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leptospirosis

leptospirosis

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Published by: somebody_ma on Sep 23, 2010
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09/19/2013

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The theme of the lesson:
LEPTOSPIROSIS
The causative agents:
about 200 pathogenic and about 60 saprophiticserotypes of Leptospira are known. Leptospira of 13 serogroups, 27 serotypesare distinguished in Russia. The most common serogroups are: Pomona,Hebdomatis, Grippotyphosa, Canicola, Tarassovi.
The source of the infection:
wild and domestic animals – mice and rats,dogs, pigs, cattle and others. Transmission of the infection among animalshappens through water and fodder. The infection is zoonotic. A man becomesinfected during a contact of skin and mucous membranes with water,contaminated with excrements of animals, as well as through foodstuffs, cuttingmeat.
 Pathogenesis:
Leptospira propagate during the incubation period in liver,lymph nodes and other organs, then they penetrate into blood – leptospiremiadevelops. Toxins of Leptospira affect walls of blood vessels and coagulatory blood system. Leptospira are hepatotropic, they fix in liver. С blood flowLeptospira are also spread in other internal organs – skeletal muscles, kidneys,myocardium, quite often – in
 
cerebrospinal fluid. Toxico-
 
infectious changeshappen in kidneys, in severe cases – they are evident, with derangement of nitrogen metabolism. Epithelium of renal tubules, cortex and subcortex of kidneys are damaged. Leptospira remain in kidneys for a long time – up to 40days. Mesenchymal hepatitis progresses in liver destructive and necroticchanges in parenchyma without evident damage of hepatocytes.
Clinical presentation
The incubation period – is from 4 to 14 days.The onset is acute, severe chill appears, temperature rises to 39-40
о
С,headache intensifies. Typical signs are muscle pains, especially ingastrocnemius muscles. A lot of patients have low back pains. Fever remainsduring 5-9 days (sometimes – up to 11 days), it has a remittent or permanentcharacter, quite often it is dual-frequency. Against a background of the fever muscle pains increase, hyperesthesia is possible. Face is puffy. Skin of face andneck is hyperemic, sclerae are injected, in a number of cases exanthema isdetected morbilliform, scarlet-fever-like or urticarial. Conjunctivitis is possible.Most of the patients have signs of renal affection up to acute renalfailure (ARF). Palpation of lumbar region can be painful (both because of muscle pains and as a result of lesions of kidneys) or painless. In urine there aresigns of toxico-infectious damage of kidneys, in severe cases uremia developsand intoxication augments against a background of ARF.Hepatomegaly is registered. In case of a severe clinical course of leptospirosis hepatic function is impaired; icterus can appear (an icteric form is
 
distinguished). Thrombohemorrhagic syndrome is possible; appearance of erosions, hemorrhages in stomach and bowels is typical, in severe casessometimes hemoptysis, uterine bleedings appear. Severity and outcome of thedisease are determined by presence of ARF and hepatorenal syndrome.
Complications:
acute renal failure, serous meningitis (in 10-35% of the patients), encephalitis, myocarditis, ocular lesions – especially of iris. During anearly recovery a recurrence of the disease is possible – after 5-10 days of apyrexia.
 Laboratory examinations
:
In common blood analysis the followingdeviations are detected: anemia, moderate leukocytosis with neutrophilic leftshift, a sharp increase of ESR – up to 50-60 mm/h. These derangements arecaused by a toxic effect of Leptospira on bone marrow and destruction of erythrocytes. Quantity of thrombocytes and blood coagulability also decrease.In common urine analysis in case of mild leptospirosis moderate proteinuria is detected – up to 1 g/l, in urinary sediment – there are hyaline andgranular cylinders, single erythrocytes. In case of a severe clinical course of thedisease these deviations are more significant: microhematuria is observed, bile pigments are detected owing to compromised liver function; diuresis is reduced.In case of mild and especially – severe course of leptospirosis biochemicalanalyses are necessary:In case of liver injury (with icteric syndrome or without it) there is anincrease of bilirubin level, to a lesser extent – of other rates,In case of a significant renal affection and development of ARF – there isan increase in levels of creatinine and rest nitrogen.
Laboratory diagnostics
A direct microscopy of Leptospira in a dark field is possible (method of “acrushed drop”; blood, urine are
 
analyzed), inoculation of blood, urine and liquor (the growth is slow). More often
 serum
diagnostics is used: reaction of agglutination-lysis, microagglutination (diagnostic titer – is 1:100), CFT.Antibodies remain in blood during many years.
Treatment 
Antibiotic therapy is necessary in early periods. An agent of choice is penicillin, its daily dose is 6-12 million Units, in severe cases – up to 20 millionUnits per day. Use of tetracyclines is possible (doxycycline by 0.1 g 2 times aday, the course – is 7 days). Preparations of reserve – are amoxiclav, ampicillin.Antibiotic therapy is carried out during 7-10 days or till the 6-8
th
day of normaltemperature because there is a probability of relapse (a new “wave”) of leptospirosis.
2
 
Leptospiral immunoglobulin (after a preliminary desensitization) is prescribed if the clinical course is severe: during the 1
st
day 10.0 ml, during the2-3
d
days of the treatment – by 5.0 ml intramuscularly.Pathogenetic therapy is emphasized in case of a severe clinical course of leptospirosis, especially – if there is acute renal failure and DIC-syndrome.Parenteral introduction of isotonic solutions of glucose (5% solution – 500.0 ml)and sodium chloride (0.9% solution – 500.0 ml) with ascorbic acid, calcium preparations,
 
aminocapronic acid is used; in case of intense muscle pains – analgesics. Treatment of ARF is expounded in section “HFRS”.
 Hospitalization
is necessary by clinical indications.
 Isolation
of contact people is not carried out.
 Discharge
 – is performed after clinical recovery. After the discharge therecovered people are subject to regular medical check-up during 6 months:depending on a lesion of a system during an acute period later on supervision of nephrologist, neurologist, ophthalmologist is required.
CONDUCTION OF THE LESSON
The aim is – to learn how to diagnose leptospirosis according to clinicaldata, epidemiological anamnesis, laboratory examination, as well as to plan thetreatment.
Control questions at the beginning of the lesson:
1.
Where the disease is common?
2.
 Name the source of the infection in case of leptospirosis
3.
Is a man a source of the infection in case of leptospirosis?
4.
Channels of leptospirosis
5.
What happens in kidneys, liver and vessels in case of leptospirosis?
6.
 Name clinical signs, which are typical of leptospirosis
7.
Which symptoms indicate a severe clinical course of leptospirosis?
8.
 Name complications of leptospirosis
9.
 Name laboratory methods of confirmation of the diagnosis
10.
Name groups of preparations for treatment of leptospirosisTo discuss the theme of the lesson a student manages a patient, makes a brief report about the patient’s history (in the absence of the patient withleptospirosis in the department). It is necessary to find out the following dataabout the patient:Surname, name, patronymic name; age, place of work and residence (city,village), date of the falling ill;
3

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