More focus on neurological aspects

1. LEPTOSPIROSIS
ADE WIJAYA, MD – DECEMBER 2018
Haake, D. A., & Levett, P. N. (2015). Leptospirosis in humans. In Leptospira and leptospirosis (pp. 65-97). Springer, Berlin, Heidelberg.
MORE FOCUS ON NEUROLOGICAL ASPECTS

3. INTRODUCTION
 Leptospirosis is primarily a zoonosis, with humans serving as accidental hosts.
 Human to human infection extremely rare
 Portals of entry include cuts and abrasions or mucous membranes such as the conjunctival, oral, or
genital surfaces.
 Exposure may occur through either direct contact with an infected animal or through indirect contact via
soil or water contaminated with urine from an infected animal
 Based on global data collected by International Leptospirosis Society surveys, the incidence was
estimated to be 350,000–500,000 severe leptospirosis cases annually
 Overall global annual incidence of endemic and epidemic human leptospirosis at 5 and 14 cases per
100,000 population

4. PATHOPHYSIOLOGY
 Penetration of tissue barriers to gain entrance to the body  Hematogenous dissemination
 Patients with severe leptospirosis have evidence of a “cytokine storm” with higher levels of IL-6, TNF-
alpha, and a number of other cytokines
 TLR
 HLA-DQ6
 Liver, lung, and renal involvement

5. CLINICAL PRESENTATION
 Incubation phase: 3 days – a month
 Sudden onset of fever, chills, and headache
 Muscle pain and tenderness is common and characteristically involves the calves and lower back
 Conjunctival suffusion (dilatation of conjunctival vessels without purulent exudate)
 Subconjunctival hemorrhages
 Uveitis

6. CLINICAL PRESENTATION
 Nonproductive cough
 Icterus
 Nausea, vomiting, diarrhea, and abdominal pain
 Bleeding
 Severe manifestation – Weil’s Disease
 Dysfunction of multiple organs including the liver, kidneys, lungs, and brain.

7. NATURAL COURSE

8. NEUROLOGIC MANIFESTATION
 Headache + meningeal signs
 CSF: a lymphocytic predominance with total cell counts of up to 500/mm3 ; normal CSF protein and
glucose
 In severe leptospirosis, altered mental status may be an indicator of meningoencephalitis.
 A variety of other neurologic complications may also occur including hemiplegia, transverse myelitis, and
Guillain–Barré syndrome

9. DIAGNOSIS
 Identification of leptospirosis in its early stages is largely a clinical diagnosis and relies on a high index of
suspicion based on the patient’s risk factors, exposure history, and presenting signs and symptoms
 Rapid diagnostic tests for leptospirosis are improving, but a negative result should not be relied on to
rule out early infection
 PCR
 Culture
 Serology

10. MANAGEMENT
 Most leptospirosis cases are mild and resolve spontaneously
 Early initiation of antimicrobial therapy may prevent some patients from progressing to more severe
disease
 Empirical therapy should be initiated as soon as the diagnosis of leptospirosis is suspected
 Inpatient: Intravenous penicillin (1.5 million units IV every 6 h), ampicillin (0.5–1 g IV every 6 h),
ceftriaxone (1 g IV every 24 h), or cefotaxime (1 g IV every 6 h)
 Outpatient: doxycycline 100 mg orally twice per day or azithromycin 500 mg orally once per day.
 Azithromycin or amoxycillin can also be given to pregnant women and children
 Severe leptospirosis: antibiotics + supportive treatments, hidration, potassium supplementation, dialysis
if needed

11. RISK FACTORS FOR MORBIDITY AND MORTALITY
 Altered mental status
 Oliguria
 Age over 36 years
 Respiratory failure

12. PREVENTION
 Environtmental
 Human Leptospirosis Vaccines (killed whole-cell vaccine for high risk group of people)
 Chemoprophylaxis: doxycycline (200 mg orally once per week)

13. SUMMARY
 Zoonosis illness
 Portals of entry include cuts and abrasions or mucous membranes such as the conjunctival, oral, or
genital surfaces.
 Exposure may occur through either direct contact with an infected animal or through indirect contact via
soil or water contaminated with urine from an infected animal
 Environtmental factor
 Most common: Liver, lung, and renal involvement
 Neurologic manifestation: headache, meningismus, altered mental status
 Treatment: antibiotics + supportive care