Leptospirosis
Hospitalist Conference 17 y.o. male CC: Fever and rash PMHx: RLL Pneumonia 1998 Mononucleosis 2005 MEDs: None Allergies: Penicillins - rash Social Hx: Lives with parents Junior in High School Works on family farm Alcohol: None Tobacco: 1 pack/wk Family Hx: Hypertension: Father Colon Cancer: PGF Case Conference 17 y.o. male CC: Fever and rash PMHx: RLL Pneumonia 1998 Mononucleosis 2005 MEDs: None Allergies: Penicillins - rash Social Hx: Lives with parents Junior in High School Works on family farm Alcohol: None Tobacco: 1 pack/wk Family Hx: Hypertension: Father Colon Cancer: PGF HPI: Felt well until 1 week ago Developed headache and neck pain No vision changes, mild sore throat After 3 days, noted fevers to 100.6 Seen in New Ulm ED Case Conference 17 y.o. male CC: Fever and rash PMHx: RLL Pneumonia 1998 Mononucleosis 2005 MEDs: None Allergies: Penicillins - rash Social Hx: Lives with parents Junior in High School Works on family farm Alcohol: None Tobacco: 1 pack/wk Family Hx: Hypertension: Father Colon Cancer: PGF HPI: Felt well until 1 week ago Developed headache and neck pain No vision changes, mild sore throat After 3 days, noted fevers to 100.6 Seen in New Ulm ED HPI Continued: Throat culture and mono spot negative LP not done Discharged with Tylenol and Advil 3 days later, fever to 102 with nausea Diffuse, non-pruritic rash “blotches” no raised lesions or blisters Rash involved trunk, back and thighs Recurrent fever to 102.7 – returned to ED Labs: 3.0 14.2 46 Neut: 69% Lymph 23% West Nile IgG, IgM sent CXR: No acute disease 17 y.o. male CC: Fever and rash Case Conference HPI Continued: Discharged from ED Thought to be viral etiology Slept 20 hours next day Fevers to 104.4 PMD referred pt to ANW ED ROS: Positive for fatigue, fevers and chills, decreased appetite, nausea, vomiting and diarrhea No cough or sputum, no SOB No recent sick contacts No recent tick bites or travel Exam: Vitals: HR 105 BP 124/58 T 102.8 RR 16 O2 97% HEENT: no scleral icterus, injected bilaterally Resp: CTA CV: Tachycardic, regular Abdomen: soft, non-tender, bowel sounds present Neuro: Alert and oriented x3, CN II-XII intact, strength 5/5 bilaterally, reflexes 2+ Skin: Diffuse erythematous rash on chest, back, abdomen with reticular appearing rash on arms 17 y.o. male CC: Fever and rash Case Conference Labs: Alk Phos: 214 Hepatitis Serology: Negative 135 97 20 34 2.8 96 AST: 305 HIV: Negative 22 3.8 1.3 Blood Cultures: No Growth ALT: 277 HPI Continued: 13.8 Ehrlichia: Negative T. bili: 2.0 Seen by ID West Nile IgM, IgG: Negative Additional History: Assisted on a pig farm during the summer Bitten by a pig 2 months prior – resolved 850 pigs died during heat wave when fan in barn malfunctioned patient assisted with disposing of dead pigs – did not use gloves or mask Empirically started on Doxycycline for presumed Leptospirosis IgG and IgM serology, Lepto urine and blood cultures 17 y.o. male CC: Fever and rash Case Conference Labs: 2.8 13.8 Alk Phos: 214 Hepatitis Serology: Negative 135 97 20 34 96 AST: 305 HIV: Negative 22 3.8 1.3 Blood Cultures: No Growth ALT: 277 T. bili: 2.0 Ehrlichia: Negative West Nile IgM, IgG: Negative LEPTOSPIROSIS History A zoonosis caused by the spirochete leptospira interrogans 1883: First recognized as an occupational disease of sewer workers 1886: Weil’s disease Named after Adolph Weil who described the disease as: “an acute infectious disease with enlargement of spleen, jaundice, and nephritis” This is most severe form of leptospirosis 1907: Stimpson, first isolate Epidemiology Worldwide distribution Most cases occur in tropics Thailand: 30-fold increased in cases from 1995-2000 In US, most cases are in southern and Pacific coastal states Hawaii has most cases of any state in US Outbreaks can occur Hypothesis: increased rat population and seasonal flooding 12% of athletes participating in Illinois triathlon after exposure to lake water in swimming phase Areas with high rat population and seasonal flooding have the highest incidence At Risk Populations Occupational Exposure: Recreational Activities: Farmers, veterinarians, sewer workers, rice field workers Fresh water swimming, canoeing, kayaking Household Exposures: Domesticated livestock, infestation by infected rodents Pathogenesis Humans become infected after exposure to environmental sources: Animal urine (wild and domestic mammals especially rodents, cattle, swine, dogs, horses, sheep, and goats) Contaminated soil or water Infected animal tissue Portals of entry: Abraded skin Mucous membranes Conjunctiva Incubation period 7-12 days Clinical Course 90% of patients have mild symptoms while 5-10% have severe form with jaundice (Weil’s Disease) Natural course has 2 distinct phases: First Stage (Leptospiremic): Lasts 4-7 days Non-specific flu-like symptoms Fevers, chills, sore throat, headaches, myalgias, rash Second Stage (Immune or Leptospiruric): Lasts up to 30 days Circulating antibodies may be detected Organism may be isolated from urine Meningeal symptoms in 50% of patients Viral etiology may be suspected Exam findings During First Stage: Fevers, pharyngeal injection, lymphadenopathy Conjunctival suffusion: Conjunctival redness due to increased blood flow During Second Stage: Adenopathy, rash, fever Jaundice, splenomegaly, abdominal tenderness Advanced Disease – Weil’s Syndrome Severe form of leptospirosis characterized by profound jaundice, renal dysfunction, hepatic necrosis, and hemorrhagic diathesis Criteria for diagnosis are not well defined Complications include: Renal failure, uveitis, hemorrhage, ARDS, myocarditis, rhabdomyolysis, liver failure Mortality rate of 5-10% Some studies suggest case fatality rates of 20-40% Laboratory Findings Thrombocytopenia Leukocytosis with left shift Elevations of transaminases (<200) in 40% of patients Elevated CK in up to 50% of patients UA with proteinuria CSF may show a neutrophilic or lymphocytic pleocytosis with normal protein and glucose CDC Diagnostic Criteria Diagnosis Culture: Blood CSF Positive in 1st 10 days of illness Isolation successful in only 50% of cases Positive in 1st 10 days of illness Urine Becomes positive in 2nd week of illness May remain positive for up to 30 days after resolution of symptoms Diagnosis Serology: Microscopic agglutination test (MAT), macroscopic agglutination test, indirect hemagglutination, and ELISA Gold standard is MAT, but is not widely available Most common tests used in clinical practice: Microplate IgM ELISA IgM dot-ELISA dipstick If one of these is positive, sera for MAT can be sent to CDC PCR is being explored and showing some promise in diagnosis, but is not yet widely available Treatment Antibiotic treatment for one week Doxycycline 100 mg IV or po q 12 hrs Ampicillin 500 - 1000 mg IV q 6 hrs Penicillin G 3-4 million units IV q 4 hrs Penicillin G 1.5 million units IV q 6 hrs Ceftriaxone 1 gram IV qd
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