Clinical aspects and prognostic factors of leptospirosis in adults. Retrospective study in France

Weil's Disease in an HIV-Infected Patient: A Case Report and Literature Review

Weil's disease, an icterohemorrhagic infection, is the most severe and fatal form of leptospirosis and is characterized by jaundice, renal dysfunction, and hemorrhagic predisposition. Weil's disease with HIV infection has rarely been reported. A 68-year-old male with HIV infection presented to our hospital with fever and dyspnea that progressed to severe hemoptysis and systemic multiple organ failure, necessitating a tracheal intubation ventilator. A diagnosis of Weil's disease was made after Leptospira interrogans was identified via metagenomic next-generation sequencing (mNGS) in bronchoalveolar lavage fluid (BALF). After immediately receiving supportive therapy and targeted antimicrobial agents, the patient achieved complete recovery upon discharge. The co-infection of HIV infection and leptospirosis resulting in systemic multi-organ failure is rare, but awareness should be raised of the differential diagnosis. mNGS can help identify pathogens and facilitate the use of targeted and efficacious antimicrobial therapy in unusual clinical environments.

Prognostic Factors for Leptospirosis Infection Severity

BACKGROUND

Leptospirosis is an important health problem in Thailand. People infected with leptospirosis may not have any mild symptoms, whereas some people have acute and severe illnesses. It is crucial to strengthen critical patients' diagnosis and treatment to prevent severe complications and reduce mortality. This study was performed to explore a set of parameters for the prediction of severe leptospirosis illness under routine clinical practice.

METHODS

A case-control study was conducted in eight general hospitals in Thailand. Retrospective collection data were used, and key information was retrieved from inpatient medical files. Patients were grouped into two severity categories, severe and non-severe infection. Backward elimination was used to reach the final multivariate model.

RESULTS

The six significant predictors identified in the study were hemoptysis (OR = 25.80, 95% CI 5.69, 116.92), hypotension (blood pressure < 90/60 mmHg) (OR = 17.33, 95% CI 6.89, 43.58), platelet count < 100,000/µL (OR = 8.37, 95% CI 4.65, 15.09), white blood cell count (WBC) > 14,000/µL (OR = 5.12, 95% CI 2.75, 9.51), hematocrit ≤ 30% (OR = 3.49, 95% CI 1.61, 7.57), and jaundice (OR = 3.11, 95% CI 1.71, 5.65). These predictors could correctly predict the severity of leptospirosis infection in 91.31% of the area under the receiver operation curve (AuROC).

CONCLUSIONS

The results of this study showed that severe leptospirosis infections have identifiable predictors. The predictors may be used to develop a scoring system for predicting the level of severity.

Monitoring of Leptospira species diversity in freshwater bathing area and in rats in Paris, France

Leptospirosis is a neglected zoonotic disease with a worldwide distribution caused by bacterial pathogenic Leptospira. Rodents are considered as the main reservoir of Leptospira and transmission usually occurs through exposure to urine-contaminated environment. However, interactions between environment, rodent reservoir and human leptospirosis remain poorly studied. Here, we evaluated the concentration of Leptospira in surface water and captured rats in the city of Paris (France) from 2018 to 2020 using an integrity qPCR (Quantitative Polymerase Chain Reaction). All environmental samples (n = 1031) were positive for saprophytic Leptospira but pathogenic Leptospira P1 group were only found in 40% (n = 363; 2018) to 0% (n = 264; 2020) of samples. In the same time, analysis of 200 brown rat corpses trapped in the city, showed about 15% of positivity for Leptospira but the different method used for rats conservation (based on presence or absence of conservative agent) showed important variations in the Leptospira prevalence. Metagenomic analysis, based on rrs gene sequencing, was also carried out to evaluate the distribution of Leptospira in samples. Results could indicate that some species of Leptospira are found in surface waters as well as rats, but further study is needed to accurately describe the nature of the link between these two reservoirs. Quantification of Leptospira and pathogenic species description circulating inside animal reservoir living in the vicinity of freshwater in urban areas, will be helpful to understand the eco-epidemiology of leptospirosis and to establish prevention and intervention strategies, especially in the context of organization of recreative activity events in these urban areas.

Leptospirosis in retirees living in rural areas: a poorly recognized emerging problem in mainland France?

Among 40 patients diagnosed with leptospirosis in 3 hospitals of western mainland France between 2014 and 2018 half were at least 60 years old and retired. Their exposure factors were mainly rural residential environment with limited remarkable risk factors. Better awareness and information on leptospirosis appear necessary in this population.

Survey of rodent-borne pathogens in Singapore reveals the circulation of Leptospira spp., Seoul hantavirus, and Rickettsia typhi

Rodents living alongside humans increases the probability of encounter and also the transmission of rodent-borne diseases. Singapore’s cosmopolitan urban landscape provides a perfect setting to study the prevalence of four rodent-borne pathogens: Seoul hantavirus (SEOV), Leptospira species, Rickettsia typhi and Yersinia pestis, and identify the potential risk factors which may influence rodent density and transmission of rodent-borne diseases. A total of 1143 rodents were trapped from 10 unique landscape structures throughout Singapore. Real-time quantitative Polymerase Chain Reactions were used to detect pathogenic and intermediate Leptospira spp. and Yersinia pestis, whereas the seroprevalence of SEOV and R. typhi were analysed by Enzyme-Linked Immunosorbent Assay and Immunofluorescence Assay respectively. Multivariable logistic regression analysis was used to evaluate the association between prevalence of infection in rodent reservoirs and risk factors. Most of the rodents were caught in public residential developments (62.2%). Among the tested rodents, 42.4% were infected with Leptospira spp., while 35.5% and 32.2% were seropositive for SEOV and R. typhi respectively, whereas Yersinia pestis was not detected. Furthermore, risk factors including habitat, species, gender, and weight of rodents, influenced prevalence of infection to a varying extent. This study highlights the presence of Leptospira spp., SEOV and R. typhi in Singapore’s rodent population, suggesting the need for effective rodent management and sanitation strategies to prevent further circulation and transmission to humans.

Leptospiral meningoencephalitis in a raccoon dog

Neuroleptospirosis is a rare disease caused by pathogenic Leptospira interrogans in humans; however, it has not been fully studied in animals. A young wild raccoon dog was found convulsing in the recumbent position and died the next day. Histologic examination revealed nonsuppurative meningoencephalitis in the cerebrum, cerebellum, midbrain, and medulla oblongata. The lesions consisted of mixed infiltrates of Iba1-positive macrophages and CD3-positive T cells, with a small number of CD79α-positive B cells and myeloperoxidase-positive neutrophils. In the frontal cortex, perivascular cuffs and adjacent microglial nodules were distributed diffusely, especially in the molecular layer. Glial nodules were comprised of Iba1- and myeloperoxidase-positive activated microglia. Immunohistochemistry revealed leptospires in mononuclear cell perivascular cuffs, but not in glial nodules. Neuroleptospirosis was accompanied by Leptospira-related nonsuppurative interstitial nephritis, pulmonary edema and hemorrhage, and coronary periarteritis, as well as Toxocara tanuki in the small intestine and nonspecific foreign-body granulomas in the lungs and stomach.

Leptospirosis with pulmonary haemorrhage and multiple organ failure: a case report and literature review

Pulmonary haemorrhage is an important complication of leptospirosis. We herein report an uncommon case of severe pulmonary haemorrhage and multiple organ failure caused by leptospirosis in a 49-year-old man who was previously healthy. He was a farm worker who was admitted to the hospital because of haemoptysis. He had worked in a paddy field 4 days prior to admission. Chest computed tomography revealed pulmonary haemorrhage, which rapidly deteriorated into haemorrhagic shock and multiple organ failure. Based on the patient’s possible history of contact with contaminated water and the DNA sequence of Leptospira detected in his bronchoalveolar lavage fluid, the patient was diagnosed with pulmonary haemorrhagic leptospirosis. Despite the administration of a fluid bolus, norepinephrine, broad-spectrum antibiotics, and haemostatics, and even with administration of a blood transfusion and extracorporeal life support, the pulmonary haemorrhage could not be controlled effectively. The patient eventually died of haemorrhagic shock. Leptospirosis can be a life-threatening disease despite aggressive treatment, even with extracorporeal life support. Next-generation sequencing can provide important diagnostic clues for patients with atypical leptospirotic symptoms.

Effect of disinfection agents and quantification of potentially viable Leptospira in fresh water samples using a highly sensitive integrity-qPCR assay

Leptospirosis is an emerging worldwide zoonotic disease, but the general biology of the causative agents is still poorly understood. Humans are an occasional host. The main risk factors are water-associated exposure during professional or recreational activities or during outbreaks in endemic areas. Detecting the presence of pathogenic bacteria in aquatic environments and their capacity to resist various inactivation processes are research fields that need to be further developed. In addition, the methods used for detecting and enumerating Leptospira still need to be improved. We aimed to describe a new quantitative polymerase chain reaction coupled to propidium monoazide treatment (PMAqPCR) that targets not only total Leptospira but also discriminates pathogenic from non-pathogenic Leptospira while also addressing PCR inhibitors, a frequently encountered problem when studying environmental water. In a second step, the killing efficiency of Leptospira to different treatments was tested and PMAqPCR compared to culture-based enumeration. This provided information about the effects of temperature, as well as ultraviolet and chlorine disinfection, that are both related to water treatment processes, in particular for the production of drinking water, on the persistence of both saprophytic and pathogenic Leptospira. Finally, PMAqPCR was used for the detection of Leptospira in freshwater samples for a proof-of-concept. In conclusion, our method could be used for routine freshwater monitoring and allows better evaluation of the presence of Leptospira, allowing evaluation of the bacterial dynamics in a designated area or assessment of the efficacy of water disinfection processes.

[Febrile episodes, headache and limb pain as well as generalized myalgia in a 27-year-old returning male traveller]

Unspezifische grippale Symptome wie Fieber, Gliederschmerzen und Kopfschmerzen kommen in der Hausarztpraxis und Notfallstation sehr häufig vor. Beim septischen Patienten mit positiver Reiseanamnese für wärmere Breitengrade muss die Differenzialdiagnose neben banalen viralen Erkrankungen auf seltenere Ursachen erweitert werden. Ein 27-jähriger Schweizer präsentierte sich mit oben genannten Symptomen nach einem Ferienaufenthalt in Südfrankreich. Nach rascher Zustandsverschlechterung mit Lungen‑, Leber- und Nierenbeteiligung musste der Patient intensivmedizinisch behandelt werden. Die klinisch vermutete Diagnose einer Leptospirose ließ sich im Verlauf serologisch bestätigen.

Pathogenic Leptospira species in rodents from Corsica (France)

Leptospirosis is a worldwide emerging zoonotic disease caused by Leptospira species, that in some patients develop severe forms with high mortality. In France, Corsica is the area where the highest incidences have been reported. The present study was focused on the analysis of pathogenic Leptospira species in rodents of Corsica, as these micromammals are the main natural reservoirs of the bacteria, in order to identify the circulating species and to locate possible risk focuses of transmission, as no previous study on the presence of Leptospira species has been carried out in the island. Rattus rattus, Rattus norvegicus, Apodemus sylvaticus and Mus musculus domesticus were captured in the proximity of water sources along Corsica, the detection of pathogenic Leptospira species was carried out by amplification of the LipL32 gene. The bacteria were found in all the rodent species analyzed and widely. The general prevalence was 10.4%, reaching the maximum value in Bastia (45%). Leptospira interrogans and Leptospira borgpetersenii were identified by phylogenetic analysis, but also two sequences which corresponded to an unnamed Leptospira species, only previously found in rodents of New Caledonia. The high incidence of human leptospirosis in Corsica could be partially explained by the wide distribution of pathogenic Leptospira species identified in this study. Also, the presence of an unknown pathogenic species of Leptospira in an area with high prevalence, may be involved in the higher incidence of Leptospirosis in this island, however, the zoonotic capacity of this species remains unknown. The results obtained are interesting for public health since all positive samples were found near water sources and one of the routes of transmission of leptospirosis is contact with contaminated water. This information could help the competent entities to take preventive measures, reducing the incidence of human leptospirosis in Corsica.

Management of Travel-Related Infectious Diseases in the Emergency Department

Purpose of Review

Emergency physicians generally have limited exposure to internationally acquired illnesses. However, travelers can present quite ill, and delays in recognition and treatment can lead to increased morbidity and mortality. This paper aims to summarize typical presentations of common international diseases and provide the emergency physician with a practical approach based on current guidelines.

Recent Findings

In the treatment of traveler’s diarrhea, azithromycin has become the treatment of choice due to the growing antibiotic resistance. Intravenous artesunate was approved in 2019 under investigational new drug protocol for the treatment of severe malaria, and artemisinin-based combination therapies (ACTs) have become the first-line treatment for most cases of uncomplicated malaria. Since the 2015 outbreak, Zika has become a concern to many travelers, but the current treatment is supportive.

Summary

Clinicians should be aware of a few noteworthy updates in the treatment of internationally acquired illnesses, but more importantly, they must recognize warning signs of severe illness and treat promptly. Future research on workup and disposition could help emergency physicians identify which patients need admission in well-appearing febrile travelers.

Significant Clinical Presentation of Leptospirosis in Relation to Sociodemographic and Risk Factors in a Tertiary Hospital, Malaysia

Introduction: Incidence of leptospirosis has increased within the past few years in many countries. Its clinical presentations were generally nonspecific, making it difficult to assist in the diagnosis. Besides the determination of the common clinical features, the sociodemographic background is essential to identify high-risk populations to assist in prevention. Methods: Data for this study were obtained from electronic medical records among patients clinically diagnosed with leptospirosis at a tertiary hospital in Malaysia from the years 2011 to 2015 and were recorded using standard pro forma. Associations between clinical features and sociodemographics were performed using bivariate analysis and logistic regression. Results: Data were collected from 283 patients. Their mean age was 30.71 years old. Out of 283 patients, 206 (72.8%) were male. Involvement in outdoor events and water activities was the highest risk factor of acquiring leptospirosis in 64 (22.7%) patients followed by 59 (20.8%) patients who were staying in crowded housing areas with poor sanitation. Although fever was the main clinical presentation in 274 (96.8%) patients with leptospirosis, gastrointestinal (GIT) symptoms were the second most frequent in 159 (56.2%) patients followed by pulmonary symptoms, myalgia, headache, and jaundice. From the total number of 283 patients, only 21 (92.6%) presented with severe leptospirosis. GIT symptoms were a significant predictor for leptospirosis severity, while the age group was the significant sociodemographic factor toward GIT presentation in leptospirosis. The relationship between GIT symptoms and crowded housing areas with poor sanitation was also significant. Multivariable logistic regression showed that crowded housing areas with poor sanitation (odds ratio [OR] = 3.570, p < 0.001) and age between 20 and 40 years old (OR = 2.056, p = 0.014) were more likely to have GIT symptoms. Conclusions: Information regarding the clinical features of leptospirosis to the public is necessary, while targeted prevention by educational outreach among 20-40 year olds especially those participating in outdoor water activities are crucial to decrease the incidence and complications of leptospirosis.

Leptospirosis: Increasing importance in developing countries

Leptospirosis is a zoonotic disease caused by the pathogenic helical spirochetes, Leptospira. Symptoms include sudden-onset fever, severe headaches, muscle pain, nausea and chills. Leptospirosis is endemic in developing countries such as Malaysia, India, Sri Lanka, and Brazil where thousands of cases are reported annually. The disease risk factors include the high population of reservoirs, environmental factors, recreational factors, and occupational factors. To end the endemicity of leptospirosis, these factors need to be tackled. The management of leptospirosis needs to be refined. Early diagnosis remains a challenge due to a lack of clinical suspicion among physicians, its non-specific symptoms and a limited availability of rapid point-of-care diagnostic tests. The purpose of this review is to provide insight into the status of leptospirosis in developing countries focusing on the risk factors and to propose methods for the improved management of the disease.

Hiding in plain sight: A case of fever, rash, and jaundice

A 25-year-old man presented to the emergency department with a 3-day history of fever, anorexia, jaundice, and a generalized skin eruption. His liver function tests showed marked cholestatic and cytolytic abnormalities without liver insufficiency. A liver biopsy was performed, and morphology with routine stains was considered non-specific. Because of the dermatological findings, the non-specific biopsy morphology, and the absence of an identified infectious etiology, a diagnosis of Kawasaki disease was presumed. However, additional colorations on liver biopsy with Warthin-Starry stain revealed multiple thin and coiled microorganisms compatible with spirochetes. His serology for leptospirosis was found to be positive for IgM, supporting the diagnosis of acute leptospirosis with liver involvement. Our case illustrates the diagnostic challenge of leptospirosis and highlights the utility of conventional laboratory tests to confirm the diagnosis. Exceptionally, Warthin-Starry stain allowed the identification of leptospires in liver biopsy and confirmed liver involvement of systemic leptospirosis.

Leptospirosis meningitis transmission from a pet mouse: a case report

Background

Leptospirosis is a reemerging zoonosis with a worldwide distribution and a wide range of clinical manifestations. We report a case of leptospirosis meningitis in a previously healthy woman infected by her pet mouse.

Case presentation

A 27-year-old Caucasian woman with pet mice presented to our institute with a 1 week history of fever, headache, myalgia, vomiting, diarrhea, and dark urine. Her admission examination revealed neck stiffness, conjunctivitis, and icteric sclera. Her liver enzymes, bilirubin, white blood cell count, and C-reactive protein were elevated. Her cerebrospinal fluid showed an elevated white blood cell count. Polymerase chain reactions using her cerebrospinal fluid, blood, and urine showed negative results for leptospirosis, but the result of her microagglutination test was positive for Leptospira interrogans serovar sejroe with a more than threefold increase in paired sera. The patient was treated with ceftriaxone for 1 week, and her condition steadily improved.

Conclusions

This case report raises awareness of pet rodents as sources of leptospirosis. Leptospirosis meningitis should be considered in patients with meningeal symptoms and pet rodents.

Identifying factors associated with treatment delay in leptospirosis: A retrospective study of patients admitted to hospital in Reunion (Indian Ocean) between 2014 and 2015

BACKGROUND

Leptospirosis is a life-threatening zoonotic disease for which delayed treatment onset has been associated to poor prognosis. The purpose of the study was to identify the determinants of therapeutic delay in hospitalized leptospirosis cases.

PATIENTS AND METHODS

We carried out a retrospective multicenter study in the 4 public hospitals of Reunion Island, South Western Indian Ocean. Medical records of confirmed leptospirosis cases occurring in 2014-2015 were reviewed for socio-economic, demographic, geographic and medical data. The primary outcome measure was the therapeutic delay, defined as the time elapsed between the onset of symptoms and initiation of antibiotics.

RESULTS

Of the 117 patients included, 107 were men, with an average age of 44.9±15years. The median therapeutic delay was 4 days (interquartile: 2-5 days) and this delay was not found to be associated with severity. The following were found to be at increased risk of having a longer therapeutic delay: cases occurring outside the epidemic period, or rainy season (OR 2.8 [1.08-7.3], P=0.04) and cases with first medical evaluation in primary health care (OR 4.63 [1.43-14.93]; P=0.01) instead of emergency unit. No socio-economic or geographic characteristics were found to be linked to a longer therapeutic delay.

CONCLUSION

Although delayed treatment was not associated to disease severity, our results indicate that leptospirosis awareness is needed all year in the subtropical area of Reunion Island and particularly in primary care.

Weil's disease with haemoptysis and acute respiratory distress syndrome

A 35-year-old male patient reached the emergency department after an episode of massive haemoptysis a few hours ago. Fever and dyspnea were mentioned to be present the last 5 days. His medical history included only malaria, successfully treated 2 years ago. Clinical examination revealed high fever, jaundice, cyanosis, tachypnea and bilateral rales on pulmonary auscultation. Laboratory investigation showed high erythrocyte sedimentation rate and C reactive protein, leucocytosis, anaemia, mild thrombocytopaenia, renal impairment, hyperbilirubinaemia and abnormal liver function tests; arterial blood gas analysis showed respiratory alkalosis with severe hypoxia. Thoracic X-ray revealed bilateral pulmonary infiltrates, whereas abdominal and heart ultrasound detected hepatomegaly and small pericardial infusion, respectively. The diagnosis of leptospirosis along with acute respiratory distress syndrome was confirmed by positive IgM Leptospira antibodies. Empirical treatment with triple antibiotic therapy and corticosteroids was applied. The patient was discharged after 1 week, without any symptoms and with almost normal laboratory tests.

Thai-Lepto-on-admission probability (THAI-LEPTO) score as an early tool for initial diagnosis of leptospirosis: Result from Thai-Lepto AKI study group

Background

Leptospirosis is one of the most important zoonosis in the tropics. Currently, specific laboratory diagnostic test for leptospirosis such as polymerase chain reaction (PCR) or direct culture cannot be applied at the primary care setting especially in the resource- limited countries. Therefore, clinical presentation and laboratory examination are still the primary diagnostic tools for leptospirosis.

Objectives

To detect clinical factors for predicting leptospirosis in suspected cases, and to create a clinical prediction score (THAI-LEPTO) that is practical and easy to use in general practice while awaiting laboratory results.

Materials and methods

We performed a prospective multicenter study with a development and a validation cohort of patients presenting with clinical suspicion of leptospirosis as per the WHO clinical criteria. The development cohort was conducted at 11 centers in 8 provinces around Thailand. The validation cohort was conducted at 4 centers in 1 province from the Northeastern part of Thailand. Leptospirosis confirmed cases were defined if any one of the tests were positive: microscopic agglutination test, direct culture, or PCR technique. Multivariable logistic regression was used to identify predictors of leptospirosis. The clinical prediction score was derived from the regression coefficients (original) or from the odds ratio values (simplified). We used receiver operating characteristic (ROC) curve analysis to evaluate the diagnostic ability of our score and to find the optimal cutoff values of the score. We used a validation cohort to evaluate the accuracy of our methods.

Results

In the development cohort, we enrolled 221 leptospirosis suspected cases and analyzed 211. Among those, 105 (50%) were leptospirosis confirmed cases. In logistic regression adjusted for age, gender, day of fever, and one clinical factor at a time, leptospirosis group had more hypotension OR = 2.76 (95% CI 1.07–7.10), jaundice OR = 3.40 (95%CI 1.48–8.44), muscle pain OR = 2.12 (95%CI 1.06–4.26), acute kidney injury (AKI) OR = 2.90 (95%CI 1.31–6.15), low hemoglobin OR = 3.48 (95%CI 1.72–7.04), and hypokalemia with hyponatremia OR = 3.56 (95%CI 1.17–10.84) than non-leptospirosis group. The abovementioned factors along with neutrophilia and pulmonary opacity were used in the development of the score. The simplified score with 7 variables was the summation of the odds ratio values as follows: hypotension 3, jaundice 2, muscle pain 2, AKI 1.5, low hemoglobin 3, hypokalemia with hyponatremia 3, and neutrophilia 1. The score showed the highest discriminatory power with area under the curve (AUC) 0.82 (95%CI 0.67–0.97) on fever day 3–4. In the validation cohort we enrolled 96 leptospirosis suspected cases and analyzed 92. Of those, 69 (75%) were leptospirosis confirmed cases. The performance of the simplified score with 7 variables at a cutoff of 4 was AUC 0.78 (95%CI 0.68–0.89); sensitivity 73.5; specificity 73.7; positive predictive value 87.8; negative predictive value 58.3.

Conclusions

THAI-LEPTO score is a newly developed diagnostic tool for early presumptive diagnosis of leptospirosis in patients presenting with severe clinical suspicion of the disease. The score can easily be applied at the point of care while awaiting confirmatory laboratory results. Each predictor used has been supported by evidence of clinical and pathophysiological correlation.

Leptospirosis is an important zoonosis in the tropics. However, there is still a major barrier of early diagnosis of leptospirosis due to a lack of specific and sensitive testing. Moreover, in resource-limited countries with small budgets, a simple and cheap diagnostic test is essential for the diagnosis of leptospirosis. The THAI-LEPTO score has been developed and validated based on the relevant clinical history and related laboratory test. This score will help the physician in early diagnosis and prompt treatment leptospirosis as a point of care test. Finally, we aim that this scoring system can be one of the key parts of diagnostic algorithm and improve leptospirosis patients’ outcome.

Cardiac Magnetic Resonance of Myocardial Involvement in Leptospirosis

Leptospirosis is a zoonotic infection caused by the Leptospira interrogans. Although it is endemic in tropical countries, global incidence has increased in several temperate and developed regions. Here, we present a cardiac magnetic resonance (CMR) and multidetector computer tomography (MDCT) chest features of active systemic leptospiral infection in a 19-year-old male. The MDCT appearances of lungs and CMR appearances of myocardium in icteric leptospirosis are described. Early diagnosis and prompt treatment is important to manage the cardiothoracic complications.

Epidemiological and clinical features of leptospirosis in a highly endemic area over three time periods

OBJECTIVES

To present the features of human leptospirosis over three time periods (1970-1975; 2000-2005; 2010-2015), to compare the collected data and to determine whether the incidence, seasonal and spatial distribution, prevalence of presumptive infective serogroups and clinical features have changed over the last 50 years.

METHODS

Epidemiological and clinical data obtained from patients hospitalised and treated in a well-known endemic focus of leptospirosis, Koprivnica-Križevci County in Croatia, were analysed.

RESULTS

We observed a steady decline in the overall incidence of leptospirosis and a change in the patient age distribution, with the age ratio changing in favour of middle-aged and older patients. Although leptospirosis was most frequently diagnosed in August in all time periods, the number of cases increased in autumn. The most prevalent serogroup during the first and the second time period was Icterohaemorrhagiae, while in the third time period, the serogroup Australis prevailed. We also noted an increase in the number of severe clinical manifestations.

CONCLUSIONS

This retrospective research demonstrates a continuous decline in the incidence of human leptospirosis in Croatia. The pattern of disease has changed from predominantly mild clinical forms observed in children to more severe clinical forms observed in middle-aged to older patients, especially those working in agriculture. Additional epidemiological changes included an increase in the number of cases during the autumn months and changes in prevailing serogroups. Statistical analysis revealed a significant relationship between the severity of the clinical picture, patient age and presumed sources of infection.

Clinical, serological and echocardiographic examination of healthy field dogs before and after vaccination with a commercial tetravalent leptospirosis vaccine

Background

Leptospirosis is a re-emerging bacterial zoonosis caused by spirochetes of the genus Leptospira. Severe disease has been reported in dogs in Europe despite vaccination with bivalent Leptospira vaccines. Recently, a tetravalent canine Leptospira vaccine (Nobivac® L4) was licenced in Europe. The goal of this study was to investigate clinical signs, microscopic agglutination test (MAT) titres, haematology, blood biochemistry, cardiac (c) Troponin I levels and echocardiography before and after vaccination with this tetravalent vaccine. Forty-eight healthy dogs were prospectively enrolled and vaccinated twice, 3–4 weeks apart (T0 and T1). Before vaccination (T0) and 16–31 days after the second vaccination (T2), MAT (n = 48), haematology (n = 48), blood biochemistry (n = 36) and cTroponin I measurements (n = 29) were performed, and MAT was repeated 347–413 days after the second vaccination (T3, n = 44). Echocardiography was performed before the first and second vaccination (T0 and T1, n = 24).

Results

Mild and transient clinical signs within 5 days following the first and second vaccination occurred in 23% and 10% of the dogs, respectively. Before the first vaccination (T0), all dogs showed negative MAT titres for the tested serovars except for Canicola (50% with titres 100–400). At T2, positive MAT titres to the serovars Canicola (100%), Australis (89%), Grippotyphosa (86%), Bratislava (60%), Autumnalis (58%), Copenhageni (42%), Pomona (12%), Pyrogenes (8%) and Icterohaemorrhagiae (2%) were found. Median to high titres (≥ 400) were most common to the serovar Canicola (92%) and less common to the serovars Australis (41%), Grippotyphosa (21%), Bratislava (12%), Autumnalis (4%), Pyrogenes (4%) and Pomona (2%). At T3, positive MAT titres (titre range: 100–400) were found in 2–18% of the dogs to serovars of the vaccine serogroups and in 2–18% of the dogs to the non-vaccine serovars Pomona, Autumnalis, Pyrogenes and Ballum. Haematology, blood biochemistry, cTroponin I levels and echocardiography results did not change significantly following vaccination.

Conclusions

Clinical signs following vaccination with Nobivac® L4 were transient and mild in all cases. Seroconversion differed considerably among individual dogs and among the vaccine serogroups.

Electronic supplementary material

The online version of this article (doi:10.1186/s12917-017-1056-x) contains supplementary material, which is available to authorized users.

Changing patterns in leptospirosis: a three-decade study in Brazil

BACKGROUND

This study was conducted to investigate changes in the clinical pattern of leptospirosis over time, analyzing its clinical and laboratory presentations in a metropolitan city of Brazil.

METHOD

This was a retrospective study including all patients with leptospirosis admitted to tertiary care hospitals in Fortaleza in the northeast of Brazil, between 1985 and 2015. Patients were divided into three groups according to the year of hospital admission: group I for the years 1985-1995, group II for 1996-2005, and group III for 2006-2015. Demographic, clinical, and laboratory data were compared between the groups.

RESULTS

A total of 507 patients were included. Their mean age was 37.3±15.9years and 82.4% were male. The mean time between symptom onset and admission was 7±4 days. There was a linear decrease in the levels of serum urea (190.1±92.7, 135±79.5, and 95.6±73.3mg/dl, respectively, p <0.0001) and creatinine (5.8±2.9, 3.8±2.6, and 3.0±2.5mg/dl, respectively, p <0.0001) in each decade, while levels of hemoglobin (10.31±1.9, 10.8±2.0, and 11.5±2.1g/dl, respectively, p <0.0001) and platelets (57.900±52.650, 80.130±68.836, and 107.101±99.699×10⁹/l, respectively, p<0.0001) increased. There was a tendency towards a linear decrease in mortality (22%, 14%, and 11.6%, respectively, p=0.060).

CONCLUSIONS

Leptospirosis showed significant changes over time in this region. The main changes point to a decrease in disease severity and complications, such as acute kidney injury. Mortality has decreased, being close to 11%.

Leptospira Infection Interferes with the Prothrombinase Complex Assembly during Experimental Leptospirosis

Leptospirosis is a worldwide zoonotic and neglected infectious disease of human and veterinary concern, caused by pathogenic Leptospira species. Although bleeding is a common symptom of severe leptospirosis, the cause of hemorrhage is not completely understood. In severe infections, modulation of hemostasis by pathogens is an important virulence mechanism, and hemostatic impairments such as coagulation/fibrinolysis dysfunction are frequently observed. Here, we analyze the coagulation status of experimentally infected hamsters in an attempt to determine coagulation interferences and the origin of leptospirosis hemorrhagic symptomatology. Hamsters were experimentally infected with L. interrogans. The lungs, kidneys, and livers were collected for culture, histopathology, and coagulation assays. L. interrogans infection disturbs normal coagulation in the organs of animals. Our results suggest the presence of a thrombin-like factor or FX activator, which is able to activate FII in the leptospirosis organ extracts. The activity of those factors is accelerated in the prothrombinase complex. Additionally, we show for the first time that live leptospires act as a surface for the prothrombinase complex assembly. Our results contribute to the understanding of leptospirosis pathophysiological mechanisms and may open new routes for the discovery of novel treatments in the severe manifestations of the disease.

Determinants of mortality and impact of therapy in patients with leptospirosis admitted for intensive care in a Sri Lankan hospital--a three year retrospective study

INTRODUCTION

Leptospirosis is a disease of epidemic proportions in Sri Lanka. There is paucity of data on the determinants of mortality and impact of therapy in patients with leptospirosis admitted to critical care settings in endemic territories.

METHODOLOGY

This retrospective cross-sectional study was performed in patients with serologically confirmed leptospirosis admitted to the intensive care unit of the General Hospital, Kalutara from January 2011 to April 2014. Associations between socio-epidemiological, clinical and laboratory parameters and patient mortality were examined.

RESULTS

Forty-five patients were included. The mean age was 49.11(SD = 16.95) and majority (92%) were male. Percentage mortality was 44.4%. Patient mortality was associated with age > 40 (p = 0.012), symptoms of uremia (p = 0.017), evidence of CNS involvement (p = 0.039), presence of oliguria (p = 0.002) and anuria (p = 0.014), presence of multi-organ dysfunction syndrome (MODS) (p < 0.001), CRP > 96 (p = 0.036), platelet count < 20,000 (p = 0.045), Potassium > 5.0 (p = 0.05), metabolic acidosis with pH < 7.2 (p = 0.03), INR > 2 (p = 0.037) and requirement of mechanical ventilation (p < 0.001). Cox regression analysis revealed MODS and potassium > 5 to be independently associated with mortality.

CONCLUSIONS

A high mortality rate is noted. The presence of MODS and serum potassium concentration > 5.0 was independently associated with mortality in this retrospective study of patients with confirmed leptospirosis in a critical care setting.

Hedgehogs and Mustelid Species: Major Carriers of Pathogenic Leptospira, a Survey in 28 Animal Species in France (20122015)

Human leptospirosis is a zoonotic and potentially fatal disease that has increasingly been reported in both developing and developed countries, including France. However, our understanding of the basic aspects of the epidemiology of this disease, including the source of Leptospira serogroup Australis infections in humans and domestic animals, remains incomplete. We investigated the genetic diversity of Leptospira in 28 species of wildlife other than rats using variable number tandem repeat (VNTR) and multispacer sequence typing (MST). The DNA of pathogenic Leptospira was detected in the kidney tissues of 201 individuals out of 3,738 tested individuals. A wide diversity, including 50 VNTR profiles and 8 MST profiles, was observed. Hedgehogs and mustelid species had the highest risk of being infected (logistic regression, OR = 66.8, CI95% = 30.9-144 and OR = 16.7, CI95% = 8.7-31.8, respectively). Almost all genetic profiles obtained from the hedgehogs were related to Leptospira interrogans Australis, suggesting the latter as a host-adapted bacterium, whereas mustelid species were infected by various genotypes, suggesting their interaction with Leptospira was different. By providing an inventory of the circulating strains of Leptospira and by pointing to hedgehogs as a potential reservoir of L. interrogans Australis, our study advances current knowledge on Leptospira animal carriers, and this information could serve to enhance epidemiological investigations in the future.

Risk factors for intensive care unit admission in patients with severe leptospirosis: a comparative study according to patients' severity

BACKGROUND

The aim of this study is to investigate predictive factors for intensive care unit (ICU) admission among patients with severe leptospirosis.

METHODS

This is a retrospective study with all patients with severe leptospirosis admitted to a tertiary hospital. Patients were divided in ICU and ward groups. Demographical, clinical and laboratory data of the groups were compared as well as acute kidney injury (AKI) severity, according to the RIFLE criteria (R = Risk, I = Injury, F = Failure, L = Loss, E = End-stage kidney disease).

RESULTS

A total of 206 patients were included, 83 admitted to ICU and 123 to ward. Mean age was 36 ± 15.8 years, with 85.9% males. Patients in ICU group were older (38.8 ± 15.7 vs. 34.16 ± 15.9 years, p = 0.037), had a shorter hospital stay (4.13 ± 3.1 vs. 9.5 ± 5.2 days, p = 0.0001), lower levels of hematocrit (29.6 ± 6.4 vs. 33.1 ± 8.6%, p = 0.003), hemoglobin (10.2 ± 2.4 vs. 11.6 ± 1.9 g/dL, p < 0.0001), and platelets (94,427 ± 86,743 vs. 128,896 ± 137,017/mm(3), p = 0.035), as well as higher levels of bilirubin (15.0 ± 12.2 vs. 8.6 ± 9.5 mg/dL, p = 0.001). ICU group also had a higher frequency of severe AKI (RIFLE-"Failure": 73.2% vs. 54.2%, p < 0.0001) and a higher prevalence of dialysis requirement (57.3% vs. 27.6%, p < 0.0001). Mortality was higher among ICU patients (23.5% vs. 5.7%, p < 0.0001). Independent predictors for ICU admission were tachypnea (p = 0.027, OR = 13, CI = 1.3-132), hypotension (p = 0.009, OR = 5.27, CI = 1.5-18) and AKI (p = 0.029, OR = 14, CI = 1.3-150). Ceftriaxone use was a protective factor (p = 0.001, OR = 0.13, CI = 0.04-0.4).

CONCLUSIONS

Independent risk factors for ICU admission in leptospirosis include tachypnea, hypotension and AKI. Ceftriaxone was a protective factor for ICU admission, suggesting that its use may prevent severe forms of the disease.

Clinical approach to fever of unknown origin in children

BACKGROUND/PURPOSE

Fever of unknown origin (FUO) can be caused by many clinical conditions and remains a diagnostic challenge in clinical practice. The etiology of FUO varies markedly among different age groups, geographic areas, and seasons. A four-stage investigative protocol for FUO is widely applied in clinical practice. The aim of this study was to evaluate the usefulness of this four-stage protocol for identifying the etiology of FUO in children.

METHODS

We enrolled children younger than 18 years of age who were admitted to the Taichung Veterans General Hospital during the period from January 2006 to December 2014 with FUO persisting for more than 3 weeks. The four-stage FUO investigative guideline was used to evaluate the etiology of fever in all patients enrolled in the study.

RESULTS

The etiology of FUO was identified in 79 (84.9%) of the 93 patients enrolled in the study. The most common cause of FUO was infectious disease (37.6%), followed by malignancy (17.2%), miscellaneous disease (16.1%), and collagen vascular disease (14.0%). With respect to the four-stage survey of FUO, 36 of the 79 patients (45.6%) were identified in Stage 3, 28 patients (35.4%) in Stage 2, 13 patients (16.5%) in Stage 4, and only two patients (2.5%) in Stage 1.

CONCLUSION

A well-designed systemic review of the epidemiological information, medical history, physical examination, laboratory analysis, and adequate invasive procedures provide adequate data to identify the most common causes of FUO in children.

The Infectious and Noninfectious Dermatological Consequences of Flooding: A Field Manual for the Responding Provider

Meteorological data show that disastrous floods are increasingly frequent and more severe in recent years, perhaps due to climatic changes such as global warming. During and after a flood disaster, traumatic injuries, communicable diseases, chemical exposures, malnutrition, decreased access to care, and even mental health disorders dramatically increase, and many of these have dermatological manifestations. Numerous case reports document typical and atypical cutaneous infections, percutaneous trauma, immersion injuries, noninfectious contact exposures, exposure to wildlife, and exacerbation of underlying skin diseases after such disasters as the 2004 Asian tsunami, Hurricane Katrina in 2005, and the 2010 Pakistan floods. This review attempts to provide a basic field manual of sorts to providers who are engaged in care after a flooding event, with particular focus on the infectious consequences. Bacterial pathogens such as Staphylococcus and Streptococcus are still common causes of skin infections after floods, with atypical bacteria also greatly increased. Vibrio vulnificus is classically associated with exposure to saltwater or brackish water. It may present as necrotizing fasciitis with hemorrhagic bullae, and treatment consists of doxycycline or a quinolone, plus a third-generation cephalosporin and surgical debridement. Atypical mycobacterial infections typically produce indolent cutaneous infections, possibly showing sporotrichoid spread. A unique nontuberculous infection called spam has recently been identified in Satowan Pacific Islanders; combination antibiotic therapy is recommended. Aeromonas infection is typically associated with freshwater exposure and, like Vibrio infections, immunocompromised or cirrhotic patients are at highest risk for severe disease, such as necrotizing fasciitis and sepsis. Various antibiotics can be used to treat Aeromonas infections. Melioidosis is seen mainly in Southeast Asia and Australia, particularly in rice farmers, and can remain latent for many years before presenting as the host's immunocompetence wanes. It can present with a variety of skin findings or as a nonspecific febrile illness, and preferred treatment consists of ceftazidime or a carbapenem with trimethoprim/sulfamethoxazole (TMP/SMX) for 2 weeks, then continuing TMP/SMX for at least 3 months. Leptospirosis is a waterborne zoonosis that is often prevalent after heavy rains or flooding. Different forms exist, including Fort Bragg fever, which produces a distinctive erythematous papular rash on the shins. Doxycycline is often sufficient; however, volume and potassium repletion may be necessary if renal involvement exists. Chromobacterium violaceum infection may occur after open skin is exposed to stagnant or muddy water. Cultured colonies produce a unique violacein pigment, and treatment typically consists of a carbapenem. Both typical and atypical fungal infections are increased in the flooding disaster scenario, such as dermatophytosis, chromoblastomycosis, blastomycosis, and mucormycosis. Appropriate antifungals should be used. In addition, land inundated with water expands the habitat for parasites and/or vectors, thus increased vigilance for regional parasitic infections is necessary after a flood. Lastly, noninfectious consequences of a flooding disaster are also common and include miliaria, immersion foot syndromes, irritant and allergic contact dermatitis, traumatic wounds and animal bites, and arthropod assault, as well as exacerbation of existing skin conditions such as atopic dermatitis, psoriasis, and alopecia areata due to increased stress or nonavailability of daily medications.

High leptospiremia is associated with low gamma-delta T cell counts

The role of innate immune cells either to mount appropriate defense mechanisms or to drive uncontrolled tissue injuries during acute leptospirosis is poorly understood. This study aimed at characterizing the selective mobilization of innate immune cells and the level of target organ injuries in response to leptospiremia. We focused on gamma-delta (γ-δ) T cells. Patients were prospectively assessed for cell count by cytometry, for bacterial load by PCR in plasma samples and for levels of soluble acute phase tissue enzymes. We found that the level of γ-δ T cells was low and inversely correlated to liver injuries and leptospiremia.

Co-existent facial palsy and myocarditis in a 50-year old farmer diagnosed with probable leptospirosis: a case report

Background

Leptospirosis is a worldwide zoonotic disease caused by spirochetes belonging to the genus Leptospira. This is a case report on a patient with probable leptospirosis, who developed lower motor neuron facial nerve palsy during the recovery phase of this illness. Leptospirosis is endemic in Sri Lanka and this complication has been reported earlier in other countries but not in Sri Lanka to the best of our knowledge.

Case presentation

A previously well 50 year old Sinhalese farmer in Sri Lanka was admitted to a tertiary care hospital with five day history of fever, headache, prostration, severe myalgia especially in the calves and yellowish discoloration of the eyes. He was febrile, icteric and had suffusion of both conjunctivae. His pulse rate and blood pressure was 98/min and 90/50 mmHg respectively. The initial laboratory examinations showed neutrophil leukocytosis and thrombocytopenia. Antibodies test for leptospirosis was done and IgM was positive. Because of this evidence the probable diagnosis of leptospirosis was made and antibiotic therapy initialed with intravenous cefotaxime 1 g 8 hrly and crystalline penicillin 2 mu 6 hrly.

On the eighth day he developed chest pain associated with shortness of breath with a heart rate of 120/min. Electrocardiograpic and echocardiograpic evidence suggested myocarditis, and trponin I titer was positive. Supportive care was provided and antibiotics were continued.

On the 13^th day of illness he developed lower motor type facial nerve palsy of the left side with positive Bell’s phenomenon. But rest of the neurological examination was normal. He was discharged on a step-down course of prednisolone and physiotherapy. He fully recovered from cardiac involvement before discharge but recovery from facial nerve palsy took place only six months later.

Conclusion

Our case emphasizes cardiac and facial nerve involvement in leptospirosis. This is the first published report in Sri Lanka of facial nerve palsy occurring in leptospirosis possibly due to immunological damage. Further literature survey revealed that this is the first case in the world with simultaneous occurrence of myocarditis and facial nerve palsy in leptospirosis. The pathogenesis of this occurrence is yet to be fully understood.

Severity markers in severe leptospirosis: a cohort study

We aimed to evaluate parameters for their value as severity markers in hospitalized leptospirosis patients. We recruited 47 informed adult consenting patients and assessed a number of clinical, hematological, biochemical, and biological variables. Patients were sorted according to severity based on fatality or the requirement of mechanical ventilation or dialysis; the parameters studied were compared between groups on inclusion and the next day. Beside septic shock presentation or a high severity score (Simplified Acute Physiology Score; SAPS II), increased lactate, total bilirubin, lipase, and AST/ALT ratio or a decreased cytokines IL-10/TNF-α ratio were all significantly associated with severity. The gene expression of the IL-1 receptor antagonist IL-1ra, IL-1α, and the long pentraxin PTX-3 were also transcribed at higher levels in most severe cases. Patients could rapidly improve or deteriorate, highlighting the need for a new assessment the next day. Our results add to the limited body of knowledge about severity markers in leptospirosis. They also suggest that patients should be reassessed the next day before being possibly discharged from the hospital. Further studies are needed in order to confirm relevant and reliable prognostic parameters in leptospirosis that would be helpful for the purpose of triage.

Does leptospirosis behave adversely in cirrhosis of the liver?

BACKGROUND AND AIM

Leptospirosis, endemic in India, is complicated by jaundice and renal failure. Whether leptospirosis could result in a worsening of preexisting chronic liver disease (CLD) is not known. Aim of the study was to analyze the clinical profile and natural course of leptospirosis in decompensated CLD in comparison to those acquiring the infection in an otherwise healthy individual.

METHODS

Cases were patients with liver cirrhosis who presented with fever and/or jaundice and were screened and found positive for leptospirosis. Controls were patients diagnosed to have leptospirosis during the same period, but in the absence of liver disease. Both cases and controls were followed up until recovery or death.

RESULTS

Thirty-one patients had cirrhosis of the liver, and 91 controls had leptospirosis. Significantly more number of cirrhotics had jaundice (87.1 % vs. 16.5 %; p = 0.001), elevated blood urea (41.9 % vs. 18.7 %; p = 0.01), and serum creatinine (41.9 % vs. 19.8 %; p = 0.03) compared to the controls. There were four deaths due to hepatorenal dysfunction and coagulopathy in cirrhotics and no deaths in the control group (4 vs. 0; p = 0.001).

CONCLUSION

Leptospirosis should be considered as yet another important cause of acute-on-chronic liver failure in endemic areas associated with poor outcome. Death is often due to hepatorenal dysfunction.

[Fever and jaundice... and if it was a leptospirosis. About a case of L. interrogans icterohaemorrhagiae in Northern France]

Leptospirosis is an anthropozoonose, an animal disease transmissible to humans, caused by a spirochete of the genus Leptospira that lives mainly among rodents but also in wetlands. It occurs worldwide, particularly in Asia, Latin America and Africa. In Europe, the incidence is small (except in France and Great Britain, where its frequency has increased in recent years) but the frequency may be underestimated. Some areas overseas are particularly affected. In France, the potential epidemic of leptospirosis is subject to climatic variations, justifying a constant monitoring of the disease provided by the National Reference Centre (CNR) of leptospires. Transmission to humans primarily occurs through contact with environments contaminated by the urine of infected animals. The disease can affect the liver and kidneys (hepatonephritis) as cytolysis, cholestasis and renal failure associated with fever. A coagulopathy usually accompanies the clinical table. Its diagnosis is difficult because of the clinical polymorphism. Early diagnosis of leptospirosis allows effective medical care, improving patient outcomes. This is currently based on gene amplification (PCR) or serology positive by the microscopic agglutination test (MAT), which is the reference method. Its evolution is usually favorable with appropriate antibiotic treatment (aminopenicillin). However 5-10% of symptomatic patients have a severe multisystem defaillance. Nearly a century after the discovery of the causative agent, this zoonosis remains a public health problem, zoonosis priority in terms of virulence, its reporting is mandatory in our country. We report the case of a severe form of hepatonephritis due to water contaminated with Leptospira observed in Northern France.

Leptospirosis: possibilities of early laboratory and clinical diagnosis

This retrospective study aims to identify and describe the problems associated with the laboratory and clinical diagnosis of leptospirosis. A total of 4,813 patients with suspected leptospirosis from an area of the Czech Republic, with a total population of 1.15 million, were examined during the period 2002–2010. Our study included only 855 patients: 545 men (mean age 41.03 ± 19.24) and 310 women (mean age 41.47 ± 20.3) who were examined using microscopic agglutination test (MAT) and a polymerase chain reaction (PCR). All patients and their physicians filled in questionnaires, which included anamnestic data, clinical symptoms and the results of laboratory tests. Out of total suspected, 89 patients (1.85%), tested positive for leptospirosis, of which 50 have been examined only serologically by MAT. Of 855 patients in our study undergoing both PCR and MAT tests, 39 have tested positive for leptospirosis. The most frequent symptom in patients with leptospirosis included fever (91.6%) and headache (69.4%). The correct laboratory diagnosis of leptospirosis depends on biological material being tested before the start of antibiotic treatment, since leptospires are extremely sensitive to antibiotics. Consequently, the PCR results alone may produce a false negative result after 24 hours following treatment with antibiotics.

Pancreatitis and myocarditis followed by pulmonary hemorrhage, a rare presentation of leptospirosis- a case report and literature survey

Background

Leptospirosis is a potentially fatal disease which can cause multi-organ dysfunction. It can rarely present as acute pancreatitis. This is the first ever report of leptospirosis presenting with acute pancreatitis and myocarditis followed by diffuse pulmonary hemorrhages to the best of our knowledge.

Case presentation

A 15-year-old South Asian boy presented with high grade fever, epigastric discomfort and was anicteric on admission. He developed tachycardia, transient hypotension, changes of electro-cardiogram and positive troponin I suggestive of myocarditis. Acute pancreatitis was diagnosed with 12 fold high serum amylase and with the evidence of computerized tomography. Then he developed diffuse pulmonary hemorrhages and later acute renal failure. Leptospirosis was confirmed by positive leptospira IgM, negative IgG and strongly positive Microscopic Agglutination Test. Other possible infective and autoimmune causes were excluded. Patient recovered completely with antibiotics and the supportive care.

Conclusion

This case illustrates diagnostic difficulties especially in resource poor settings where leptospirosis is common. Additionally it highlights the fact that leptospirosis should be considered in patients presenting with pancreatitis which can be complicated with myocarditis and diffuse pulmonary hemorrhages. We hypothesize that Toll like receptors may play a role in such systemic involvement.

Risk factors and predictors of severe leptospirosis in New Caledonia

BACKGROUND

Leptospirosis is a major public health concern in New Caledonia (NC) and in other tropical countries. Severe manifestations of the disease are estimated to occur in 5-15% of all human infections worldwide and factors associated with these forms are poorly understood. Our objectives were to identify risk factors and predictors of severe forms of leptospirosis in adults.

METHODS AND FINDINGS

We conducted a retrospective case-control study of inpatients with laboratory-confirmed leptospirosis who were admitted to two public hospitals in NC in 2008-2011. Cases were patients with fatal or severe leptospirosis, as determined by clinical criteria. This approach was meant to be pragmatic and to reflect the routine medical management of patients. Controls were defined as patients hospitalized for milder leptospirosis. Risk and prognostic factors were identified by multivariate logistic regression. Among the 176 patients enrolled in the study, 71 had criteria of severity including 10 deaths (Case Fatality Rate = 14.1%). Three risk factors were independently associated with severe leptospirosis: current cigarette smoking (OR = 2.94 [CI 1.45-5.96]); delays >2 days between the onset of symptoms and the initiation of antibiotherapy (OR = 2.78 [CI 1.31-5.91]); and Leptospira interrogans serogroup Icterohaemorrhagiae as the infecting strain (OR = 2.79 [CI 1.26-6.18]). The following post-admission laboratory results correlated with poor prognoses: platelet count ≤50,000/µL (OR = 6.36 [CI 1.79-22.62]), serum creatinine >200 mM (OR = 5.86 [CI 1.61-21.27]), serum lactate >2.5 mM (OR = 5.14 [CI 1.57-16.87]), serum amylase >250 UI/L (OR = 4.66 [CI 1.39-15.69]) and leptospiremia >1000 leptospires/mL (OR = 4.31 [CI 1.17-15.92]).

CONCLUSIONS

To assess the risk of developing severe leptospirosis, our study illustrates the benefit for clinicians to have: i) the identification of the infective strain, ii) a critical threshold of qPCR-determined leptospiremia and iii) early laboratory results. In New Caledonia, preventative measures should focus on early presumptive antibacterial therapy and on rodent (reservoir of Icterohaemorrhagiae serogroup) control.