2. A 11 Y/M child presented to district hospital,
Makawanpur with complains of :
• Fever
• Headache
• Fatigue
• Muscle pain
• On Examination: Child is alert, pallor
present, icterus absent, other vitals
stable
• Investigations show :
• Anemia ( Hb 8gm/dl)
• Thrombocytopenia (68000)
• Neutrophilia with Normal TLC
DIFFERENTIAL DIAGNOSIS ??
3. EPIDEMIOLOGY
• Estimated that more than one million human cases occur worldwide
annually, including almost 60,000 deaths
• Regions with highest incidence includes south and southeast asia ,
Oceania, the Caribbean, parts of sub-saharan Africa and parts of latin
America
• In united states, incidence is 100 to 150 cases annually
• In Nepal, Prevalence of clinical leptospirosis is 5.4%
UpToDate
Determinants of clinical leptospirosis in Nepal, R Shrestha et al.
4. LEPTOSPIRA UNDER THE MICROSCOPE
Long, Thin, Highly Coiled
Dark Field Microscopy FL
5. EPIDEMIOLOGY
• Rainfall; Contaminated environment
• Poor Sanitation; Inadequate drainage facilities
• Presence of rodents, cattle & stray dogs
• Walking/ working bare foot poses high risk
• Difficult to pinpoint the source of infection
• Any person can get infected, if exposed to contaminated environment
7. RESERVOIRS OF INFECTION
• Rodents
• (Rattus rattus, Rattus norvegicus, Mus musculus)
• Dogs
• Wild animals
• Domesticated animals
• Leptospira are excreted in the urine
8. MODES OF TRANSMISSION
1. Direct contact with urine or tissue of infected animal
Through skin abrasions, intact mucus membrane
2. Indirect contact
Broken skin with infected soil, water or vegetation
Ingestion of contaminated food & water
3. Droplet infection
Inhalation of droplets of infected urine
9.
10. PATHOGENESIS OF SEVERE DISEASE
Leptospira
Damage to small
blood vessels
Vasculitis
Direct cytotoxic injury
Immunological injury
Massive migration of fluid from
Intravascular to interstitial compartment
Renal dysfunction, vascular
Injury to internal organs
20. CARDIAC FORM
Cardiac manifestations
• Hemorrhagic Myocarditis
• Cardiomyopathy / Cardiac failure
• Arrhythmias, Hypotension / Death
• Atrial fibrillation / Conduction defects
ECG changes
• Non Specific ST-T changes
• Low voltage complexes
Reported in Srilanka, Barbados & Portugal
21. OTHER MANIFESTATIONS
Aseptic Meningo-encephalitis
• It is rare; It occurs in the Immune phase
• CSF – proteins , lymphocytes
• Convulsions, Encephalitis, Myelitis & Polyneuropathy
Ocular manifestations
• Late complication; Conjunctival suffusion/hemorrhage
• Anterior uveitis, Iritis, Iridocyclitis, chorioretinitis
• Occurs in 2 weeks to 1 yr. (average 6 months)
22. BACK TO CASE
• Child was admitted with diagnosis of Dengue Fever and and kept on i/v fluids,
anti-pyretics and rest.
• On 3rd day of admission: Child is still febrile, thrombocytopenia, leukocytosis,
Decreased hemoglobin, jaundice (increased TSB)
• Investigations: Dengue NS1, IgM, HAV, HCV Negative
Increased AST and ALT
• Rapid IgM test for leptospira : Positive
24. LABORATORY TESTS
• TC / DC / ESR / Hb / Platelet count
• Serum Bilirubin / SGOT/ SGPT
• Blood Urea, Creatinine & Electrolytes
• Chest X-Ray; ECG
• Tests for diagnosis of Leptospirosis
• Culture for Leptospira: Positive
• MAT: Sero conversion or 4 fold rise/ high titer
• ELISA / MSAT : positive
• MAT: Microscopic agglutination test
• (M)SAT: Macroscopic slide agglutination Test
25. INTERPRETATION OF TESTS
MAT
• Antibody IgM titers of >1/80 or IgG 1/400
• titers indicate current infection
• Declining titers indicate past infection
• To confirm, second sample is essential
ELISA
SAT
• Valuable for Dx of current infection
• IgM antibodies alone are useful
26. INTERPRETATION OF TESTS
ELISA/SAT MAT Interpretation
Positive Positive Current Infection
Positive Negative Current Infection
Negative Positive Past Infection
Negative Negative R/o Leptospirosis
Not available Rising titers Current Infection
27. WHO Guide - Faine’s Criteria
• Headache
2
• Fever
2
• Temp > 39 F
2
• Conjn. suffusion
4
• Meningism
4
• Muscle pain
4
• Jaundice
1
• Alb, creatinine
1
• Rain fall
5
• Contaminated
water
4
• Animal contact
1
• ELISA IgM + ve
15
• SAT positive
15
• MAT high titer
15
• MAT rising titer
25
• Culture positive
Definite
28.
29. ROLE OF CORTICOSTEROIDS AND
PLASMAPHERESIS
• Due to vasculitic nature of severe leptospirosis, particularly in setting of
pulmonary involvement
• Plasmapheresis also used in severe leptospirosis
32. 1) Which among the following is NOT used in Leptospirosis?
• Microscopic agglutination test
• Dark field illumination
• Macroscopic agglutination test
• Weil felix reaction
33. 2) Which of the following statements about Leptospirosis is true ?
• Rats are prime reservoirs
• Fluoroquinolone are the drug of choice
• Person to person transmission is common
• Hepatorenal syndrome may occur in upto 50% of patients
34. 3) Which of the following organism can cause acalculous cholecystitis ?
• Leptospirosis
• Malaria
• Staphylococcus
• Nocardiosis
35. REFERENCES
• Nelson Textbook of pediatrics, 21st Edition
• Indian academy of pediatrics Guidelines
• UpToDate
• Textbook of pediatrics by Piyush Gupta
Leptospires enter humans through mucous membranes (primarily eyes, nose, and mouth) or abraded skin or by ingestion of contaminated
water. After penetration, they circulate in the bloodstream to all body organs, causing endothelial lining damage of small blood vessels
with secondary ischemic damage to end organs.
Stages of anicteric and icteric leptospirosis.
Correlation between clinical findings and presence of leptospires
in body fluids. CSF, cerebrospinal fluid.
The septicemic phase of anicteric leptospirosis has an abrupt onset with flu-like symptoms of fever, shaking chills, lethargy, severe headache,
malaise, nausea, vomiting, and severe debilitating myalgia most prominent in the lower extremities, lumbosacral spine, and abdomen.
Conjunctival suffusion with photophobia and orbital pain, generalized lymphadenopathy, and hepatosplenomegaly may also be present. A transient (<24 hr) erythematous maculopapular, urticarial, petechial, purpuric, or desquamating rash occurs in 10% of cases. Rarer manifestations include pharyngitis, pneumonitis, arthritis, carditis, cholecystitis, and orchitis. The second or immune phase can follow a brief asymptomatic interlude and is characterized by recurrence of fever and aseptic meningitis. Although 80% of infected children have abnormal CSF profiles, only 50% have clinical meningeal manifestations. CSF abnormalities include a modest elevation in pressure, pleocytosis with early polymorphonuclear leukocytosis followed by mononuclear predominance rarely exceeding 500 cells/μL, normal or slightly elevated protein levels, and normal glucose values. Encephalitis, cranial and peripheral neuropathies, papilledema, and paralysis are uncommon. A selflimited unilateral or bilateral uveitis can occur during this phase, rarely resulting in permanent visual impairment. Central nervous system symptoms usually resolve spontaneously within 1 wk, with almost no mortality.
Weil syndrome is a rare (<10% of cases) severe form of leptospirosis seen more commonly in adults (>30 yr) than in children. The initial manifestations are similar to those described for anicteric leptospirosis.
The immune phase, however, is characterized by jaundice, renal failure, thrombocytopenia, and, in fulminant cases, hemorrhage and cardiovascular
Collapse.
Hepatic involvement leads to right upper quadrant pain, hepatomegaly, direct and indirect hyperbilirubinemia, and modestly elevated serum levels of hepatic enzymes. Liver function usually returns to normal after recovery.
All patients have abnormal findings on urinalysis (hematuria, proteinuria, and casts), and azotemia is common, often associated with oliguria or anuria. Acute kidney failure occurs in 16-40% of cases and is the principal cause of death.
Abnormal electrocardiograms are present in 90% of cases, but congestive heart failure is uncommon.
MAT: taken at least 2 weeks apart and tested in same laboratory
