Paul Lane, an Intensivist from tropical Queensland gave this lecture at Bedside Critical Care 2012. The talk can be heard at www.intensivecarenetwork.com

1. Tropical Microbiology
Dr Paul Lane
CICM Daydream Is 2012

2. Outline
Melioidosis
Leptospirosis
Questions…

3. Leptospirosis
Zoonotic disease, spirochaetes called
leptospires
Natural reservoir in Rodents
Enter thru skin cut, intact mucous
membranes with subsequent bloodstream
spread to all organs
Soldiers, Banana workers (1million/yr)
Outbreaks can occur in tropical areas
affected by disaster

4. Presentation
Weil’s/ Canecutters disease
Proinflammatory cytokines activate Toll
like receptors…detonation!
Unwell, fever, myalgia, liver, renal injury
with low platelets
Pulmonary Haemorrhage, ARDS…main
cause of DEATH
Vasodilation, inotropes
Spirochaetes found in CNS

5. Immune response
Patients often get worse!!
Cochrane support this!
Traditional recommendation is Penicillin
Onset of Jarisch Herxheimer reaction
Immune mechanisms play a key role in
pathogenesis of disease, particularly
pulmonary

6. Evolution of my practice…
Constantin etal J Rheum 1996
Antineutrophil cytoplasmic antibodies in
leptospirosis
Returned travellers treated with
immunosuppression and got better!!
Change to meropenum, IV steroids as
initial therapy….less pulmonary bleeding

7. What’s out there
Sri Lanka 2008 outbreak, started IV
methylprednisolone ( 500mg/3dys then
oral)…studied 230 patients
20% down to 10%
Once severe organ dysfunction
established steroids less helpful

8. Other studies
India Shenoy etal 2006 30 patients
Mumbai floods 2005
60% vs 18%
IF GIVEN EARLY….(first 12 hrs)
Other small case series…

9. Newer advancements
Cyclophosphamide (IV 60mg/kg stat)
Trivedi etal 2009 Severe Pulmonary
Involvement…failed steroids
90% to 40% mortality
Plasma Exchange ( same author)
236 severe pulm disease…protocol of 2
washes 25ml/kg removal and low dose
cyclophosphamide…again better survival

10. What do I do…
Early steroid (1mg/kg BD MP)
Meropenum by infusion
Get aggressive early if lung hit
Early CRRT
Plasma Exchange +/- CP

11. Extras
Prophylaxis probably doesn’t work
Doxycycline if allergic
Diagnosis….CLINICAL
Finding Leptospira (CSF, blood, urine)
Rising titre (MAT)
Positive IgM (EIA)
NAT

12. Questions??

13. Melioidosis
Whitmore Disease/ Flanders
Bacteria isolated from morphine addicts in
Ragoon 1912
B. mallei vs B. pseudomallei
“Vietnamese Time Bomb”…26yr
incubation
Inhalation, cut in skin exposed to
soil/water, ingestion

14. In NQ
15-25 cases/yr, 1/5 die
1/3 cases in ‘dry season’
Better with public education
Recent JCU work reveals run off water
during high rainfall contains more
organisms then soil

15. Presentation
Acute Fulminant Sepsis
Lethal CAP plus Sepsis (50%)
Genitourinary infection
Abscesses/Osteomyelitis/Septic Arthritis
Encephalitis, Paralysis
Reactivated disease, often asymptomatic
Chronic Disease (1/16)
Prostatic Melioidosis in 20%

16. Presentation
DM, excess ETOH, CRF, steroids and
Chronic Lung Disease
Can be ‘normal’
Normally easily Dx, tell lab-modified
culture
Serology occasionally-Neuro/reactivated
disease.
RETURNED TRAVELLER- no advice is
given….

17. Antibiotics
Resistant organism ( pen, ceph, gent, cipro)
Guidelines for CAP in endemic areas
1990’s IV Ceftazadime (14days)
oral trimethoprim/sulfamethoxazole (6mths)
Now Meropenum infusion (lower MIC)
No seizures, better killing profile and decrease
endotoxin release ( yet to show better survival)
Dramatic fall in mortality (Stephens, Currie)
G CSF??? ( Not in NEJM review)

18. Case
Febrile child.
Limb weakness following laceration
Camping in bush
Mild encephalopathy

21. Questions?