Robert Sinto

Birth place, date : Jakarta, 21 Juni

E-mail : rsinto@yahoo.com
Formal education
2008 : Medical Doctor, Universitas Indonesia, Jakarta
2014 : Internal Medicine Specialist, Universitas Indonesia, Jakarta
2018 : Tropical and Infectious Diseases Consultant, Universitas Indonesia, Jakarta

Informal education
2015 : Clinical training on Transplant-Oncology-Immunocompromised Host Infectious
Diseases, Singapore General Hospital, Singapore
2016 : Antimicrobial Stewardship Training Course, Singapore
2018 : Antimicrobial Stewardship and Reviewer Training Course, MoH Republic of Indonesia
2018-now : Clinical Epidemiology, Julius Centre UMC Utrecht, University College of
London and Autonomous University of Barcelona.
2019 : Transplant Infectious Diseases Course, The Transplant Society, Dubai

Workplace & Position

2016-now : Department of Internal Medicine, FM Universitas Indonesia-RS Cipto Mangunkusumo
(Medical & academic staff, member of antimicrobial stewardship committee)
2015-now : Indonesian College of Internal Medicine (Officer)
2014-now : The Indonesian Society of Tropical Medicine and Infectious Diseases (Officer)
Leptospirosis:
Diagnosis and Treatment Approach

Robert Sinto
Division of Tropical and Infectious Diseases
Department of Internal Medicine
Faculty of Medicine Universitas Indonesia, RS Cipto Mangunkusumo
RS PELNI Jakarta
RS St. Carolus
Epidemiologic & Clinical Problems of
Leptospirosis
• Clinically underdiagnosed due to:
• Sub-clinical or mild infection
• Difficulty in clinical diagnosis
• No simple diagnosis criteria
• Lack of reliable diagnostic test
• Misdiagnosed as other febrile illnesses
• Lack of awareness of doctors/clinicians
• Less awareness of public health sector
Gassem MH. Leptospirosis.
 137 (67 inpatients & 70 outpatients) with acute fever
headache (85%), myalgia (70%), nausea (64%),
cough (44%), abdominal pain (38%) etc

9 (13% ) of 67 hospitalized pts with acute fever → anicteric leptospirosis

(confimed by MAT& PCR)

6 ( 9% ) of 67 hospitalized pts with acute fever: murine typhus (by IFA)

Emerging Infectious Diseases. Vol. 15, No. 6, June 2009

Leptospirosis Spread in Indonesia
• DKI Jakarta
• Jawa Barat
• Jawa Tengah
• DI Yogyakarta
• Lampung
• Sumatera Selatan
• Bengkulu
• Riau
• Sumatera Barat
• Sumatera Utara
• Bali
• NTB
• Sulawesi Selatan
• Sulawesi Utara
• Kalimantan Timur
• Kalimantan Barat
Gassem MH. Leptospirosis.
Leptospirosis di Jakarta, 2014-2018
JUMLAH KASUS LEPTOSPIROSIS DKI JAKARTA PER WILAYAH
WILAYAH Tahun 2014 TAHUN 2015 TAHUN 2016 TAHUN 2017 TAHUN 2018
JAKARTA PUSAT 12 2 6 4 1
JAKARTA UTARA 5 2 9 3 1
JAKARTA BARAT 66 25 22 15 15
JAKARTA SELATAN 9 3 6 6 4
JAKARTA TIMUR 14 2 5 5 4
KAB KEP SERIBU 0 0 0 0 1
JUMLAH 106 34 48 33 26
Situasi Leptospirosis 2019
Clinical Spectrum
Mild, anicteric leptospirosis 85-90%
• Flu-like or acute fever
• Most cases can be misdiagnosed as other acute
febrile illnesses
• Patient may not seek medical attention

Severe, icteric leptospirosis 5-15%

• Weil`s disease (Weil syndrome) → CFR is 5 -
30%
• Jaundice, hemorrhage and acute kidney injury
Gassem MH. Leptospirosis.
Multi-organs involvement in severe,
icteric leptospirosis
Organ Clinical involvement
Gastro- jaundice, hypoalbuminemia, liver
hepatobiliary dysfunction without necrosis, hematemesis,
acute pancreatitis, acalculous cholecystitis etc.
Hematologic hemorrhagic diathesis due to vascular damage,
thrombocytopenia, uremic platelet
dysfunction, multi-organ hemorrhage,
anemia, imbalance of coagulation &
fibrinolysis
Renal acute kidney injury, oliguric/non-
oliguric, mostly reversible, uremic syndrome,
metabolic acidosis

Gassem MH. Leptospirosis.

Leptospirosis and Liver Failure
• Its mimicry of common diseases such as viral hepatitis.
• Liver involvements:
▫ Transaminase levels moderately elevated in the 100s IU/L, with a
mild increase of AlP.
▫ An AST/ ALT ratio of >3 may indicate a poorer prognosis.
▫ Serum bilirubin may rise as high as 30 to 40 mg/dL.
• Jaundice as a result of septic cholestasis typically
appears during day 5 to 9 of the disease course.
• Liver function usually returns to normal without
complications.
Wysocki, et al. Proc (Bayl Univ Med Cent).2014;27:257–258.
Bharti AR, et al. Lancet Infect Dis 2003;3:757–71.
Chang ML, et al. World J Gastroenterol 2005;11:5553–6.
Gancheva G, et al.Journal of IMAB. 2007;13:27-30.
Gancheva G, et al.Journal of IMAB. 2007;13:27-30.
Gancheva G, et al.Journal of IMAB. 2007;13:27-30.
 Multi-organs involvement in severe, icteric leptospirosis

Organ Clinical involvement

Pulmonary hemoptysis, hemorrhagic pneumonitis, ARDS
Cardiac involvement is common but underestimated →
myocarditis, pericarditis, endocarditis
EKG abnormalities (~60%) arrhythmias: atrium
fibrilation, AV block, inverted T, ST elevation, rarely
with increasing CK-MB, congestive heart failure
Shock hypovolemic, cardiogenic and may be septic shock
Ocular uveitis, visual disturbance, vitreous opacities, retinal
haemorrhage etc
CNS aseptic meningitis, nerve palsy, GB like syndrome,
unconsciousness, intracranial bleeding, “stroke like”.
Skeletal rhabdomyolysis, severe myalgia, paraparesis
Gassem MH. Leptospirosis.
Major Differential Diagnoses

Severe falciparum malaria

Severe complicated typhoid

fever

Viral hemorrhagic fevers with

renal failure (HFRF)

Gassem MH. Leptospirosis.

Etiological Test
• MAT (microscopic agglutination test)
• IgM-ELISA (enzyme linked immuno
sorbent assay)
• RDTs: Lepto Dri Dot & Lepto Lateral Flow
• Real time PCR: SecY gene for early
diagnosis
• Culture

Gassem MH. Leptospirosis.

Harmonizing Clinical and Laboratory Test
Establishing Diagnosis
History of exposure to
Leptospira-contaminated environment
• Walking in flooded streets or stagnant water
• Living in flood prone areas
• Personal hygiene, wounds
• Large rat population
• Recreational exposures (water sports, triathlon)
• Occupational risk factors
Establishing Diagnosis (cont’)
Establishing Diagnosis (cont’)
Establishing Diagnosis (cont’)
DIAGRAM ALUR DIAGNOSIS KLINIS DAN LAB LEPTOSPIROSIS DI PELAYANAN KESEHATAN
Establishing Diagnosis (cont’)
Supportive Treatment
▪ Fluids and electrolytes balance

▪ Blood transfusion as indicated: platelets and/or

PRC

▪ Ventilator for patients with ARDS

▪ Dialysis (peritoneal or hemodialysis)

Gassem MH. Leptospirosis.