LEPTOSPIROSIS

INTRODUCTION
Leptospirosis is a worldwide zoonosis caused by pathogenic species of the genus
Leptospira. In 90% of cases, leptospirosis manifests as an acute febrile illness with a
biphasic course and an excellent prognosis. Nonspecific signs and symptoms of
leptospirosis (eg, fever, headache, nausea, vomiting) are often confused with viral
illness.
DEFINITION
Leptospirosis is a febrile disease caused by infection with the bacterium Leptospira
interrogans. The disease can range from very mild and symptomless to a more
serious, even life threatening form, which may be associated with kidney failure.
HISTORY
Weil is credited with providing the first description of leptospirosis in 1886. Not
until 1915, however, was the causal agent, spirochaeta icterohaemorrhagiae,
identified by Inada and associates. Eight years earlier, Stimson unknowingly had
identified the same organism within sections of kidney obtained from a patient in
whom yellow fever had been diagnosed incorrectly.
In 1944, Randall and Cooper isolated this agent from a naturally infected dog, and
L. icterohaemorrhagiae subsequently has been associated with many animal hosts,
including goats, swine, cattle, and hamsters.
OTHER NAMES
Leptospirosis is known by many other names including Weil's syndrome,
Hemorrhagic jaundice, Mud fever, and Swineherd disease


CAUSES
Leptospirosis is caused by an infection with the bacterium Leptospira interrogans.
The bacteria are spread through contact with urine from infected animals.
EPIDEMIOLOGY
Agent factors:
Agent:Leptospira are thin and light motile spirocheates .The organisms are visible by
dark field illumination and silver staining.
Source of infection:Leptospira are excreated in the urine of infected animals for a long
time often for an entire life time in cases of rodents.
Animal reservoirs:Leptospirosis affects wild and domestic animals worldwide
especially rodents such as rats,mice and volves.
Host factors:
Age: Children acquire the infection from dogs more frequently than do adults.
Occupation: Humen infections are usually due to occupational exposure to the urine of
infected animals.
Immunity: A solid serovar specific immunity follows infection
Environmental factors: Leptospirosis infection is unique in that it is acquired through
contact with an environment contaminated by urine and faeces from carrier animal or
other infected animals.
Mode of transmission:
Direct Contact: Leptospira can enter the body through skin abrasions or through
intact mucous membrane by direct contact with urine or tissue of infected animal
Indirect contact: through the contact of broken skin with soil, water or vegetation
contaminated by urine of infected animals or through ingestion of food or water
contaminated with leptospirae.
Direct droplet infection: Infection may also occur through inhalation as when milking
infected cows or goats by breathing air polluted with droplets of urine.
PATHOPHYSIOLOGY
Leptospires are believed to enter the host through abrasions in healthy skin,
through sodden and waterlogged skin, directly through intact mucus membranes or
conjunctiva, through the nasal mucosa and cribriform plate, through the lungs (after
inhalation of aerosolized body fluid), or through the placenta during pregnancy.
Virulent organisms in a susceptible host gain rapid access to the bloodstream through
the lymphatics, resulting in leptospiremia and spread to all organs.
Incubation period: The incubation period is usually 5-14 days
TYPES CLINICAL FEATURES
Leptospirosis can occur as
Anicteric leptospirosis
Icteric leptospirosis

Anicteric leptospirosis: Occurs as a biphasic illness. The first phase is the
Septic phase followed by immune phase
i. Septic phase: Associated with the multiplication of leptospira in the
blood stream. Last for 4-7 days
The child may present with fever of abrupt onset, associated with
muscle pain, headache, nausea, vomiting, abdominal pain, etc. Less
common finding include conjunctival suffusion, a transient skin or
muscular rash, photophobia, and mild signs of meningism.
ii. Immune phase: is characterized by circulating antibodies.
Clinical features include; fever,Aseptic meningitis with abnormal CSF
profile is seen occasionally among children.
Hepatitis is characterized by enlargement of liver, elevation of bilirubin
with a modest increase in liver enzymes.
Renal involvement is characterized by abnormal findings in the urine
analysis (hematurea, protein urea and casts).

Icteric leptospirosis (Weil`s syndrome):characterized by liver, kidney and
vascular dysfunction in addition to the other symptoms of anicteric
leptospirosis. Individuals with weil`s syndrome will usually develop jaundice
without hepatocyte destruction .The liver may be enlarged and there may be
right upper quadrant tenderness. With increasing severity of jaundice, the
individual is greater risk of developing renal failure, hemorrhage and cardio
vascular collapse. Uremia, oligurea and anurea may occur with the onset of
kidney failure unless dialysis is provided.
DIAGNOSIS
Blood samples taken over a period of a few days would show an increase in the
number of antibodies. Isolating Leptospira bacteria from blood, cerebrospinal fluid
(performed by spinal tap), and urine samples is diagnostic of leptospirosis.
A second technique is an IgM- enzyme-linked immunosorbent assay (ELISA),
which detects the presence of IgM antibodies to L. interrogans in blood serum
samples.
Dark field microscopy: used to detect leptospirosis in blood with in the first 10 days
of illness and from the urine from the second week onwards.
Macroscopic agglutination test (MAST):it is a genus specific test and uses killed
leptospira as antigen.
Microscopic agglutination test (MAT): It is a serover specific test and is the gold
standard of serological test to determine leptospirosis.MAT is positive usually 10-12
days after the symptoms onset.

TREATMENT
Leptospirosis is treated with antibiotics, penicillin(250,000 units /kg/24hr in 4-5
divided doses for a period of 7 days.
Tetracycline 10-20 mg/kg/day in three divided doses for children beyond years.
Doxycycline is the alternative choice;100 mg twice for 5days.
It is generally agreed that antibiotic treatment during the first few days of illness is
helpful.
However, leptospirosis is often not diagnosed until the later stages of illness. The
benefit of antibiotic treatment in the later stages of disease, however, is controversial.
A rare complication of antibiotic therapy for leptospirosis is characterized by fever,
chills, headache, and muscle pain.

Patients with severe illness will require hospitalization for treatment and
monitoring. Medication or other treatment for pain, fever, vomiting, fluid loss,
bleeding, mental changes, and low blood pressure may be provided. Patients with
kidney failure will require hemodialysis to remove waste products from the blood.

NURSING MANAGEMENT
NURSING DIAGNOSIS
Acute pain related to bacterial infections in the body
Hyperthermia related to infectious process
impaired nutrition less than body requirement related to anorexia
activity intolerance related to physical weakness


Management
Isolate the patient and concurrent disinfection of soiled articles.
Stringent community-wide rat eradication program.Remove rubbish from work
and domestic environment to reduce rodent population.
Assess the reports of any pain including location and intensity.
Maintain adequate fluid intake
Report all cases of leptospirosis.
Investigation of contacts and source of infection
Chemoprophylaxis can be done in a group of high risk infected hosts.
Health teaching
Provide education to clients telling them to avoid swimming or wading in
potentially contaminated water or flood water.
Use of proper protection like boots and gloves when work requires exposure to
contaminated water.
Drain potentially contaminated water when possible.
Control rats in the household by using rat traps or rat poison, maintaining
cleanliness in the house.
COMPLICATIONS
Kidney damage
Kidney failure
Meningitis
Liver failure
Respiratory distress
Death


PREVENTION.
There are many ways to decrease the chances of being infected by Leptospira. These
include:
Avoid swimming or wading in freshwater ponds and slowly moving streams,
especially those located near farms.
Boil or chemically treat pond or stream water before drinking it or cooking
with it.
Control rats and mice around the home.
Have pets and farm animals vaccinated against Leptospira.
Wear protective clothing (gloves, boots, long pants, and long-sleeved shirts)
when working with wet soil or plants.











RESEARCH ABSTRACT
Pediatric presentations of leptospirosis.
Rajajee S, Shankar J, Dhattatri L
Kanchi Kamakoti Childs Trust Hospital, Nungambakkam, Chennai, India.
saralarajaje@yahoocom
Indian Journal of Pediatrics
ABSTRACT
OBJECTIVE: Leptospirosis in children is an often under diagnosed condition due
to the non specificity of the presentations except for the classical Weil's disease.
METHODS: Children presenting with symptoms and signs suggestive of
Leptospirosis were included in the study. Diagnostic criteria were fever, myalgia,
conjunctival suffusion, Jaundice, headache, altered sensorium, seizures, bleeding
manifestation and oliguria. Their clinical profile, lab parameters (general and
specific), response to treatment and outcome were analysed.

RESULT: One hundred and thirty nine cases were diagnosed during a 4-year
period. The commonest symptoms were fever 133 (96%), headache and myalgia
34 (24%). Jaundice was present in only 25 (18%) of cases with renal failure in 2
cases. The frequently encountered clinical signs were hepatomegaly in 100 (72%),
myalgia in 34 (24%) with icterus in 25 (18%), 12 (9%) of children presented with
shock and 10 (7%) had meningitis. CPK estimated was a useful index of myositis.
The diagnosis was confirmed by Dark field microscopy and paired or single high
serological tests (MAT, ELISA IgM). Overlapping infections such as culture
positive Salmonella typhi with leptospirosis (Serology positive) or Dengue
Hemorrhagic fever with Leptospirosis presented with complications such as a
myocarditis, shock and ARDS.
CONCLUSION: Presentation of non-icteric forms of Leptospirosis are often non-
specific and may be missed unless there is a high index of suspicion. This study
emphasizes the myositis and meningitis forms of leptospirosis. Delayed diagnosis
leads to increased mortality and morbidity.


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