Leptospirosis

Sung Chul Hwang Dept. of Pulmonary and Critical Care Medicine Ajou University School of Medicine

Introduction
Spirochetal disease, finely coiled, motile, 0.1 m x 6 20 m Systemic infection manifested as widespread vasculitis Zoonosis L. interogans 23 serogroups and 187 serovars L. biflexa : non-pathogenic, saprophyte

Historical back ground

1921 : Takaki L. icterohemorragiae 1942 : sekiguchi L. canicola from mouse 1951 : , 401 - ictohemorrhagiae 1975 : , 1984 10 : , 1984 : 9-11 leptospira

Epidemiology
Disease of the wild animals Incidental human infection by direct or indirect contact with the animal 20-40s active males: farmers or soldiers in harvest time 9-10 peak into November , , , , , ,

Reservoires of Infection
Rats Dogs Live stocks Rodents including rabbits Wild animals Cats

Sources of Human Infections

Contaminated Water or soil from infected urine Direct animal contacts Occupational exposure : farmers, vets, abattoire workers Recreational exposure : campers, swimmers, visiting graveyards

Routes of Infection
Contact with water or soil contaminated animals Direct contact with the by urine from infected source, farmer, vets, butchers, recreational activities Rodents carry EH fever, scrub typhus, paratyphus, leptospirosis Factors for high incidence : rain during harvest time, carrier rate in rodents Spirochetes survive longer in wet swampy conditions


1985.2 1986.7 : 11.69% 1987.2 1987. 7 : 5.9 % 1985 in febrile patients : 20% 1986- 1987 in febrile patients : 11.6%

1984 1985 1986 1987

: : : :

15.5% 14.9% 16% 30.9% ( , )

Microbiology and distribution

Mainly serogroup ictohemorrhagiae and canicola , , , , CH-48 : , Serovar : mainly lai

Pathogenesis
Entry sites : skin wounds or abrasions in hand and feet and mucous membranes, conjunctiva, nasal, oral Bacteremia involving the entire body including eye, CSF Systemic effect and vasculitis due to endotoxin (hyaluronidase) and burrowing motility Hemorrhagic necrosis esp. in liver, lung, and kidneys jaundice, ARF, hemorrhages

Clinical types
Types 1986 1987

Pneumonitis Rash type Weils disease

Renal failure Flue-like Acute Hepatitis Combination

33% 17% 15% 13% 15% 8%

57.7%

53.8% 13.5% 86.5%

Phase I (Septicemic)
Following incubation period of 7-10 days High spiking fever, headaches, myalgia, arthralgias Lasting 4 7 days Proteinuria and increased creatinnine Organism detectable but serologic diagnosis not possible

Phase II (Immune)
Much more variable Induction of IgM Antibodies 1- 3 day freedom recurrence of symptoms Lower fever, CNS signs Maybe cultured from urine but not from blood or CSF

Weils Disease
Less common but severe form Mild phase I, initially Followed by severe Jaundice , Azotemia, and Hemorrhage from Lungs, GI tract, and other organs (3-6 day) Oliguric renal failure and Liver dysfunction dominate the clinical picture

Clinical Signs of Leptospirosis

Pulmonary infiltrates, pneumonitis, hemorrhages Conjunctival injection Jaundice Muscle tenderness Abdominal tenderness CVA tenderness Abnormal auscultation Erythema, petechiae, neck stiffness, adenopathy

Lab. Diagnosis
Microbiologic identification : Blood or CSF first 10 days Urine second week (Fletchers, EMJH Medium) Serology: screeningMicroscopic Slide Agglutination (MST), titration & serogroup identification Microscopic Agglutination (MAT), detection of IgM (ELISA)

Chest X-rays
33 64 % of patientssjows abnormality Bilateral nodules, rosette densities Diffuse ill-defined infiltrates Massive confluent consolidation Bilateral, Non-lobar, peripheral predominance Rare pleural reaction Complete resolution within 5 to 10 days

Treatment
Early anti-microbial therapy is importantshorten the course and prevent carrier state Choice : Penicillin G, Ampicillin May cause Jarish-Huxheimer type reaction Mild cases oral Doxycycline or Amoxicillin

Prevention
Vaccination of domestic animals Rodent control Protective gloves and boots Avoid swimming in contaminated waters Vaccination in endemic region

Differential Diagnosis
EH fever Rickettsial disease : Scrub typhus, murine typhus Acute viral hepatitis Sepsis Influenza Aseptic Meningitis

Conjunctival hemorrhage in leptospirosis