Over the past decade, pulmonary hemorrhage has been increasingly recognized throughout the world as a grave manifestation of leptospirosis [1–8] Physicians in regions where the disease is endemic often fail to recognize the association of pulmonary involvement with leptospirosis Available diagnostic methods, such as microscopic agglutination testing (MAT) and culture, are insufficiently sensitive, specific, or timely to be of much practical use Clinicians typically consider leptospirosis in the differential diagnosis of an acute undifferentiated fever, but only when patients present with classic textbook manifestations, such as the triad of fever, jaundice, and renal failure known as Weil disease Moreover, when patients present with less common forms of leptospirosis [9], as occurred in the epidemic of leptospirosis resulting in pulmonary hemorrhage that occurred in Nicaragua in 1995, the diagnosis is frequently either not considered or only discovered at autopsy [10]

This report demonstrates the underdiagnosis of leptospirosis and the underrecognition of severe pulmonary involvement with this disease in a region of high endemicity Pulmonary leptospirosis was present in subjects living in urban, not rural, areas A quantitative real-time PCR assay provided rapid diagnosis of leptospirosis in severe cases These cases of pulmonary involvement in leptospirosis, the first to be reported from Peru, again point out the high importance of this syndrome for public health Appropriate surveillance and control measures need to be established in this and similar regions

http://www.ins.gob.pe/repositorioaps/0/4/jer/-1/Leptopirosis/ClinicalSpectrumofPulmonaryInvolvement.pdf

Clinical Spectrum of Pulmonary Involvement in Leptospirosis in a Region of Endemicity, with Quantification of Leptospiral Burden

The risk factors for death and changes in clinical patterns in leptospirosis (Weil's disease) have not been well studied. We retrospectively studied 110 patients with Weil's disease hospitalized in Brazil between 1985 and 1996. Univariate statistical analysis showed that nonsurvivors were older than survivors, and had higher frequency of oliguria, cardiac arrhythmia, dyspnea, and pulmonary rales. Logistic regression showed that the only independent factor associated with death was oliguria (odds ratio [OR] = 8.98). The presence of arthralgia (OR = 4.71), dehydration (OR = 6.26), dyspnea (OR = 17.7), and pulmonary rales (OR = 9.91) increased after 1994. These data suggest that in Weil's disease the clinical patterns have changed and the presence of oliguria is a risk factor for death.

Risk factors for death and changing patterns in leptospirosis acute renal failure.

Background Two weeks after the cyclone during October-November 1999, several persons in Orissa suffered from a febrile illness with haemorrhagic manifestations. Serum samples from a few such patients tested positive for anti-leptospiral IgM antibodies. We conducted a study in four villages that were flooded after the cyclone to examine the possibility of leptospirosis being the cause of the outbreak. Methods One hundred forty-two persons living in four flooded villages in the Jaipur district of Orissa were interviewed for their disease history and possible risk factors after the cyclone. Blood samples were collected and tested for anti-leptospiral antibodies using the microscopic agglutination test, IgM ELISA and lepto-dipstick. Follow up samples were collected from those who had inconclusive results on the first test and the microscopic agglutination test was repeated on these samples. Results Eighty-four of the 142 study subjects had suffered a febrile illness and 40 of them had positive results in one or more IgM-based tests and 28 had a positive microscopic agglutination test result as well. Thus, 19.2% of the study subjects (28/142) had serological evidence of symptomatic leptospiral infection after the cyclone. Also, 8.5% of the subjects had low levels of antibodies indicative of the level of background seroprevalence. Conclusions The results indicate that there was an outbreak of leptospirosis in the flooded villages and the attack rate was high. A carrier state might have existed in the animal population and the cyclone and floods changed the environment drastically making it conducive for transmission of infection. Large numbers of persons were continuously exposed to flood waters and this resulted in the outbreak.

Outbreak of leptospirosis after the cyclone in Orissa.

Leptospira Species (Leptospirosis)

Leptospirosis is an infectious disease caused by pathogenic leptospires and may vary in degree from an asymptomatic infection to severe and fatal illness. Sixteen patients (all males; aged 40+/-17 years) with leptospirosis were admitted to Sisli Etfal Training and Research Hospital between July 1998 and August 2003 and were retrospectively reviewed. Age, gender, occupation, clinical presentation, laboratory features, seasonal distribution of the disease, diagnostical approach, and prognostic factors were evaluated. Eleven patients were cured with no complication; four patients died of hepatic and/or renal failure. Eight patients presented with acute renal failure; seven of them needed dialytic support. One patient developed chronic renal failure and had to undergo regular hemodialysis. All deceased patients (aged 61+/-7 years) were anuric at admission and their serum bilirubin changed between 39-44 mg/dL (mean 41.3+/-2.2 mg/dL). Cured patients ranged in age from 14-62 years (34+/-14 years) and their serum bilirubin levels ranged from 9-35 mg/dL (23.1+/-11.4 mg/dL). Crystalline penicillin G 12 million U/day was administered to all patients. Six patients also received hepatic coma treatment. This study emphasizes that leptospirosis presenting with renal failure is a severe disease, and mortality is frequently related to delays in diagnosis due to lack of clinical understanding. The association of acute renal failure and jaundice should lead the clinician to suspect leptospirosis. We concluded that old age, oliguria/anuria, high serum bilirubin levels (>36 mg/dL), and high serum potassium levels might be risk factors that increase mortality in leptospirosis.

Acute renal failure: a common manifestation of leptospirosis.

Leptospirosis is a zoonosis with protean clinical manifestations. Its diagnosis requires a high index of suspicion and is confirmed by isolation of the organism or, more commonly, by serologic tests. In the fall of 1987, after severe flooding, we saw 93 patients with leptospirosis, confirmed by a microagglutination test. Thirteen percent of the patients had no clinical or laboratory findings except fever and headache, but the rest had mild to severe manifestations. Jaundice, renal failure, and aseptic meningitis were not common, but pulmonary symptoms, when present, were striking. The mortality rate was 5%. The main cause of death was asphyxiation due to massive hemoptysis from pulmonary hemorrhage and acute respiratory failure.

Young Kyu Park

Papers

Leptospirosis in Chonbuk Province of Korea in 1987.