homeless persons who have exposed to rat urine.
Symptoms:
Anicteric leptospirosis:
Milder & more common, often biphasic.
Incubation period- usually 1-2 weeks, ranges 1-30 days.
Initial or septicemic phase- abrupt fever 39–40°C, chills, severe headache, myalgias, especially in calf muscles, bodyache, abdominal pain, marked conjunctival suffusion.
Leptospires isolated from- blood, CSF, & tissues.
organism can be cultured from blood and detected by polymerase chain reaction (PCR).
After 1- to 3-day, improvement in symptoms, absence of fever- second or “immune” phase starts; Leptospires absent from blood & CSF but present in the kidney, specific antibodies appear. Leptospires can be cultured from the urine.
A recurrence of symptoms in first phase with the onset of meningitis, diarrhea, nausea, vomiting, and adenopathy.
usually self-limited, lasting 4–30 days.
complete recovery is the rule.
Signs:
fever, muscle tenderness, conjunctival suffusion, pharyngeal injection, lymphadenopathy, rash- macular, maculopapular, hemorrhagic (petechial or ecchymotic), or erythematous, meningismus, splenomegaly & hepatomegaly.
Lung auscultation may show crackles. Mild jaundice may present
Icteric leptospirosis (Weil’s syndrome):
more severe form, impaired kidney and liver function, hypotension, abnormal mental status, hemorrhagic pneumonia, respiratory insufficiency, myocarditis & arrhythmias. & 5–40% mortality rate.
Patients die because of septic shock with multiorgan failure &/or severe bleeding complications.
Enlarged and tender liver may be seen.
Acute kidney injury is common in Weil’s syndrome: Hypotension seen in acute tubular necrosis, oliguria, or anuria.
Skeletal muscle involvement, & rhabdomyolysis. Pancreatitis (necrotizing), cholecystitis.
Investigations:
A definitive diagnosis- isolation of organism from the patient- positive PCR result, or a rise in antibody titer.
Diagnosis is usually made- by serologic tests- microscopic agglutination test (gold standard), and (ELISA) enzyme-linked immunosorbent assay.
IgM Leptospiral antibody
PCR molecular diagnostics- sensitive, specific, positive in early disease, can able to detect leptospiral DNA in urine, blood, CSF, and aqueous humor.
Early disease, the organism identified by darkfield examination.
Cultures take 1–6 weeks usually to become positive.
Organism grown from urine- tenth day to the sixth week.
Leukocyte (WBC)- normal or as high as 50,000/mcL, predominant neutrophils.
Mild to moderate thrombocytopenia.
Increased serum bilirubin with disproportionately low elevation of SGOT & SGPT. Elevated bilirubin & aminotransferases in 75%.
Increased blood urea. Elevated creatinine (more than 1.5 mg/dL) in 50% of cases.
Chest xray: non-homogenous patchy opacities if ARDS develops.
ECG: tachycardia disproportionate to fever with non-specific ST-T changes, arrhythmias..
Serum creatine kinase (CK or CPK) is usually elevated, (more in rhabdomyolysis, also serum and urine myoglobin elevated).
Leptospirosis Treatment:
Many cases are self-limited.
Mild leptospirosis-
C. Doxycycline (100 mg bid) or
C. Amoxicillin (500 mg tid) or
C. Ampicillin (500 mg PO tid)
Moderate/severe leptospirosis-
IV or IM Penicillin (1.5 million units q6h) or
IV Ceftriaxone (2 g/d) or
IV Cefotaxime (1 g q6h) or
IV Doxycycline (loading dose of 200 mg, then 100 mg q12h)
Chemoprophylaxis
C. Doxycycline (200 mg once a week) or
T. Azithromycin (250 mg once or twice a week)
I/V Pantoprazole 40mg SOS.
I/V Ondansetron 4mg SOS if nausea vomiting occur.
Requiring I/V fluid resuscitation & occasional vasopressor therapy if hypotension.
Hemodialysis can be lifesaving in acute renal failure.
Complication of rhabdomyolysis is acute renal failure, so maintain renal output & treat carefully- I/V NaHCo3 SOS, normal saline, furosemide, etc.
Regular monitoring of RFT.
Monitor fluid intake-output chart for adequate hydration.
Prevention:
Animal housing to be kept away from human dwellings. Use gloves, boots, waterproof dressings to prevent injuries and contact with infective liquids.
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