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Leptospirosis 1

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    Leptospirosis 1 Leptospirosis 1 Presentation Transcript

    • Leptospirosis
      2008 Batch- V Term
      Infectious Diseases Series
    • It’s raining diseases with monsoon in stateExpress News ServicePosted: Sep 01, 2010 at 0210 hrs ISTAhmedabad/Vadodara/Surat
      While the good spell of monsoon has brought in cheer, the health barometer has been a cause for concern this month. Gujarat health department recorded outbreak of at least six diseases in a week in six different areas across the state. Kutch reported 349 suspected cases of Chikungunya on August 17, a Gandhinagartaluka reported two cholera cases on August 18, 24-odd cases of gastroenteritis were reported in Surat district while 35 cases of unknown fever were reported in Surat on the same day. According to the state health department, 20 more jaundice cases were reported in Ahmedabad on August 20. They are unlikely to be due to viral hepatitis due to the unusual association of kidney failure. leptospirosis is suspected but not confirmed. In another incident, 10 cases of diarrhoeawere reported in Surat on August 21.
    • Leptospirosis: meaning
      Leptospira (from the Greek leptos, meaning fine or thin, and the Latin spira, meaning coil) is a genus of spirochaetebacteria, including a small number of ...
    • Alternate Names
      Weil’s disease
      Ictero-hemorrhagic fever
      Swineherd's disease
      Rice-field fever
      Cane-cutter fever
      Swamp fever
      Mud fever
      Hemorrhagic jaundice
      Stuttgart disease
      Canicola fever
    • Butchers, tourists, residents, animals
    • Butchers, tourists, residents, animals
    • Learning Objectives
      Historical Perspective
      Introduction
      Pathogenesis
      Clinical Features
      Complications
      Diagnosis
      Treatment
    • Historical Perspective
      A syndrome of severe multisystem disease presenting as profound jaundice and renal function impairment was described by Weil in Heidelberg in 1886
      Earlier descriptions also exist
      Leptospires were first visualized in autopsy specimens in a case thought to be Yellow Fever
      Simultaneously isolated in Japan and Germany
      Many researchers (Stokes, Noguchi, others) died of the disease
    • Introduction
      Zoonosis: Leptospirosis is a bacterial disease that affects both humans and animals.
      Not well documented, often overlooked & under-reported
      Emerging Infectious Disease: Several recent outbreaks in Asia, South America & USA
      In the wake of hurricane Mitch in 1995, an outbreak with pulmonary hemorrhages was reported in Nicaragua.
      In 1998, there were outbreaks in USA, Peru and Ecuador.
      A post-cyclone outbreak was reported in Orissa, India in 1999
      During outbreaks and in high-risk groups
      >100 per 100 000 may be infected.
    • Pathogenesis
    • Pathogenesis- contamination of soil and water
    • Soil and water contamination
    • Pathogenesis: Agent
      Order:Spirochetales
      Family: Leptospirideae
      Genus:Leptospira
      Species: interrogans (pathogenic) biflexa
      Serovars: > 200
      Serogroups: > 25; icterohemorrhagica, gryppotyphosa, caniciola, pomona, andmanii, etc
    • Pathogenesis: Agent
    • Pathogenesis:Agent
      Can survive outside the body for long
      Organism is excreted in the urine even after clinical infection settles down (symbiotic)
      Leptospirosis is maintained in nature by chronic renal infection of carrier animals
    • Animal Urine
    • Pathogenesis: Agent
      Coiled, thin, highly motile
      Hooked ends and flagellae
      Stain poorly
      Seen by DGI & Silver impregnation
      Need special media
      Take long for culture
    • Pathogenesis: Agent
      DGI
    • Pathogenesis: Host
      Mammals - wild and domestic
      Animals- Rodents, insectivores, dogs, cattle, pigs, horses, etc
      Humans
      • Direct contact with urine of infected animals
      • Urine-contaminated surface water, soil and plants
      Even some birds
      • Micro-abrasions, intact skin and mucosa
      • Infected animal tissues and blood
    • Pathogenesis: Host
      Occupational hazard:people who work outdoors /with animals
      rice and sugar-cane field workers, farmers
      sewer workers
      veterinarians and dairy workers
      butchers and abattoirs
      military personnel
      Recreational hazard:
      tourists, Water sports
    • Flooding, Farming, Camping waterlogging
    • Butchers, tourists, residents, animals
    • Pathogenesis: Environment
      Worldwide
      Both rural and urban areas
      Temperate and tropical climates
      Incidence peaks during the rainy season and during flooding
      Tourism in tropics with adventure water sports
    • Distribution
    • Environment
    • Pathogenesis
      Entry: through cuts and abrasions in skin & mucous membranes of the eyes, nose and mouth
      Inhalation- rare
      Ingestion- rare
      Human-to-human transmission –rare
      Incubation Period: 5 to 14 days (mean 10 days)
    • Pathogenesis
      Leptospiremic/ Septicaemic phase
      Systemic vasculitis
      Migration of organisms into tissues- inflammation and multi-organ dysfunction from direct cyto-toxicity
      Immune phase/ Leptospiruric Phase
      Second fever and organ involvement through immunological mechanisms-
      Persistence of organisms
      Renal tubules, aqueous humor
    • Pathogenesis
      Renal Failure:
      Migrate to interstitium, renal tubules and tubular lumen – interstitial nephritis and tubular necrosis
      Hypovolemia – dehydration and leakage
    • Liver
      Liver:
      Centrilobular necrosis and Kupffer cell hyperplasia
      No hepatocellular necrosis
    • Pathogenesis
      Pulmonary: Hemorrhage
      and not much inflammation
      • hemoptysis, patchy lung
      • infiltrates and ARDS
      Muscles: Direct cytotoxicity
      CNS: Organisms in the CSF X 2 weeks with
      mild CSF changes
      Meningitis in immune phase
    • Jaundice & Red eyes
    • Clinical Features
      Wide range of severity and clinical features
      Subclinical infection
      Self limited systemic illness 90 %
      Severe potentially fatal illness consisting of
      Renal failure 15 %
      Liver failure 15%
      Pneumonitis >30 to 40% mortality
      Hemorrhagic diathesis
    • Bimodal illness
      Leptospiremic/ Septicaemic phase
      Immune phase/ Leptospiruric Phase
      Distinction maybe blurred
    • Clinical Features
      Factors influencing severity:
      Serovar
      Size of innoculum
      Prior infection
      Early antibiotic use
      Pregnancy
    • Clinical Features- early (5 -7 days)
      High fever and chills
      Severe headache, eyeball pain, photophobia
      Mental confusion
      Muscle pain & tenderness (calves and back)
      Redness in the eyes & conjunctival injection
      Sore throat
      Rash- maculopapular
    • Clinical Features- early (5 to 7 days)
      Abdominal pain
      Vomiting and diarrhea
      Jaundice, hepatosplenomegaly
      Lymphadenopathy -rare
      Hemorrhages in skin and mucous membranes
      Cough, chest pain & hemoptysis
    • Clinical Features- Late(A) AnictericVariety
      After 2 to 3 days of seeming recovery
      New fever
      Milder myalgias
      Aseptic meningitis- similar to viral meningitis- clue- Neutrophilicleucocytosis
      Uveitis (Iridocyclitis)
      Choreoretinitis
    • Clinical Features- Late(B) Icteric Variety
      Severe Leptospirosis (Weil’s Disease)
      Jaundice
      Renal Dysfunction
      Hemorrhagic Diathesis
      Mortality 5 to 15 %
    • To Sum Up Clinical Features
      Bacteraemic Leptospirosis
      Aseptic Meningitis
      Icteric Leptospirosis with Renal involvement
      Pulmonary Syndrome
    • Other Complications
      Rhabdomyolysis
      Hemolysis
      Myocarditis
      Pericarditis
      CHF
      Necrotising Pancreatitis
      MOF
    • Differential Diagnosis
      Ac Febrile Syndrome (Dengue, Chick, Malaria, Influenza, Typhus, Mono, Enteric, Hanta)
      Jaundice (VH, Yellow Fever, Complicated Malaria)
      Aseptic Meningitis (.., .., .. )
    • Lab Diagnosis
      Urine: Sediment (RBCs, WBCs, Casts) & proteinuria
      Blood Counts:
      PMN –Leucocytosis,
      ESR elevation
      Thrombocytopenia
      Biochemistry: LFT (Enzymes not very high); KFT
      Coagulation Profile -Vit K dep factors low
      CPK MM
      CSF Abnormalities
      X Ray Chest- patchy alveolar pattern- lower lobes
    • Lab Diagnosis
      Antigen Detection:
      DGI and Silver impregnation
      staining- urine, CSF
      Culture (EMJH )
      PCR
    • Lab Diagnosis
      Antigen Detection:
      DGI and Silver impregnation staining- urine, CSF
      Culture (EMJH )
      PCR
      Antibody Detection (second week)
      IgM & IgG
      • MAT
      • ELISA
      • Indirect Hemagglutination Test
      • Microcapsule Agg test
    • Treatment
      General and Supportive Care
      Antipyretics
      Rest
      Hydration
      Ventilator support
      Liver support
      Renal support
      Transfusion support
    • Treatment
      General and Supportive Care
      Penecillin G
      Amoxycillin
      Ampicillin
      Tetracyclines
      Doxycycline
      Ceftriaxone
      JH Reaction
    • Prevention
      Rodent and wild plus peri-domestic animal control
      Avoid exposure to urine and tissues of animals
      Avoid wading through water collections
      Vaccination of animals
      Chemoprophylaxis- weekly Doxycycline (200 mg)
    • Take Home Messages
      Leptospirosis is an infectious disease
      (zoonosis) caused by a bacterium.
      Leptospirosis is transmitted to humans by direct exposure to urine or tissue of an infected animal.
      Leptospirosis typically progresses through two phases of nonspecific symptoms.
      Leptospirosis can be diagnosed by culture of infected blood, urine, or spinal fluid, as well as using antibody testing.
      Animals are also at risk for contracting Leptospirosis.
      Leptospirosis is treated with antibiotics and is rarely fatal.
    • Every jaundice is not viral Hepatitis