A 11-year-old male child presented to the district hospital in Makawanpur, Nepal with fever, headache, fatigue, muscle pain. On examination, the child was alert with pallor. Laboratory tests showed anemia, thrombocytopenia, and neutrophilia. Differential diagnoses included leptospirosis. Leptospirosis is caused by Leptospira bacteria and transmitted through contact with infected animal urine. It has a worldwide distribution and high prevalence in Nepal. Clinical presentations include anicteric or icteric illness. Icteric leptospirosis can lead to liver and kidney damage. Rapid IgM testing was positive, confirming leptospirosis as the diagnosis in

1. LEPTOSPIROSIS
PRESENTOR: DR PRAKASH MAN SHAH
MODERATORS: DR ARUN KUMAR SINGH
DR MUKESH BHATTA
DR LALAN RAUNIYAR
DR SAGUN KHANAL

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

6. RISK GROUPS
Occupational exposure
• Farmers – Rice, Sugarcane, Vegetables, Cattle, Pigs
• Sewerage workers; Abattoirs, Butchers
• Vetenarians, Lab staff, Miners, Soldiers
• Fishermen – Inland (not on the sea)
Recreational activities
• Swimming, Sailing , Canoeing, Gardening

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

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

11. CLINICAL ILLNESSES
Types Anicteric (common 95% recover)
Icteric ( Weil’s Syndrome) (rare, fatal)
Hepato-renal syndrome
Hemorrhagic syndrome with ARF
Atypical pneumonia syndrome
Aseptic meningo-encephalitis
Myocarditis, Chronic uveitis

12. CLINICAL PRESENTATION
Anicteric
Common, mild
< 2% Mortality
Icteric
Rare, Severe
15% Mortality
90%
of
Cases
10%
of
Cases

15. ANICTERIC PRESENTATION
Leptospiremic Phase
Fever, Myalgia
Severe head ache
Conjunctival suffusion
Abd. pain, Epistaxis
Immune Phase
Mild fever
Meningism
Uveitis
I.P: 5 to 14 days (21days)

16. ICTERIC LEPTOSPIROSIS
(WEIL SYNDROME)
• LIVER
• Jaundice : Occurs in 4-6 days (2-9 days)
• Serum Bilirubin : Markedly (20-40 mg/dl)
• SGOT / SGPT : Mild elevation
• Hepatocellular necrosis / Intra hepatic cholestasis
• Death : Not due to Liver disease

17. ICTERIC LEPTOSPIROSIS
(WEIL SYNDROME)
KIDNEYS – Mild to Severe
Urinalysis : Hematuria / Pyuria / Proteinuria
Renal Failure: Pre renal azotemia, ATN / AIN
Oliguric / Non Oliguric
Mechanism
Nephrotoxicity – Endotoxin (Direct ), Bacterial migration, Toxic Metabolites
Hypoperfusion – Hypotension, Fluid loss/ Fluid shift

18. HEMORRHAGIC MANIFESTATIONS
Hemorrhagic Fever - Vascular injury
• Respiratory, Alimentary, Renal & Genital tracts
• More common in Icteric & with Renal Failure
Hemorrhagic Pneumonitis
• Hemoptysis / Respiratory failure
• CXR : Single/ Multiple ill defined opacities
• Occurs in 2nd week (as early as 24-48 hours)

19. ATYPICAL PNEUMONIA

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

23. DIFFERENTIAL DIAGNOSIS
• Fever: Viral fever, Malaria, Typhus
• Jaundice: Malaria, Viral hepatitis, Sepsis
• Renal Failure: Malaria, Hanta virus, Sepsis
• Meningitis: Bacterial / Viral causes
• Hemorrhagic Fever: Dengue, Hanta virus, Typhus

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

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

31. COMPLICATIONS
• Renal Failure
• Acute hepatic failure
• Acute cardio vascular failure
• Hemorrhage
• Meningitis
• Pneumonia

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

36. THANK YOU