Leptospirosi

Rochelle Veronica Miravalles

BSN IV – F

San Lazaro Hospital

Aida Iran RN, MAN

 LEPTOSPIROSIS

Leptospirosis, also known as canicola fever, hemorrhagic jaundice, infectious

jaundice, mud fever, spirochetal jaundice, swamp fever, swineherd's disease,

caver's flu or sewerman's flu, is a disease that is caused by pathogenic spirochetes

of the genus Leptospira. It is considered the most common zoonosis in the world.

Leptospirosis has recently been recognized as a re-emerging infectious disease

among animals and humans1 and has the potential to become even more prevalent

with anticipated global warming. Leptospirosis is distributed worldwide (sparing the

polar regions) but is most common in the tropics.

Humans and a wide range of animals, including mammals, birds, amphibians,

and reptiles can develop Leptospira infection. However, humans are rarely chronic

carriers and are therefore considered accidental hosts. Leptospirosis is transmitted

via direct contact with the body fluid of an acutely infected animal or by exposure to

soil or fresh water contaminated with the urine of an animal that is a chronic carrier.

Human leptospirosis is often acquired via contact with fresh water

contaminated by bovine, rat, or canine urine as part of occupational contact with

these animals. The disease is also acquired during adventure travel or vacations

that involve water sports or hiking, or even as a consequence of flooding.

is a bacterial infection resulting from exposure to the Leptospira interrogans

bacterium. Human leptospirosis can be a difficult infection to describe, as the

symptoms can vary dramatically between patients. Some symptoms are extremely

common, but only a small number of patients will experience the severe life-

threatening illness known as Weil's disease. The severity of the infection depends
on the age and general health of the patient, plus the serovar (strain) of bacteria

involved and the number of bacteria that entered the patient's body.

The infection is usually systemic (affecting the whole body) and causes a

sudden fever. In mild cases it lasts a few days, following a pattern similar to flu but

often in two phases - a period of illness lasting a few days, then a slight recovery,

then a second period of illness. In mild cases the second phase lasts a short time

and the patient recovers, but in severe types the illness develops and progresses

rapidly, leading to organ failure and often death if not treated with intervention and

support.

Leptospirosis is primarily an occupational disease that affects farmers,

veterinarians, sewer workers or others whose occupation involves contact with

animals, especially rats. It is spread mainly by the urine of infected animals and is

generally not transmitted from person to person.

INCUBATION TIME

From the time you were infected with the bacteria, there is a period where it

has to reproduce enough to cause illness - called the 'incubation time'. With human

leptospirosis this is typically 3 to 21 days, with most patients developing illness

after about 3 to 14 days. It does not usually take more than 28 days, but in rare

cases very long incubation periods have been reported. It generally cannot show

illness in less than 24 hours unless the volume of bacteria taken into the

bloodstream was massively larger than normal.

PERIOD OF COMMUNICABILITY

Leptospira are found in the urine between 10 – 20 days after onset.

SOURCES OF INFECTIONS

Contaminated food and water, and infected wild life and domestic animals

especially rodents.

• RATS ( L. leterohemoragaie) – the Weil;s disease frequently observed among

miners,

sewer, and abattoir workers.

• DOGS ( L. canicola) – observed in veteranians, breeders, and owners of the

dogs.

• MICE ( L. grippotyphosa) – attacks farmers and flax workers.

• RATS ( L. bataviae) – attacks rice – field worker.

MODE of TRANSMISSION

It can be accuired through ingestionor contact with the skin and mucous

membrane such as eyes, nose, mouth or through a break on skin with the infected

urine or carcasses of wild and domestic animals. Leptospira enters the blood to
cause damge therafter, the kidneys, the liver, meniges and conjuctivae. It is

contagious as long as it is still moist. Although rats, mice and voles are important

primary host, a wide range of other mammals including deer, rabbits, hedgehog,

cows, sheep, raccoons, possums, skunks, and even certain marine mammals are

also able to carry and transmit the disease as secondary hosts.

Dogs may lick the urine of an infected animal off the grass or soil, or drik

from an infected puddle. There have been reports of “ house dogs” contracting

leptospirosis apparently from licking the urine of infected mice that entered the

house. The type of habitats most likely to carry infective bacteria are muddy

riverbanks, ditches, gulleys and muddy livestock rearing areas where there is a

regular passage of either wld or farm mammals.

There is a direct corellation between the amount of rainfall and the incidence

of leptospirosis, amking it seasonal in emperate climates and year – round in

tropical climates. It is also transmitted by the semen of infected animals. Workers

can contract the disease through contact with infected blood or body fluids.

PATHOPHYSIOLOGY
 The leptospires are thin, coiled, gram-negative, aerobic organisms 6-20 µm in

length. They are motile, with hooked ends and paired axial flagella (one on each

end), enabling them to burrow into tissue. Motion is marked by continual spinning

on the long axis. They are unique among the spirochetes in that they can be

isolated on artificial media.

Leptospires belong to the order Spirochaetales and the family

Leptospiraceae. Traditionally, the organisms are classified based on antigenic

differences in the lipopolysaccharide envelopes that surround the cell wall.

Serologic detection of these differences, therefore, is based on identifying serovars

within each species. Based on this system, the genus Leptospira contains two

species—the pathogenic Leptospira interrogans, with at least 218 serovars, and the
nonpathogenic, free-living, saprophytic Leptospira biflexa, which has at least 60

serovars.

Although not fully understood, leptospires are believed to enter the host

through abrasions in healthy skin, through sodden and waterlogged skin, directly

through intact mucus membranes or conjunctiva, through the nasal mucosa and

cribriform plate, through the lungs (after inhalation of aerosolized body fluid), or

through the placenta during pregnancy. Virulent organisms in a susceptible host

gain rapid access to the bloodstream through the lymphatics, resulting in

leptospiremia and spread to all organs. The incubation period is usually 5-14 days

but has been described from 72 hours to a month or more.

If the host survives the acute infection, septicemia and multiplication of the

organism persist until the development of opsonizing immunoglobulin in the

plasma, followed by rapid immune clearance. However, after clearance from the

blood, leptospires remain in immunologically privileged sites, including the renal

tubules, brain, and anterior chamber of the eye, for weeks to months. In humans,

leptospires in the renal tubules and resulting leptospiruria rarely persist longer than

60 days.

CLINICAL MANIFESTATIONS

During acute infection, leptospires are thought to multiply in the small blood

vessel endothelium, resulting in damage and vasculitis. The major clinical

manifestations of the disease are believed to be secondary to this mechanism,

which can affect nearly any organ system.

 • In the kidneys, interstitial nephritis, tubular necrosis, and impaired capillary

permeability, as well as the associated hypovolemia, result in renal failure.

• Liver involvement is marked by centrilobular necrosis and Kupffer cell

proliferation, with hepatocellular dysfunction.

• Pulmonary involvement is secondary to alveolar and interstitial vascular

damage resulting in hemorrhage. This complication is considered to be the

major cause of leptospirosis-associated death.

• The skin is affected by epithelial vascular insult.

• Skeletal muscle involvement is secondary to edema, myofibril vacuolization,

and vessel damage.

• The damage to the vascular system as a whole can result in capillary

leakage, hypovolemia, and shock. Many patients with leptospirosis may

develop disseminated intravascular coagulation (DIC), hemolytic uremic

syndrome (HUS), thrombotic thrombocytopenic purpura (TTP), and vasculitis.

Thrombocytopenia indicates severe disease and should raise suspicion for a

risk of bleeding.

Clinical manifestations of leptospirosis after the acute infection are the result

of the inflammatory response, as well as action of the remaining organisms in

the aqueous humor.

THREE STAGES OF LEPTOSPIROSIS

First stage ( Septic Stage)

 Leptospirosis starts suddenly, with a severe headache, redness in the eyes,

muscle pains, fatigue and nausea and a fever of 39°C (102°F) or above. There is

sometimes a red non-blanching pinprick rash on the skin, similar to that seen in

meningitis. Young children can be tired or distressed and may show an aversion to

bright light. The severe headache is almost always present and can be

incapacitating. Nausea may or may not cause vomiting. Muscle pains can be

extreme and are often particularly bad in the calf and back areas - muscles will be

sore to move and to touch. A rapid pulse is also common in the first few days.

The skin rash develops in the first one or two days and often the skin is warm and

pink just beforehand, with the patient complaining of feeling warm. Rashes can

occur anywhere but in some cases are confined to local regions of skin such as the

front of the legs. Sometimes they will be itchy, but rashes are only seen in about

30% of all cases so the lack of any rash is not too significant.

Psychological changes are often seen, with patients feeling depressed, confused,

aggressive and sometimes psychotic - with schizophrenia and hallucinations,

personality changes and violence.

This phase lasts between three and five days, then the patient (temporarily)

recovers. During this phase the bacteria are active in the patient's bloodstream (so

it is sometimes called the septecaemic phase) and so can be detected by lab tests.

Second stage (Immune or Toxic Stage)

 In many mild cases this doesn't happen at all, but where the infection is more

severe, the patient enters a second phase of illness after a few days of apprent

recovery. The initial symptoms and fever return, accompanied with chest and

abdominal pain, some renal problems and psychological changes. Increased

symptoms of meningitis are often seen with neck stiffness and vomiting, but in

most mild cases the patient will not suffer kidney or liver failure and will eventually

recover. There may be a sore throat and dry cough, with a litle blood. With

treatment, mild cases will recover within a few weeks.

During this second phase the bacteria are only really active in the tissues of the

patient, and so can be difficult to find in the bloodstream, making lab tests a

problem. This second phase is usually called the 'tissue' or 'immune' phase.

Severe infections

In cases of particularly virulent serovars or patients with poor health, the

infection follows a different pattern and the patient develops very rapid and severe

symptoms from the start, without much of a remission. Symptoms are the same as

for the mild type but more pronounced, and multiple organs are damaged - liver

and kidney failure can occur within 10 days, leading to jaundice and death if not

treated. Hemorrhages are common (including bleeding from the mouth, eyes and

other mucous membranes), plus infection of the heart and significant internal

bleeding. Dialysis is the most important intervention and the patient will require

antibiotics and hospital admission in order to stand a chance of survival. Death,

when it occurs, is usually due to heart, liver or respiratory failure. Severe infections

are often called 'icteric' because of the presence of jaundice, and these are the only

cases that can really be called Weil's disease.

 Symptoms can take 2 – 26 days ( average 10 days) to develop, and may

include :

• Dry cough • Muscle pain

• Fever • Nausea, vomiting and

diarrhea
• Headache

• Shaking chills.

Less common symptoms include:

• Abdominal pain

• Abnormal lung sounds

• Bone pain

• Conjunctivitis

• Enlarged lymph glands

• Enlarged spleen or liver

• Joint aches

• Muscle rigidity muscle tenderness

• Skin rash

• Sore throat
Recovery

Patients with mild infections recover quite quickly, so are usually feeling OK

after a few weeks, but they can suffer from fatigue and depression for a while and

may be at risk from persistent infection. Patients with the more severe infections

can take several weeks to recover, as removing the bacteria is not the problem -

they will have caused damage to the body's tissues that take time to heal. Although

some patients can die, with medical treatment the chances of survival are good -

though patients that have had a severe illness may suffer long-term symptoms due

to organ damage that cannot completely heal. Psychological changes (mood

swings, depression, psychoses) are common for a few months following recovery.

MANAGEMENT

1. Medical

Leptospirosis tretment is a relatively complicated process comprising two

main components:

a) Suppressing the causative agent

b) Figting possible complications

  Aetiotropic drugs are antibiotics, such as cefotaxime, doxycycline,

penicillin, ampicillin, and amoxicillin.

 There are no human vaccines; animal vaccines are only for few strains,

and are only effective for a few months.

 Human therapeutic dosage of drugs is as follows:

a) Doxycycline 100 mg orally every 12 hours for 1 week.

b) Penicillin 1 – 1.5 MU every 4 hours for 1 week.

c) In dogs, penicillin is most commonly used to end the

leptospiremic phase ( infection of teh blood), and doxycyline is

used to eliminate the carrier state.

 Supportive therapy measures

a) Detoxication and normalization of the hydroelectrolytic balance.

Glucose and salt solution infusions may be administered;

b) Dialysis is used in serious cases. Elevation of the serum

potassium are common and if the potassium level gets too high

special measures must be taken. Serum phosphorus levels may

likewise increase to unacceptable levels due to renal failure.

c) Corticosteroids administration in gradually reduced doses

during 7 – 10 days is reccomended by some specialist in cases

of severe haemorrhagic effects.

 d) Organ soecific care and treatment are essential cases of renal,

liver or heart involvement.

2. Nursing

a) Isolate the patient, urine must be properly disposed

b) Keep patient under close surveillance

c) For home car, cleaning near dirty places, pools, and stagnant water

d) Eradicate rats and rodents

PREVENTION AND CONTROL

1. Sanitaion in homes, workplaces and farms

2. Proper drainage system and control of rodents

3. Vaccination of animals ( cattle, dog, cats and pigs)

4. Treatment of infected human and pets

5. Effective information – dissemination campaign