LEPTOSPIROSIS

Dr. Naresh T Chauhan

Background
 

 

Most common zoonosis in the world Especially in tropical countries with heavy rainfall. Flooding after heavy rainfall helps spread the bacteria in the environment. An infectious disease that affects human & animals Also known as,

Cane cutters disease in Australia Weil Disease Hemorrhagic Jaundice Rice field Leptospirosis in Indonesia Mud Fever Fort Bragg fever in U.S Swineherd Disease Andaman hemorrhagic fever(AHF) Canicola Fever seven-day fever found commonly in Japan

Background

The infection causes a systemic illness that often leads to renal & hepatic dysfunction. First recognized as an occupational disease of sewer worker in 1883. Weil described clinical manifestations in 4 men who had severe jaundice,fever,haemorrhage with renal involvement.

Distribution


Leptospirosis occurs worldwide,

in both rural and urban areas in temperate and tropical climates. It is an occupational hazard for people


 

who work outdoors or with animals, such as rice and sugarcane field workers, farmers, sewer workers veterinarians, dairy workers and military personnel. It is also a recreational hazard to those who swim or wade in contaminated waters.

In endemic areas the number of leptospirosis cases may peak during the rainy season and even may reach epidemic proportions in case of flooding.

Distribution


The number of human cases worldwide is not well-documented. It probably ranges from 0.1 to 1 per 100 000 per year in temperate climates to 10 or more per 100 000 per year in the humid tropics During outbreaks and in high-risk groups, 100 or more per 100 000 may be infected underreported in many areas of the world

Leptospirosis in India


The first of its kind in India was reported in the 1920s from Andaman and Nicobar Islands In 1997, Leptospirosis spread to Surat district from Valsad district south of Surat where the diseases has been reported for many years An outbreak of Leptospirosis emerged in Orissa following supercyclone in 1999

Maharashtra, Kerala

SERO POSITIVITY RATE - INDIA

    

S.India N.India W.India E.India &C.India

25.6% 8.3% 3.5% 3.1% 3.3%

Epidemiological triad

leptospira

Agent

Man
Host

Urine and faeces of infected Environment animals

Agent
 The genera Leptospira contains three species,

namely L interrogans, L biflexa and L parva. The first includes 23 serogroups and more than 250 serovars and is the principal cause of leptospirosis in humans and animals. most common being L. canicola, L. hardjo and L. hebdomadis.  Two types of leptospirosis: 1. Anicteric leptospirosis or self-limited illness (85% to 90% of the cases) 2. Icteric Leptospirosis or weils syndrome (5% to 10% )

 These spirochetes are thin, highly motile, slow growing anaerobes with hooked ends.  0.1-0.2 um wide & 5-15 um long ,having flagella allow them to burrow in tissue.  Visible by dark field illumination & silver staining

Source of Infection: Urinary sheddings of organisms from infected animals.

Animal Reservoirs:


Wild and domestic animals rodents, livestock (cattle, horses, sheep, goats, swine), canines, and wild mammals are the reservoir for leptospirosis

Many animals have prolonged leptospiruria without suffering from the disease themselves

Mode of transmission
leptospira

Wild animals urine Water & soil Domestic animal infected during grazing urine Transmitted to humans

Modes of Transmission


By direct or indirect contact of nasal, oral, or eye mucosal membranes or abraded or traumatized skin with urine or carcasses of infected animals. Urine: Indirect exposure through water, soil, or foods contaminated by urine from infected animals is the most common route. After a short period of circulating high levels of the spirochete in their blood, animals shed the spirochete in their urine, contaminating the environment. Inhalation of droplet aerosols of contaminated fluids can occasionally occur

Host factors
 

Age : children & middle aged men Sex : males are more affected because they are employed in at risk occupations Occupation: 30-50 % of cases Agricultural & live stock farmers, Workers in rice & sugarcane fields Underground sewers, Meat & animal handlers Veterinarians Recreational activities presenting some risk including swimming, traveling to tropical countries

Environmental factors
 

  

Acquired through contact with an environment contaminated with urine of infected animals. Leptospira shed in urine survive for weeks in soil & water so environmental contamination may reach high levels in areas where carrier animals frequently urinate. Cases occur in warm season & rural areas because leptospira persist in water for many months. They survived best in fresh water,damp alkaline soil,mud. Followed by heavy rainfall & consequently floodings.

Clinical features
 

Incubation period: 10 days (4-20 days) First stage: Septicemic or leptospiremic phase Characterized by;
flu like illness fever chills weakness myalgias affecting calves, back & abdomen

 

Other symptoms are sore throat, cough, chest pain, hemoptysis, rash, frontal headache, photophobia, mental confusion, and other symptoms of meningitis. This stage lasts for 4-7 days Organism may isolated from blood culture & CSF

         

Second stage: Immune or leptospiruric Nonspecific symptoms such as fever & myalgia become less severe Intense headache Jaundice Aseptic Meningitis Uveitis & subconjuctival haemorrhage (92%) Renal symptoms such as azotemia, proteinuria,oliguria This stage is due to bodys immune response to infection Circulating antibodies may be detected or organism may be isolated from urine Lasts for 0-30 days

Weil syndrome


Severe form of leptospirosis Jaundice Renal dysfunction Haemorrhagic diathesis Jaundice develop 4-9 days after onset of disease, and gives orange cast to the skin Patients with severe jaundice are more likely to develop renal failure, hemorrhage, and cardiovascular collapse Weil syndrome carries a mortality rate of 5-10%.

 

COMPLICATIONS
      

Azotemia Oliguria Hemorrhage Purpura Hemolysis Gastrointestinal bleeding Hypoprothrombinemia and Thrombocytopenia

Differential diagnosis
         

Influenza Meningitis (encephalitis) Viral hepatitis Rickettsiosis Typhoid fever Septicemia Toxoplasmosis Legionnaires disease If with jaundice during or after an acute febrile illness, Malaria, septicemia, alcoholic hepatitis and typhoid fever

Laboratory diagnosis
Definitive diagnosis isolation of the organism by culture positive result on the microscopic agglutination test (MAT). Cultures leptospira may be isolated from blood & CSF during first week from the urine after 10 days. Microscopic agglutination test detects antibody, positive after 2nd week a 4 fold rise in titers indicate positive result. Macroscopic slide agglutination test ELISA uses a broadly reactive antigen. detects IgM, useful for diagnosis of new infections within 3-5 days Rapid commercial tests IgM Dip-STicks ELISA(PanBio, Inc, Baltimore, Maryland) detects leptospira antibodies in acute phase

Treatment
Mild leptospirosis Doxycycline, 100 mg bd for 7 days or Ampicillin, 500-750mg qid, Penicillin G, 1.5 million units IV qid Ampicillin,1 g iv qid Amoxycillin,Erythromycin 10 to 14 days Doxycycline,200 mg orally once a week

Moderate/severe leptospirosis

Chemoprophylaxis

Prevention


Prevention is difficult because

The organism has not been eradicated from wild animals They constantly infect domestic animals. control of livestock infection with good sanitation Immunization, and proper veterinary care

Important control measures include

 

Minimizing human contacts with contaminated water, soil or vegetation Use of personal protective measures such as gloves & rubber boots when handling with infected tissues or animals. Measures should be taken to control rodents.

vaccines
Human vaccines offered to high risk workers serovar specific,repeated yearly associated with painful swelling not effective Animal vaccines are available to domestic livestock help to prevent illness but not infection & renal shedding of organism.

PRECUATIONS

Everyone should be aware of any illness during and in the weeks following a flood, and seek medical attention for any fever matching the symptoms above. Where medication is generally issued, stick to the doses and instructions given to you.

WHO Collaborating Centre for Diagnosis, Reference, Research and Training in Leptospirosis Regional Medical Research Centre Indian Council of Medical Research (ICMR) Port Blair, India