Leptospirosis is a bacterial disease that affects humans and animals. It is caused by bacteria of the genus Leptospira. In humans, it can cause a wide range of symptoms, some of which may be mistaken for other diseases. Some infected persons, however, may have no symptoms at all.

1. Mukesh sah, MD,JI
Virgen Milagrosa University Foundation

3.  C.R.
 18 yrs old
 Sitio Sagur Pugaro Suit Dagupan city
 Single
 Oct. 7, 1999
 Roman Catholic
 Admitted at R1MC for the first time
 Informant : Mother
 Realiability : 90 %

4. Chief complaint:
“3 DAY HISTORY OF FEVER”

5. 1 WEEK HISTORY

6. 3 days
DAY 1 ILLNES
• + undocumented fever, + myalgia, Headache
• + Abdominal pain, +Dec appetite and activity
• Took Paracetamol 2X, no consultation done
2 days
DAY 2 ILLNES
•+ persistence of above S/SX
•↓ urine output with yellow orange in color
•+ calf pain
1 WEEK HISTORY OF WADING TO FLOOD

7. 1 day
•+ persistence of above S/SX
•LBM and vomiting
•Last urine output: 12noon < 1ml
Few hrs
•+ anuria
•+DOB
•Sought consult to R1MC

8. Review of Systems:
• General: (+) body weakness (-) weight loss (+) decrease appetite
(-) chills (-) fatigue
• Skin: (+) Jaundice (-) pallor (-) pruritus
(-) cyanosis (-) rashes (-) hematoma
• Head & neck:(-) nodules (-) stiffness (-) swelling
(-) pain (-) trauma (+) headache
(+) dizziness (-) lightheadedness (-) pain
• Eyes: (-) asymmetry (-) infection
(+) icteric sclera (-) itchiness (-) diplopia
(-)use of glass/lenses (-) lacrimation (-) blurred vision
• Ears: (-) hearing problem (-) itching
• Mouth & throat: (-) hoarseness (-) sore throat (-) dysphagia
• Respiratory: (-) cough (-) colds (-) dyspnea (-) cyanosis (-) hemoptysis

9.  Cardiac: (-) palpitation (-) chest pain (-) orthopnea (-) paroxysmal nocturnal
dyspnea (-) easy fatigability (-) edema
 GIT: (-) pain (-) anorexia (-) vomiting (-) melena (-)
constipation (-) excessive belching (-) bloated (-) loss of appetite (-) abdominal
pain(-) diarrhea
 Renal: (-) dysuria (-) hematuria (-) nocturia (-) incontinence (-)
polyuria (+) anuria (-) urgency (-) frequency (-) gross hematuria (-) tea-
colored urine
 Genitalia: (-) pain (-) swelling (-) discharge (-) infection
 Musculoskeletal: (-) stiffness (-) numbness (+) joint pain
(+) muscle pain (calf) (-) change in strength (-) backache
 Hematological: (-) pallor (-) hematoma (-) bleeding (-)
anemia
(-) easy bruising
 Endocrine: (-) weight loss (-) edema (-) polyuria (-)
polyphagia
(-) polydipsia (-) heat intolerance (-) cold intoleranc
(-) excessive sweating

10.  Past medical history:
EPI Completion
No pertinent childhood illnesses
No previous surgical interventions
 Family history:
No history of herediofamilial diseases
No history of TB, asthma, DM and cardiac disease.

11.  Personal and Social History:
Patient is staying with his father and 2
siblings in a Well- lit, well ventilated
bungalow wooden house with own pour-
flush toilet.
Garbage collected 2-3 times a week
Drinking water is tap water
No history of travel

12. H- The patient lives with his father with his 2
siblings (his parents are separated)
E- He stop schooling at Grade 10
A- He accompanies his father during fishing and
usually play basketball during free time.
D- No history of illegal drugs. Usually drinks SAN
MIG light with his friends and a smoker as well.
S- No sexual experience
S- No suicidal Ideation

13.  Awake, conscious, coherent, ambulatory, GCS
15, in cardiorespiratory distress with the
following vital signs:
 BP: 50/30
 PR: 98bpm
 CR: 85bpm
 Temp: 37C

14.  SKIN:
 Brown in complexion, no pallor, mild jaundice, no
lesions, normal skin turgor, multiple scars on bilateral
lower extremities
 HEENT:
 No areas of balding, no swelling, tenderness
 EYES: pale palpebral conjunctivae, icteric sclera,
conjunctival suffusion, no cataract, no asymmetry
 EARS: at level of lateral canthus of the eyes,
symmetrical, non-tender, with no erythema, no
discharges, no scaling
 NOSE: Nasal mucosa is pink, patent nares, non-
deviated septum and no Nasal discharge, non-
tendersinuses.

15. MOUTH: pinkish lips, Buccal mucosae is pink,
no ulcer, Dry lips
 CHEST AND LUNGS:Symmetrical chest wall
expansion,No intercostal or subcostal
retraction,no tenderness, normal resonant
breathing sound,
 Heart: Adynamic precordium, Apex beat at 5th
ICS left MCL, , (-) thrills, (-) loud and palpable
P2; normally split S2; (-) S3, (-) S4.normal rate.
(-) murmur, tachycardic.

16. Abdomen.
Inspection:, no scars, no spider angioma
Auscultation: hypoactive bowel sounds at 6 per minute.
Percussion: Tympanic, liver span 8 cm in right
midclavicular line, non palpable liver edge.
Palpation: (-) tenderness
Musculoskeletal: (+) tenderness Gastrocnemius, No bone
nor joint deformity, no joint swelling
Extremities: full pulses, warm extremities, CRT 2 seconds,
no cyanosis, no edema
Neurologic: Conscious, coherent, oriented to three spheres,
follows commands
 GCS 15 (E4V5M6)
 The rest of the neurologic examinations were
unremarkable

17. SUBJECTIVE OBJECTIVE
 18 years old
 Male
 History of wading in flood
 Fever for 3 days
 Headache
 Decreased urine output
for 2 days
 Vomiting and Loose
Stools
 Abdominal Pain
 Calf Pain
 Hypotension (BP 50/30)
 Tachycardia (CR: 115bpm)
 Signs of Dehydration (dry
lips)
 Icteric Sclera
 Conjunctival suffusion
 Multiple scars on lower
extremities
 Tenderness on
Gastrocnemius

18. To consider LEPTOSPIROSIS

19.  HD/PICU DAY 1:
 3:40 pm
 Patient was admitted at Pediatric ICU under GREEN
service
 Secure consent
 Diagnostics: CBC, typings, BUN , Crea, S. Electrolytes,
AST, ALT, PT APTT, blood cs, U/A, dengue test,
leptospira test, CXR PAL
 Therapeutics
Line 1: PNSS 1L TRA 52gtts/ min x 6hrs then refer for
RA
Line 2:PNSS 1L TRA 22gtts/,in x 24 hrs (M%)

20.  Penicillin 2million units Q4 (-)ANST
 Please insert IFC
 Refer to nephro
 Monitor vs q1
 Monitor I and O q shift
 Hook to norepinephrine 31cc + D5w 69cc with
rate of 5
 For possible HD explained to mother
 Hook to o2 via face mask via 10 LPM
 Give dopamine drip at 10 cc / hr

21. 5:40pm
 BP: 110/50
 (-) urine output
10:30pm
please give metolazone 5mg now, then furosemide 4mg
IVP after 1 hr of giving metolazone
HD/PICU DAY 2 : Nephrology Notes
BP: 100/50 (+) Neck vein distention (-) desaturation
give furosimide 80mg now
for hep B and C
PICU notes
Line 1 please regurate to PNSS 22gtts/min as maintenace
Line 2 shift to heplock

22.  12pm :
 (+) Tachypnea
 For “E” intubation, conditioned well explained to
patient
 For repeat CXR APL

23.  HD/PICU DAY 2 :
 labored breathing, + distention neck vein , GCS
15 , + crackles
 IVF: PNSS 1 L TRA 22 gtts/min
 O2 via face mask at 10 LPM
 for “E” intubation (refused)
 Meds: Pen G
 Norepinephrine drip @ 5cc/hr
 Dopamine drip @ 10cc/hr
 For hemodialysis once IJ cath is secured
 For IJ cath insertion

24.  TCVS notes
 S/P femoral cath insertion
 May proceed to HD
1:45PM
HD order: duration 2hrs
blood flow 25ml per min
dialysate flow 400 per hr
Ultrafiltrate 500 per hr
Follow up hepatitis profile
2:33 Pm
+ desaturation
cr=20s
rr=30s fair pulses warm extremeties
CPR STARTED with 5 cycles
3:10: pronounced clinically dead

25. Septic Shock
Acute Kidney Injury probably secondary to
Leptospirosis

26. Pulmonary Hemorrhage
Weil’s Disease

28.  Human leptospiral infections can occur when
mucus membranes and skin are contaminated
by the urine of infected animals, or upon
ingestion of contaminated food and water.
 Rat is the principal source of human infection.
 Leptospirosis is endemic in the Philippines and
the number of cases peak during the rainy
months of June to August. Outbreaks have
been associated with wading in flood waters.

29.  most important
zoonotic disease in the
world
 Leptospira sp. - obligate
aerobic, motile tightly
coiled spirochetes
 23 pathogenic
species
 8 non-pathogenic
species
LEPTOSPIROSIS

30.  Reservoir: rodents
 Transmission:
 direct contact (blood, tissues, organs or
urine of infected animals)
 indirect contact (injured mucosa or
skin is exposed to contaminated water
or soil)
LEPTOSPIROSIS

31.  Common in tropical and subtropical
countries
 The median incidence
 20.6 among males < 19 years of age
 6.8 in females (10 – 19 years of age)
 Increasing incidence in the Philippines
 2,495 cases in 2017 (49.1% higher)
 234 cases from Jan to Jun 2018 (16% higher)
LEPTOSPIROSIS

32. Leptospires enter human through moist and
abraded skin or mucous membranes
Circulate in the bloodstream
Primary lesion is damage to the
endothelial lining of small blood vessels with
ischemic damage to the liver, kidneys, meninges
and muscles.

34.  Incubation period 2 to 20 days (mean: 15
days)
 Varied manifestations
 Severity of Illness:
 Asymptomatic or subclinical self-limited
febrile systemic illness (90%)
 Life-threatening illness - jaundice, renal
failure myocarditis, hemorrhage, and
refractory shock (10%)
CLINICAL MANIFESTATIONS
Handbook of Pediatric Infectious Diseases. Philippine Pediatric Society. 2014 Edition.

35.  ANICTERIC LEPTOSPIROSIS
 initial or the SEPTICEMIC PHASE
 Abrupt with fever, chills, severe headache, malaise,
nausea, vomiting, severe muscular pain and tenderness.
 Conjuctival suffusion with photophobia and orbital pain
w/o chemosis and purulent exudate.
 Hepatosplenomegaly, generalized lymphadenopathy.
 Truncal red maculopapular rash
 Second or immune phase follows a brief asymptomatic
interlude with recurrence of fever (bi phasic)
 Aseptic meningitis

36.  Icteric / Weil’s Syndrome
 Severe form affecting < 10 % of children
 Hemorrhage and Cardiovascular collapse
 RUQ pain, hepatomegaly, inc. liver enzymes,
hyperbilirubinemia
 Azotemia Oliguria ANURIA

37.  Clinical features associated with increased risk
for mortality :
 altered mental status,
 respiratory insufficiency (rales, infiltrates),
 hemoptysis,
 oliguric hyperkalemic acute renal failure,
 and cardiac involvement (myocarditis,
complete or incomplete heart block, atrial
fibrillation).

46.  If children are exposed for more than 7 days,
the dose should be repeated after 1 week.
 Prophylaxis is not 100% effective. Prevention of
exposure is most prudent. Monitor all those
exposed for the occurrence of symptoms of
leptospirosis. The early signs of infection occur
between 4 and 10 days after exposure

47.  All patients with a presumptive diagnosis of
Leptospirosis will be triaged under the
 Department of Pediatric Nephrology (Patients
< 18 yo) with the following criteria:
 1. Serum Creatinine : > 3 mg/ dl
 2. Presence of any ONE of the Criteria for Pulse
Therapy (See Appendix II)

51.  Indications for acute renal replacement
therapy or dialysis
 Uremic Symptoms
 Serum creatinine > 3mg/dL
 Serum K > 5 meqs/L in an oliguric patient
 ARDS, Pulmonary hemorrhage
 pH <7.2
 Fluid overload
 Oliguria
RENAL REPLACEMENT THERAPY

52.  Hemodialysis is preferred over peritoneal dialysis
 Hemodialysis - faster way of removal of toxins
 Hemodialysis versus Peritoneal Dialysis
 mortality (0 vs 10 %)
 renal recovery time (8.3 days vs. 16.2 days)
 reduction of serum bilirubin, urea, and creatinine
RENAL REPLACEMENT THERAPY
Wiwanitkit V. (2006). Comparison between blood exchange and classical therapy for
acute renal failure in Weil’s disease: appraisal on Thai reports. Nephrology
(Carlton);11(5):481.

57.  Incidence: 20 - 70%
 Consider if with: cough, hemoptysis,
dyspnea
 Pulmonary symptoms usually appear
between the 4th and 6th day of illness
 Pulmonary hemorrhage and Acute
Respiratory Distress Syndrome are
most common
Gouveia, E.L, Metcalfe, J., de Carvalho, A.L.F., Aires, T.S.F., Villasboas-Bisneto, J.C., Queirroz, A., Santos, A.C., Salgado, K., Reis, M.G., and
Ko, A.I. Leptospirosis-associated Severe Pulmonary Hemorrhagic Syndrome, Salvador, Brazil. Emerging Infectious
Diseases • www.cdc.gov/eid • Vol. 14, No. 3, March 2008

58.  Patients with pulmonary complications
had:
 longer duration of fever
 delayed antibiotic treatment
 platelet count <100,000
 serum creatinine >177umol/L
 bilirubin 32.4 umol/L

61.  1. Parents should instruct children not to wade
or swim in flood waters.
 2. If exposure to flood waters is unavoidable,
protective gear such as boots, goggles, overalls,
and rubber gloves should be used.
 3. All food and drinking water should be
protected against contamination. Fresh
vegetables and fruit should be washed in
previously boiled or clean water and then
 cooked or peeled.
 .

62.  4. Boil drinking water for at least 10-15 minutes.
Physical filtration through ceramic orcharcoal
filters is not adequate for leptospirosis.
 5. Food should be protected against rodent attack
or contamination.
 6. If children are exposed to flood waters, antibiotic
prophylaxis may decrease occurrence of clinical
disease and mortality. Prophylactic antibiotics
should be given under the supervision of a
physician, who can give advice regarding effects,
 precautions and contraindications for these
medications.