Acute pancreatitis as a rare complication of leptospirosis: A case report and literature review

Leptospirosis is a zoonotic disease. We present a case of acute pancreatitis associated with leptospirosis. An 88-year-old woman was admitted to the hospital with high fever and severe myalgia of the lower extremities. Based on the clinical presentation, hepatic dysfunction with a mild increase in bilirubin, renal dysfunction, and life history, the possibility of leptospirosis was considered. Plain computed tomography of the trunk on admission revealed no special findings. Appropriate antimicrobial therapy was administered at an early stage. After treatment initiation, the clinical symptoms and blood test abnormalities began to improve, and the patient appeared to be doing well. Although no abdominal or back pain was consistently noted during hospitalization, the serum amylase level increased over time; therefore, the patient underwent another computed tomography scan on the ninth day. Acute pancreatitis, which was absent upon admission, was noted. Appropriate treatment for pancreatitis was administered, and the patient was discharged. A subsequent serum antibody test confirmed the diagnosis of leptospirosis. Herein, we also summarized previous cases of acute pancreatitis associated with leptospirosis. The time of onset for pancreatitis was inconsistent, and there were a few cases of pancreatitis without abdominal or back pain. In contrast, serum amylase or lipase levels were elevated in all patients, which could be an important trigger for suspected complications of pancreatitis. When leptospirosis is suspected, complications of pancreatitis should always be considered, even in the absence of apparent abdominal pain. Regular monitoring of pancreatic enzymes such as amylase and lipase is recommended.

Use of Advanced Diagnostics for Timely Identification of Travel-associated Leptospira santarosai Infection in Four Adolescents Through Plasma Microbial Cell-free DNA Sequencing With the Karius Test

BACKGROUND

Leptospirosis is an important zoonotic infection worldwide. Diagnosis of leptospirosis is challenging given its nonspecific clinical symptoms that overlap with other acute febrile illnesses and limitations with conventional diagnostic testing. Alternative advanced diagnostics, such as microbial cell-free DNA (mcfDNA), are increasingly being used to aid in the diagnosis of infections and can be applied to pathogens with public health importance such as Leptospira , a nationally notifiable disease.

METHODS

The Karius Test uses plasma mcfDNA sequencing to detect and quantify DNA-based pathogens. This test offered through the Karius lab detected 4 cases of Leptospira santarosai during a 5-month period across the United States in 2021 and were clinically reviewed.

RESULTS

In our case series, 4 adolescents with recent travel to Central America (Costa Rica, n = 3 and Belize, n = 1) from April to August 2021 were diagnosed with leptospirosis. While a large workup was performed in all cases, mcfDNA testing was the first test to detect L. santarosai as the microbiological diagnosis in all cases.

CONCLUSIONS

Results of the Karius Test enabled rapid, noninvasive diagnosis of leptospirosis allowing for targeted therapy. Use of mcfDNA can be utilized for diagnosis of pathogens where conventional testing is challenging or limited. This in turn can enable quick diagnosis for targeted treatment and potentially aid in supporting case definitions of reportable diseases of public health concern.

Efficacy and safety of antibiotics for treatment of leptospirosis: a systematic review and network meta-analysis

BACKGROUND

Leptospirosis, an important zoonotic bacterial disease, commonly affects resource-poor populations and results in significant morbidity and mortality worldwide. The value of antibiotics in leptospirosis remains unclear, as evidenced by the conflicting opinions published.

METHODS

We conducted a search in the PubMed, Web of Science, and Cochrane Library databases for studies. These studies included clinical trials and retrospective studies that evaluated the efficacy or safety of antibiotics for leptospirosis treatment. The primary outcomes assessed were defervescence time, mortality rate, and hospital stays. Subgroup analyses were performed based on whether there were cases involving children and whether there were cases of severe jaundice. Safety was defined as the prevalence of adverse events associated with the use of antibiotics. p scores were utilized to rank the efficacy of the antibiotics.

RESULTS

There are included 9 randomized controlled trials (RCTs), 1 control trial (CT), and 3 retrospective studies (RS) involving 920 patients and 8 antibiotics. Six antibiotics resulted in significantly shorter defervescence times compared to the control, namely cefotaxime (MD, - 1.88; 95% CI =  - 2.60 to - 1.15), azithromycin (MD, - 1.74; 95% CI =  - 2.52 to - 0.95), doxycycline (MD, - 1.53; 95% CI =  - 2.05 to - 1.00), ceftriaxone (MD, - 1.22; 95% CI =  - 1.89 to - 0.55), penicillin (MD, - 1.22; 95% CI =  - 1.80 to - 0.64), and penicillin or ampicillin (MD, - 0.08; 95% CI =  - 1.01 to - 0.59). The antibiotics were not effective in reducing the mortality and hospital stays. Common adverse reactions to antibiotics included Jarisch-Herxheimer reaction, rash, headache, and digestive reactions (nausea, vomiting, diarrhea, abdominal pain, and others).

CONCLUSIONS

Findings recommend that leptospirosis patients be treated with antibiotics, which significantly reduced the leptospirosis defervescence time. Cephalosporins, doxycycline, and penicillin are suggested, and azithromycin may be a suitable alternative for drug-resistant cases.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022354938.

Antibiotics for treatment of leptospirosis

BACKGROUND

Leptospirosis is a disease transmitted from animals to humans through water, soil, or food contaminated with the urine of infected animals, caused by pathogenic Leptospira species. Antibiotics are commonly prescribed for the management of leptospirosis. Despite the widespread use of antibiotic treatment for leptospirosis, there seems to be insufficient evidence to determine its effectiveness or to recommend antibiotic use as a standard practice. This updated systematic review evaluated the available evidence regarding the use of antibiotics in treating leptospirosis, building upon a previously published Cochrane review.

OBJECTIVES

To evaluate the benefits and harms of antibiotics versus placebo, no intervention, or another antibiotic for the treatment of people with leptospirosis.

SEARCH METHODS

We identified randomised clinical trials following standard Cochrane procedures. The date of the last search was 27 March 2023.

SELECTION CRITERIA

We searched for randomised clinical trials of various designs that examined the use of antibiotics for treating leptospirosis. We did not impose any restrictions based on the age, sex, occupation, or comorbidities of the participants involved in the trials. Our search encompassed trials that evaluated antibiotics, regardless of the method of administration, dosage, and schedule, and compared them with placebo or no intervention, or compared different antibiotics. We included trials regardless of the outcomes reported.

DATA COLLECTION AND ANALYSIS

During the preparation of this review, we adhered to the Cochrane methodology and used Review Manager. The primary outcomes were all-cause mortality and serious adverse events (nosocomial infection). Our secondary outcomes were quality of life, proportion of people with adverse events considered non-serious, and days of hospitalisation. To assess the risk of bias of the included trials, we used the RoB 2 tool, and for evaluating the certainty of evidence we used GRADEpro GDT software. We presented dichotomous outcomes as risk ratios (RR) and continuous outcomes as mean differences (MD), both accompanied by their corresponding 95% confidence intervals (CI). We used the random-effects model for all our main analyses and the fixed-effect model for sensitivity analyses. For our primary outcome analyses, we included trial data from the longest follow-up period.

MAIN RESULTS

We identified nine randomised clinical trials comprising 1019 participants. Seven trials compared two intervention groups and two trials compared three intervention groups. Amongst the trials comparing antibiotics versus placebos, four trials assessed penicillin and one trial assessed doxycycline. In the trials comparing different antibiotics, one trial evaluated doxycycline versus azithromycin, one trial assessed penicillin versus doxycycline versus cefotaxime, and one trial evaluated ceftriaxone versus penicillin. One trial assessed penicillin with chloramphenicol and no intervention. Apart from two trials that recruited military personnel stationed in endemic areas or military personnel returning from training courses in endemic areas, the remaining trials recruited people from the general population presenting to the hospital with fever in an endemic area. The participants' ages in the included trials was 13 to 92 years. The treatment duration was seven days for penicillin, doxycycline, and cephalosporins; five days for chloramphenicol; and three days for azithromycin. The follow-up durations varied across trials, with three trials not specifying their follow-up periods. Three trials were excluded from quantitative synthesis; one reported zero events for a prespecified outcome, and two did not provide data for any prespecified outcomes. Antibiotics versus placebo or no intervention The evidence is very uncertain about the effect of penicillin versus placebo on all-cause mortality (RR 1.57, 95% CI 0.65 to 3.79; I2 = 8%; 3 trials, 367 participants; very low-certainty evidence). The evidence is very uncertain about the effect of penicillin or chloramphenicol versus placebo on adverse events considered non-serious (RR 1.05, 95% CI 0.35 to 3.17; I2 = 0%; 2 trials, 162 participants; very low-certainty evidence). None of the included trials assessed serious adverse events. Antibiotics versus another antibiotic The evidence is very uncertain about the effect of penicillin versus cephalosporin on all-cause mortality (RR 1.38, 95% CI 0.47 to 4.04; I2 = 0%; 2 trials, 348 participants; very low-certainty evidence), or versus doxycycline (RR 0.93, 95% CI 0.13 to 6.46; 1 trial, 168 participants; very low-certainty evidence). The evidence is very uncertain about the effect of cefotaxime versus doxycycline on all-cause mortality (RR 0.18, 95% CI 0.01 to 3.78; 1 trial, 169 participants; very low-certainty evidence). The evidence is very uncertain about the effect of penicillin versus doxycycline on serious adverse events (nosocomial infection) (RR 0.62, 95% CI 0.11 to 3.62; 1 trial, 168 participants; very low-certainty evidence) or versus cefotaxime (RR 1.01, 95% CI 0.15 to 7.02; 1 trial, 175 participants; very low-certainty evidence). The evidence is very uncertain about the effect of doxycycline versus cefotaxime on serious adverse events (nosocomial infection) (RR 1.01, 95% CI 0.15 to 7.02; 1 trial, 175 participants; very low-certainty evidence). The evidence is very uncertain about the effect of penicillin versus cefotaxime (RR 3.03, 95% CI 0.13 to 73.47; 1 trial, 175 participants; very low-certainty evidence), versus doxycycline (RR 2.80, 95% CI 0.12 to 67.66; 1 trial, 175 participants; very low-certainty evidence), or versus chloramphenicol on adverse events considered non-serious (RR 0.74, 95% CI 0.15 to 3.67; 1 trial, 52 participants; very low-certainty evidence). Funding Six of the nine trials included statements disclosing their funding/supporting sources and three trials did not mention funding source. Four of the six trials mentioning sources received funds from public or governmental sources or from international charitable sources, and the remaining two, in addition to public or governmental sources, received support in the form of trial drug supply directly from pharmaceutical companies.

AUTHORS' CONCLUSIONS

As the certainty of evidence is very low, we do not know if antibiotics provide little to no effect on all-cause mortality, serious adverse events, or adverse events considered non-serious. There is a lack of definitive rigorous data from randomised trials to support the use of antibiotics for treating leptospirosis infection, and the absence of trials reporting data on clinically relevant outcomes further adds to this limitation.

Severe leptospirosis with rhabdomyolysis in a traveller visiting Thailand

We present a case of leptospirosis in a 32-year-old German who exhibited a progressing fever, calf pain complicated with acute kidney injury, and rhabdomyolysis following engagement in freshwater activities at a waterfall in Thailand. Fortunately, the patient made a full recovery without the need for renal replacement therapy.

Case Report: Locally Acquired Leptospirosis in a Minnesota Boy and His Dog

Leptospirosis affects numerous animal species, including domestic dogs, but documented transmission to humans is rare. Here, we describe epidemiologically linked cases in a 12-year-old Minnesota boy and his pet dog. While human leptospirosis is often thought of as a disease of tropical locations, this case report describes a rare documented example of local transmission in the northern United States, a region historically not perceived to be at high risk of Leptospira species transmission to humans. This case highlights an unusual presentation, with facial nerve palsy, underappreciated epidemiological risks, and diagnostic challenges of this reemerging infection.

A case of leptospirosis in transcarpathia complicated with Jarisch-Herxheimer reaction

A case report of Jarisch-Herxheimer (JHR) reaction on a 10th day of Leptospirosis caused by Leptospira Pomona. JHR occurs as a complication of an antibiotic treatment of various spirochetes and may lead to respiratory distress syndrome, renal failure, hepatic insufficiency, and multiple organ failure. This case represents a skin and cardio-vascular form of JHR with no lung involvement. The patient was treated with benzylpenicillin and low dexamethasone doses for 5th day of the disease with a shift to ceftriaxone and high doses of methylprednisolone. The fastest diagnosis of a sporadic zoonotic disease, early start of antibiotic therapy, and adequate doses of corticosteroids are key to the successful treatment of leptospirosis.

Case Report: Leptospirosis Complicated by Persistent, Bilateral Sensorineural Hearing Loss

The clinical manifestations of leptospirosis range from mild to life-threatening and can impact on multiple organ systems. A wide array of neurological manifestations of leptospirosis have been reported, although the pathophysiology of neuroleptospirosis remains incompletely understood. We present a case of leptospirosis complicated by bilateral sensorineural deafness, with nodular meningitis demonstrated in the internal auditory meatus on magnetic resonance imaging. The patient was treated with doxycycline, ceftriaxone, systemic and topical steroids, and hyperbaric oxygen therapy, with modest, but incomplete, improvement.

In silico identification and characterization of potential druggable targets among hypothetical proteins of Leptospira interrogans serovar Copenhageni: a comprehensive bioinformatics approach

Leptospirosis is one of the neglected zoonosis, affecting human and animal populations worldwide. Reliable effective therapeutics and concerns to look for more research into the molecular analysis of its genome is therefore needed. In the genomic pool of the Leptospira interrogans many hypothetical proteins are still uncharacterized. In the current research, we performed extensive in silico analysis to prioritize the potential hypothetical proteins of L. interrogans serovar Copenhageni via stepwise reducing the available hypothetical proteins (Total 3606) of the assembly to only 15, based on non-homologous to homosapien, essential, functional, virulent, cellular localization. Out of them, only two proteins WP_000898918.1 (Hypothetical Protein 1) & WP_001014594.1 (Hypothetical Protein 2) were found druggable and involved in protein-protein interaction network. The 3 D structures of these two target proteins were predicted via ab initio homology modeling followed by structures refinement and validation, as no structures were available till date. The analysis also revealed that the functional domains, families and protein-protein interacting partners identified in both proteins are crucial for the survival of the bacteria. The binding cavities were predicted for both the proteins through blind and specific protein-ligand docking with their respective ligands and inhibitors and were found to be in accordance with the druggable sites predicted by DoGSiteScorer. The docking interactions were found within the active functional domains for both the proteins while for Hypothetical Protein 2, the same residues were involved in interactions with Cytidine-5'-triphosphate in blind and specific docking. Furthermore, the simulations of molecular dynamics and free binding energy revealed the stable substrate binding and efficient binding energies, and were in accordance to our docking results. The work predicted two unique hypothetical proteins of L. interrogans as a potential druggable targets for designing of inhibitors for them.Communicated by Ramaswamy H. Sarma.

Leptospirosis-associated meningitis in a patient with sjögren's syndrome: a case report

BACKGROUND

Leptospirosis is a zoonotic disease that afflicts both humans and animals. It progresses from flu-like symptoms to more severe hepatic and renal failure, and may also lead to aseptic meningitis. Individuals with autoimmune diseases (ADs) are potentially more susceptible to Leptospirosis. Thus far, limited data has documented the association between Leptospirosis and autoimmune disorders.

CASE PRESENTATION

The patient had a definitive pathological diagnosis of Sjögren's syndrome (SS). Due to recurrent headaches, the patient sought consultation with a neurologist. Lumbar puncture revealed elevated white blood cells and protein levels in the cerebrospinal fluid, along with decreased glucose. Tuberculous meningitis was suspected. Radiographic imaging exhibited meningeal enhancement, ventricular enlargement, and hydrocephalus. The patient commenced treatment with anti-tuberculosis therapy and corticosteroids. Subsequently, high-throughput sequencing (HTS) of cerebrospinal fluid identified the presence of Leptospira interrogans. The patient was ultimately diagnosed with Leptospiral meningitis, and underwent antimicrobial and immunosuppressive therapy, resulting in stabilization of the condition and gradual symptom recovery.

CONCLUSIONS

The case highlights the challenges in diagnosing and managing leptospirosis-related meningitis in the presence of ADs and emphasizes the importance of utilizing HTS for accurate pathogen detection. The potential correlation between leptospirosis and SS warrants further investigation, as does the need for multidisciplinary involvement in treatment strategies for such complex cases.

Successful treatment with streptomycin of genital leptospirosis in naturally infected cows under field conditions

The single-dose protocol of streptomycin treatment has been recommended to treat renal leptospirosis in bovines. However, treating genital infection remains a challenge. Recently, a protocol using three doses of streptomycin demonstrated effectiveness in the genital clearance of experimentally infected ewes. Therefore, the present study aimed to apply this three-dose protocol for genital infection treatment in naturally infected cows under field conditions. Thirty beef cows were diagnosed as positive by lipL32-PCR in their genital samples. Nucleotide sequences (n = 10) characterized them as Leptospira interrogans sg Sejroe, genetically related to Hardjoprajitno strains. After molecular diagnosis, 13 cows received a single dose of 25 mg/kg streptomycin. The other 17 cows were submitted to the three-dose protocol. The successful treatment rate of genital infection on the single streptomycin dose was 7/13 (53.8%), while the cows that received the three doses 16/17 were negative (94.1% of efficacy). Based on those results, we conclude that the standard treatment preconized for renal infection is not adequate for genital infection, and the three-dose protocol was successful in eliminating the carrier status of genital leptospirosis.

Case Report: Relapsing Leptospirosis in an Immunocompromised Host

Leptospirosis is typically a self-limited febrile illness; when it occurs, meningitis usually develops early in the course. Here, we describe a patient who had engaged in freshwater activities in Kauai that was immunocompromised due to a history of mantle cell lymphoma, autologous hematopoietic cell transplant, and hypogammaglobulinemia. He developed leptospiral meningoencephalitis 11 weeks after illness onset and persistently detectable Leptospira DNA in blood and cerebrospinal fluid along with ongoing clinical illness, despite appropriate treatment.

Hemoperfusion in Leptospirosis

Leptospirosis is the most common zoonosis frequently seen in the tropics and subtropics especially during the rainy season when humans wade in floods contaminated by the urine of infected rats in urban areas. Aside from direct toxicity of the leptospires, the role of an exuberant immune response to the pathogen leading to secondary organ damage has been recognized. Thus, our treatment protocol for patients with severe leptospirosis characterized by renal failure, acute liver injury, and lung hemorrhage now includes a short course of methylprednisolone and intravenous cyclophosphamide. In some patients, however, hemodynamic collapse and acute respiratory distress syndrome ensue, which may be due to the release of cytokines resulting from the dysregulated immune response. Blood purification in the form of hemoperfusion (HP) with neutral macroporous resin-adsorbing beads adsorbs cytokines and other inflammatory mediators leading to cardiovascular stability and stabilization of endothelial membranes. HP may be considered part of a multiorgan system therapeutic approach in diseases with reversible multiorgan failure that can lead to an improvement in patient survival.

Evaluating the Antimicrobial and Anti-Hemolytic Activity of Synthesized Pseudopeptide against Leptospiral Species: In Silico and In Vitro Approach

Bacterial infections are one of the leading causes of morbidity, mortality, and healthcare complications in patients. Leptospirosis is found to be the most prevalent, re-emergent, and neglected tropical zoonotic disease worldwide. The adaptation to various environmental conditions has made Leptospira acquire a large genome (~4.6 Mb) and a complex outer membrane, making it unique among bacteria that mimic the symptoms of jaundice and hemorrhage. Sph2 is another important virulence factor that enhances hemolytic sphingomyelinase-capable of moving inside mitochondria-which increases the ROS level and decreases the mitochondrial membrane potential, thereby leading to cell apoptosis. In the present study, 25 suspected bovine serum samples were subjected to the Microscopic Agglutination Test (MAT) across the Mysuru region. Different samples, such as urine, serum, and aborted materials from the confirmed MAT-positive animals, were used for isolation and genomic detection by conventional PCR targeting virulence gene, Lipl32, using specific primers. Further, in vitro and in silico studies were performed on isolated cultures to assess the anti-leptospiral, anti-hemolytic, and sphingomyelinase enzyme inhibition using novel pseudopeptides. The microdilution technique (MDT) and dark field microscope (DFM) assays revealed that at a concentration of 62.5 μg/mL, the pseudopeptide inhibited 100% of the growth of Leptospira spp., suggesting its efficiency in the treatment of leptospirosis. The flow cytometry analyses show the potency of the pseudopeptide against sphingomyelinase enzymes using human umbilical vein endothelial cells (HUVECs). Thus, the present study demonstrated the efficacy of the pseudopeptide in the inhibition of the growth of Leptospira, and therefore, this can be used as an alternative drug for the treatment of leptospirosis.

Leptospirosis: Epidemiological and Clinical Characteristics at the National Reference Hospital in Panama

Leptospirosis represents a public health problem in Panama, with an incidence rate of 1 in 100,000 inhabitants in 2014. Despite active surveillance and reports of outbreaks in the news, publications about human leptospirosis in Panama are scarce. The objective of this study was to describe the epidemiological and clinical features of leptospirosis in a cohort of patients admitted to the national reference hospital from January 2013 to December 2018. A total of 188 patients with suspected leptospirosis were identified, but only 56.9% (107 of 188) of the medical records could be retrieved. Microagglutination assays were completed in 45% (48 of 107) of the patients, confirming leptospirosis in 29.2% (14 of 48) of the patients. The most prevalent serogroup identified was Leptospira interrogans icterohemorrhagiae (4 of 14, 28.6%). The majority of patients with confirmed disease were middle-aged (36.4 ± 15.7 years), male (11 of 14, 78.6%), and symptomatic for 6.8 ± 0.7 days before admission. The predominant clinical presentation was fever (13 of 14, 92.9%), abdominal pain (7 of 14, 50%), and jaundice (8 of 14, 57.1%). Respiratory failure (8 of 14, 57.1%), elevated creatinine levels on admission (8 of 14, 57.1%), transfusion of blood-derived products (6 of 14, 42.9%), and required use of vasopressors (4 of 14, 28.6%) were common complications. Mortality was 28.6% (4 of 14). Empiric antibiotic therapy was initiated in almost all patients (10 of 12, 83.3%), and was appropriate in 90% (9 of 10) of them. Our study highlights the high prevalence of severe disease and reveals the diagnostic challenges concealing the true burden of leptospirosis in Panama. However, the small number of confirmed patients limits the generalization of these findings.

Anti-macrophage migration inhibitory factor (MIF) activity of ibudilast: A repurposing drug attenuates the pathophysiology of leptospirosis

To develop the macrophage migration inhibitory factor (MIF) directed therapeutic approach for the treatment of leptospirosis, we identified potential MIF inhibitors by screening 10 essential tautomerase inhibition classes of chemical compounds and 7 existing anti-inflammatory and anti-microbial drugs. Dopachrome tautomerase assay was performed to measure the anti-MIF activity of selected compounds. Among 17 chemical compounds, ibudilast, an anti-inflammatory agent showed the MIF tautomerase IC50 value at a very lower concentration (9.5 ± 5.6 μM) which is considered similar to the IC50 of standard MIF antagonist, ISO-1 (6.2 ± 3.8 μM) with non-significant cytotoxicity. The in vitro analysis of the therapeutic potential of MIF inhibitor revealed that ibudilast significantly reduced the leptospiral lipopolysaccharide (LPS) mediated expression of inflammatory mediators such as intercellular adhesion molecule (ICAM), p38 and p44/42 mitogen-activated protein kinase (MAPK), inflammatory cytokines, and decreased the reactive oxygen species (ROS) production, mitochondrial membrane potential (ΔΨm) loss and cell death of LPS treated THP-1 cells. In vivo analysis demonstrated that the administration of anti-MIF Ibudilast significantly reduced the histopathological changes, downregulates the pro-inflammatory cytokines, and protects the leptospiral BALB/c model from lethality by increasing the survival rate from 25% to 66%. Finally, the biocompatibility of the evaluated anti-MIF compound was explored by cytotoxicity, hemocompatibility, and cell death assay. Ibudilast showed no significant cytotoxicity and hemolytic activity was noticed even at the higher concentration of ≤50 μM and ≥250 μM, when compared with the positive control, 0.1% Triton X-100; no significant cell death was observed at ≤50 μM concentration of Ibudilast in THP-1 cells. From these lines of evidence, we propose that Ibudilast may be a great MIF targeting repurposing drug for reliable supportive treatment of severe leptospirosis.

[Severe paediatric leptospirosis caused by a pet rat]

BACKGROUND

Leptospirosis is a bacterial infection which may cause multiple non-specific symptoms. Transmission of the disease can occur via rats or surface water infected by rats. The Netherlands have seen a record number of cases of leptospirosis in 2019. Diagnosis is often delayed and not always considered because of the variable clinical presentation of the disease. Surveillance of disease prevention concerning rat breeders is inadequate.

CASE DESCRIPTION

An 11-year-old girl visited the paediatrician with fever, myalgia and a headache followed by a stiff neck. Two days earlier she was bitten by one of her pet rats. Diagnostic testing confirmed a meningitis caused by leptospirosis-infection. The pet rats were found to be infected with leptospirosis. All rats were euthanized.

CONCLUSION

Consider the diagnosis leptospirosis in patients with unexplained non-specific symptoms following rat exposure. Information regarding visits to tropical areas and animal exposure is vital. More awareness of zoonoses is needed among physicians and pet breeders.

Clinical disease and treatment of Leptospira kirschneri sv Grippotyphosa in a Sumatran tiger (Panthera tigris sumatrae)

CASE DESCRIPTION

A 12-year-old sexually intact male zoo-managed Sumatran tiger (Panthera tigris sumatrae) was evaluated for a 3-day history of vomiting, hyporexia, and lethargy. Radiographs were supportive of gastrointestinal obstruction, and an exploratory laparotomy was performed.

CLINICAL FINDINGS

Diffuse tan foci were present on the liver parenchyma, and the tiger became icteric throughout the procedure. Hepatic histopathology and immunohistochemistry resulted in a diagnosis of leptospirosis. Serum microagglutination testing for Leptospira spp antibody titers were positive for L kirschneri serovar Grippotyphosa, rising from 1:400 to 1:3,200 in 2 days.

TREATMENT AND OUTCOME

The tiger was treated with antimicrobials, ursodiol, and mirtazapine, and increased biosecurity measures were instituted. Free-ranging wildlife on grounds were trapped, euthanized, and submitted for necropsy to screen for disease vectors. The tiger's urine was intermittently opportunistically collected from the enclosure and remained PCR assay negative for Leptospira spp until being positive once again on day 595. Although the tiger was without clinical signs at that time, antimicrobial therapy and increased biosecurity protocols were instituted a second time until urinary Leptospira shedding was confirmed to have stopped. By 1,071 days after initial presentation, the tiger remained nonclinical, with no additional urinary shedding episodes.

CLINICAL RELEVANCE

While domestic and nondomestic free-ranging felids have been reported as subclinical Leptospira spp carriers, this report indicates the clinical importance of leptospirosis when a tiger presents with generalized gastrointestinal signs and icterus. Due to the zoonotic potential, biosecurity measures are necessary. This patient had a clinically successful outcome with antimicrobial therapy and supportive care.

Anuria, an Atypical Presentation of Leptospirosis: A Case Report

Leptospirosis, an underreported disease, is a highly prevalent spirochaetal zoonotic disease in both tropical and temperate climates. Symptoms can range from mild illness to potentially life-threatening infection. Laboratory tests are nonspecific. Microbiological confirmation is not widely available in endemic developing countries like Nepal. We need to rely on the serologic test, which has its own pitfalls in the initial days of illness. Here, we report a case of 56 years old female from the western region of Nepal who presented with fever, jaundice and anuria. She initially tested negative for leptospirosis but was later found to be positive in the second week of illness. Unlike the usual non-oliguric renal failure in leptospirosis, she presented with anuria requiring haemodialysis and subsequently had a good recovery with treatment. We highlight the importance of clinical suspicion and logical interpretation of serologic tests based on its timing from the onset of illness.

Severe leptospirosis complicated with multiorgan dysfunction successfully managed with plasma exchange: a case report

BACKGROUND

Leptospirosis is a common zoonotic infection caused by the spirochete Leptospira. The disease is more prevalent in the tropics, causing subclinical to severe illness leading to high morbidity and mortality.

CASE PRESENTATION

A 77-year-old healthy Sri Lankan man presented to the Teaching Hospital Peradeniya with severe leptospirosis complicated with acute kidney injury, pulmonary hemorrhages, myocarditis, and severe thrombocytopenia. He was deteriorating despite treatment with intravenous antibiotics and methylprednisolone boluses. He made a dramatic improvement with two cycles of plasma exchange.

CONCLUSION

Therapeutic plasma exchange is a life-saving treatment modality in severe leptospirosis with multiorgan failure.

Pituitary apoplexy and panhypopituitarism following acute leptospirosis

Leptospirosis is a common tropical febrile illness which may manifest with the hepatorenal syndrome and systemic hemorrhagic manifestations. Pituitary apoplexy is a rare but life-threatening condition characterized by a hemorrhage within the pituitary gland or a pituitary adenoma. Apoplexy is very rarely associated with some inducing events such as infectious diseases such as dengue hemorrhagic fever, Hantaan virus, Puumala virus have also been reported to cause pituitary apoplexy. We present the first case of pituitary apoplexy in a patient who was being treated for leptospirosis and discuss the possible mechanisms of apoplexy in the scenario presented. We also review other reports of infectious causes that may result in pituitary apoplexy.

[Glucocorticoids in leptospira alveolar hemorrhage]

We present the clinical cases of two patients who were admitted to the HIGA San Martín de La Plata emergency ward with a clinical picture compatible with leptospirosis, who evolved with respiratory failure and alveolar hemorrhage. In both, glucocorticoids were administered with good evolution. A bibliographic search of articles published since 2005 in Spanish and English and a review of the topic was carried out. Based on the current evidence, no clear recommendation can be made for the use of corticosteroids in severe leptospirosis. The published bibliography is scarce and of low quality. There would appear to be a benefit in the use of corticosteroids in cases of pulmonary involvement due to severe leptospirosis. High-quality studies are needed to make recommendations with scientific evidence, to verify the adequate dose of corticosteroids, time of initiation, duration of treatment and the cases in which this therapy should be administered.

Multiple Pulmonary Nodules in Leptospirosis

A 21-year-old man presented with the chief complaints of fever and sore throat after visiting Cambodia and Thailand. Computed tomography revealed multiple pulmonary nodules. After performing antibiotic therapy, the pulmonary nodules without bacteremia disappeared completely. Paired microscopic agglutination tests revealed seroconversion against Leptospira serogroup Autumnalis. Thus, he was diagnosed with multiple pulmonary nodules caused by leptospirosis. Leptospirosis is a common zoonosis that occurs in tropical and subtropical areas. Its various clinical features include unspecified fever and Weil's disease. Although diffuse alveolar hemorrhaging is known to occur in severe leptospirosis, multiple pulmonary nodules resembling septic emboli or vasculitis are a rare complication.

When and what to test for: A cost-effectiveness analysis of febrile illness test-and-treat strategies in the era of responsible antibiotic use

BACKGROUND

Febrile illness caused by viral and bacterial diseases (e.g., dengue and leptospirosis) often have similar symptoms and are difficult to differentiate without diagnostic tests. If not treated appropriately, patients may experience serious complications. The question of what diagnostic tests to make available to providers in order to inform antibiotic therapy remains an open problem for health services facing limited resources.

METHODS AND FINDINGS

We formulated the problem of minimizing the weighted average of antibiotic underuse and overuse to inform the optimal diagnostic test and antibiotic treatment options for given occurrence probabilities of several bacterial and viral infections. We modeled the weight of antibiotic overuse as a monetary penalty per unnecessarily administered course, which we varied in both the base case and sensitivity analysis. Detailed Markov cohort models of febrile illness progression were used to estimate the weight of antibiotic underuse. The model accounted for multiple infections simultaneously and incorporated test, treatment, and other direct and indirect costs, as well as the effect of delays in seeking care and test turnaround times. We used the Markov models to numerically estimate disability-adjusted life years (DALYs), pre-penalty costs, and likelihood of antibiotics overuse per patient for fifteen different strategies in two example settings in Thailand, one with a higher probability of bacterial infections (Northern Thailand, Scenario A) and one with a higher probability of viral infections (Bangkok, Scenario B). We found that empirical antibiotic treatment to all patients always incurs the lowest pre-penalty cost (Scenario A: $47.5/patient, $100.6/patient, $149.5/patient for patients seeking care on day one, day four, and day ten respectively; Scenario B: $94.1/patient, $108.7/patient, $122.1/patient on day one, day four, and day ten respectively), and the lowest DALYs, (Scenario A: 0.2 DALYs/patient, 0.9 DALYs/patient, 1.7 DALYs/patient on day one, day four, and day ten, respectively; Scenario B: 0.5 DALYs/patient, 0.7 DALYs/patient, 0.9 DALYs/patient on day one, day four, and day ten, respectively). However, such strategy resulted in the highest proportion of antibiotic overuse per patient (Scenario A: 38.1%, 19.3%, 7.5% on day one, day four, and day ten, respectively; Scenario B: 82.9%, 42.1%, 16.3% on day one, day four, and day ten, respectively). Consequently, empirical antibiotic treatment became suboptimal with antibiotic overuse penalties above $12,800/course, $18,400/course, $23,900/course for patients presenting on day one, day four, and day ten in Scenario A and above $1,100/course, $1,500/course, $1,600/course for patients presenting on day one, day four, and day ten in Scenario B.

CONCLUSIONS

Empirical antibiotic treatment to all patients provided the best outcomes if antibiotic overuse was not the primary concern or if presenting with viral disease (such as dengue) was unlikely. Empirical antibiotic treatment to severe patients only was in most cases not beneficial. Otherwise, strategies involving diagnostic tests became optimal. In particular, our results indicated that single test strategies (bacterial RDT or viral PCR) were optimal in regions with a greater probability of presenting with viral infection. PCR-led strategies (e.g., parallel bacterial PCR, or multiplex PCR) are robust under parameter uncertainty (e.g., with uncertain disease occurrence probabilities).

Locally Acquired Leptospirosis in Expedition Racer, Manitoba, Canada

Leptospirosis is found worldwide, except in northern regions. We report a case associated with a backcountry adventure race in Manitoba, Canada. Initially, nonspecific symptomatology and diagnostic pitfalls contributed to a delay in identification. Careful attention needs to be paid to exposure to and risk for leptospirosis in northern and temperate climates.

Severe pulmonary haemorrhage syndrome in leptospirosis in a returning traveller

Clinical presentation of leptospirosis ranges from asymptomatic infection to fulminant, life-threatening disease. Pulmonary involvement in terms of severe pulmonary haemorrhage syndrome (SPHS) has recently become a more frequently reported facet of leptospirosis and correlates with high mortality rates. It has not yet been described in returning German travellers. We present a case of a healthy young man developing massive pulmonary haemorrhage and severe ARDS requiring mechanical ventilation and high-dose catecholamines after travelling to Indonesia. Leptospirosis was verified by blood PCR as well as serology and treated with high-dose, intravenous penicillin. Outcome was favourable, the patient recovered completely. Leptospirosis and SPHS should be taken into account as an emerging infectious disease in patients with fever and lung involvement.

Leptospirosis among Returned Travelers: A GeoSentinel Site Survey and Multicenter Analysis-1997-2016

Leptospirosis is a potentially fatal emerging zoonosis with worldwide distribution and a broad range of clinical presentations and exposure risks. It typically affects vulnerable populations in (sub)tropical countries but is increasingly reported in travelers as well. Diagnostic methods are cumbersome and require further improvement. Here, we describe leptospirosis among travelers presenting to the GeoSentinel Global Surveillance Network. We performed a descriptive analysis of leptospirosis cases reported in GeoSentinel from January 1997 through December 2016. We included 180 travelers with leptospirosis (mostly male; 74%; mostly tourists; 81%). The most frequent region of infection was Southeast Asia (52%); the most common source countries were Thailand (N = 52), Costa Rica (N = 13), Indonesia, and Laos (N = 11 each). Fifty-nine percent were hospitalized; one fatality was reported. We also distributed a supplemental survey to GeoSentinel sites to assess clinical and diagnostic practices. Of 56 GeoSentinel sites, three-quarters responded to the survey. Leptospirosis was reported to have been most frequently considered in febrile travelers with hepatic and renal abnormalities and a history of freshwater exposure. Serology was the most commonly used diagnostic method, although convalescent samples were reported to have been collected infrequently. Within GeoSentinel, leptospirosis was diagnosed mostly among international tourists and caused serious illness. Clinical suspicion and diagnostic workup among surveyed GeoSentinel clinicians were mainly triggered by a classical presentation and exposure history, possibly resulting in underdiagnosis. Suboptimal usage of available diagnostic methods may have resulted in additional missed, or misdiagnosed, cases.

Imported Leptospira licerasiae Infection in Traveler Returning to Japan from Brazil

We describe a case of intermediate leptospirosis resulting from Leptospira licerasiae infection in a traveler returning to Japan from Brazil. Intermediate leptospirosis should be included in the differential diagnosis for travelers with fever returning from South America. This case highlights the need for strategies that detect pathogenic and intermediate Leptospira species.

Leptospirosis in three workers on a dairy farm with unvaccinated cattle

AIM

We report a one-health investigation of three cases of leptospirosis on a dairy farm with unvaccinated cattle in New Zealand. The cases are discussed in the context of diagnostics, risk factors, persistence of symptoms and outbreak mitigation measures.

METHOD

Clinical and laboratory records from the human cases were reviewed and serological and molecular investigations were conducted into the Leptospira status of cattle and pigs on the farm.

RESULTS

Cases presented early in their illness and all three were confirmed within seven days of onset of symptoms by urine PCR and within 18 days by convalescent MAT (two Hardjo, one Pomona). Cattle and pigs had serological evidence of recent infection with Hardjo/Pomona and Pomona/Copenhageni respectively. Pigs were slaughtered and cattle were vaccinated. Post-exposure prophylaxis was given to staff in-contact with the milking herd until the herd had antibiotic treatment at drying-off (approximately four months after the initial case).

CONCLUSION

The utility of PCR testing for Leptospira DNA as both an early and rapid test for leptospirosis was demonstrated. Two of three cases reported persistence of symptoms at least six months after the acute episode and one of these remains unable to work. Risk mitigation measures such as post-exposure prophylaxis, animal vaccination, heightened clinical suspicion of leptospirosis and recognition of context specific risk factors (eg, effluent spreading) demonstrate the value of medical and veterinary experts working together.

The Use of Chemoprophylaxis after Floods to Reduce the Occurrence and Impact of Leptospirosis Outbreaks

Record-breaking and devastating rainfall events have occurred in the past decade. Rain and floods are considered the main risk factors for leptospirosis and several outbreaks have been reported following extreme weather events. In such situations, one possible intervention to prevent leptospirosis cases in high-risk groups is the use of chemoprophylaxis. However, not enough evidence of its effect is available. The objectives of this study were to review the literature on the current practices of chemoprophylaxis for leptospirosis and to explore, using a mathematical model, how various chemoprophylaxis scenarios may affect the progression of a leptospirosis outbreak. Twenty-six peer-reviewed publications were selected (10 quantitative studies, two systematic reviews and 14 articles of other types). Oral doxycycline was the most used antibiotic for chemoprophylaxis of leptospirosis. Post-exposure prophylaxis was assessed in four studies following a natural disaster. Although evidence of the effectiveness of post-exposure prophylaxis is inconsistent, the direction of association supported a protective effect for morbidity and mortality. The theoretical model showed how the assumed benefit of chemoprophylaxis was influenced by the time and rate of administration. Future models should consider the heterogeneity of affected communities, improved estimates of the effect of chemoprophylaxis on leptospirosis infection and disease, as well as potential detrimental impacts. Additional research is critical to provide clear evidence-based recommendations for leptospirosis control during an outbreak. The results of this study suggest that chemoprophylaxis may provide some protection in reducing the number of leptospirosis cases after a high-risk exposure; however, the effective benefit may depend on a variety of factors such as the timing and coverage of prophylaxis. The information summarized can be used to support decision-making during a high-risk event.

Spiraling Out of Control

A 22-year-old man presented to the emergency department on Christmas Day with a 5-day history of myalgias, cough, dyspnea, nonbilious emesis, and nonbloody diarrhea. Although he had been ill for several days, he ultimately sought treatment because of intractable vomiting. He reported feeling feverish, although he had not measured his temperature, and noted one episode of hemoptysis.

Sustained Tubulointerstitial Inflammation in Kidney with Severe Leptospirosis

Leptospirosis is frequently associated with acute kidney injury. Some survivors are known to progress to chronic kidney disease due to sustained tubulointerstitial inflammation. We present a case of severe leptospirosis with acute renal failure. Although antibiotic therapy resolved the infection, moderate renal dysfunction remained. A renal biopsy demonstrated marked inflammatory infiltration in the tubules and interstitium. Many of the inflammatory cells were CD68-positive monocytes/macrophages, predominantly M1 phenotype. An intermediate dose of oral corticosteroids normalized the patient's serum creatinine levels. We suggest that corticosteroid therapy may be a therapeutic option for some patients with sustained tubulointerstitial nephritis who survive severe leptospirosis.

[A Case of Leptospirosis in which the Causative Pathogen was Detected Using Cerebrospinal Fluid PCR Eight Days after Onset]

We report a patient with leptospirosis caused by infection with Leptospira interrogans serovar Rachmati. A 30-year-old Japanese man took part in a survival camp on Iriomote Island, Okinawa, from July 9 to July 15, 2014. During the camp, he swam in the river and kayaked. He developed a high fever and fatigue 7 days after completing his trip and was admitted to our hospital on July 22. On admission, he complained of a posterior cervical pain and a loss of appetite. Laboratory findings revealed granulocytosis, mildly elevated AST and ALT levels, elevated BUN and Cr levels, and a significantly elevated CRP level. No pathogenic bacteria were isolated from blood, urine, or cerebrospinal fluid cultures. We included leptospirosis in the differential diagnosis because of the patient's history of participating in a survival camp on Iriomote Island. Minocycline 200 mg, p.o. showed an excellent efficacy. The Leptospira flagellar gene FlaB was detected using a cerebrospinal fluid PCR. A microscopic agglutination test (MAT) during the convalescent stage demonstrated significant increases in antibodies against L. interrogans serovar Rachmati, confirming the diagnosis of leptospirosis. A medical history including occupation and recent travel history, and an adequate specimen sampling are crucial for the accurate and early diagnosis of leptospirosis.

Is it Time to Rethink the Use of Steroids for Pulmonary Leptospirosis?

Pulmonary involvement is a fairly common complication of leptospirosis. A high dose of steroids is often used in the treatment of pulmonary leptospirosis. Here we report two cases who developed severe invasive fungal infections following the use of steroids for pulmonary leptospirosis. Routine use of steroids for pulmonary leptospirosis may do more harm than good as the evidence for this practice is sparse.

Different clinical spectrum of leptospirosis

Leptospirosis is a prevalent zoonotic disease. Human infection usually occurs through exposure to environmental sources. Clinical course of leptospirosis is variable. We presented five patients, aged between 4-14 years, having a history of contact with rodents and symptoms 7-10 days after contact. The first three cases were relatives and had contact with dead rats after applying insecticides to bakery across from their house. The first case diagnosed as isolated meningitis, others as flu-like illness. The fourth case had a contact history with a rat inundate in the canalization and diagnosed as acute hepatitis. The last case, living in a village with poor sanitation, developed secondary hemophagocytic syndrome. ELISA was performed for diagnosis. High dose penicillin and additional immunosuppressive drugs for the last case were used. All cases showed recovery within 10 days. Leptospirosis should be considered in any patient presenting with an abrupt onset or prolonged fever, myalgia, headache and jaundice.

An Unprecedented High Incidence of Leptospirosis in Futuna, South Pacific, 2004 - 2014, Evidenced by Retrospective Analysis of Surveillance Data

Futuna is a small Polynesian island in the South Pacific with a population of 3,612 in 2013. The first human leptospirosis case was confirmed in 1997. Active surveillance started in 2004. Cases were confirmed by PCR or real time PCR, or by serology using MAT or a combination of IgM-ELISA and MAT. A retrospective analysis of surveillance data shows that the disease was endemic with a mean annual incidence of 844 cases per 100,000 over an 11-year period from 2004 to 2014. An epidemic peak as high as 1,945 cases per 100,000 occurred in 2008. Serogroup Australis was predominant until 2007, Icterohaemorrhagiae was dominant afterwards. Cluster analysis revealed different hot spots over time. Lifestyle habits, such as walking barefoot in irrigated taro fields or pig pens probably contributed to contamination from the swine and rodent reservoirs to humans. Severe forms were rare, and the case fatality rate was 0.5%. The medical community and general population were aware of leptospirosis and rapid treatment with amoxycillin was the main treatment, probably contributing to this low fatality rate.

[Leptospirosis in a family after whitewater rafting in Thailand]

Leptospirosis is a zoonosis found worldwide, with an incidence that is approximately 10 times higher in the tropics than in temperate regions. The main reservoir of leptospirosis is the rat and human infection usually results from exposure to infected animal urine or tissues. Only 10% of cases are symptomatic. We present here two confirmed and two probable cases of leptospirosis in a family returning from whitewater rafting in Thailand, illustrating the wide variety of the clinical manifestations of this infection. Two of the patients were hospitalized and presented a probable Jarisch-Herxheimer reaction after initiation of beta-lactam therapy. The two others patients were treated empirically with doxycycline. We discuss here some relevant aspects of the epidemiology, clinical manifestations, therapy and the challenge of an early diagnosis of leptospirosis.

[Leptospirosis]

Leptospirosis is a zoonosis caused by pathogenic Leptospira species. Leptospira infection can range from subclinical to life-threatening disease. Renal failure and severe respiratory symptoms may occur and are associated with a high mortality rate. It is important to realise that renal failure and other symptoms can occur in the absence of icterus. Leptospiraemia occurs mostly during the first week of acute illness, so blood cultures should be taken as soon as possible. Most cases of leptospirosis are diagnosed by serology. Antibodies are detectable in the blood approximately 5 to 7 days after onset of symptoms. Early recognition and treatment with either cephalosporins or penicillin may shorten the duration and severity of multi-organ failure and is therefore mandatory.

High dose corticosteroids in severe leptospirosis: a systematic review

The role of corticosteroids in the treatment of severe leptospirosis is unclear. The rationale for their use is that, in severe leptospirosis, there is a severe immunological response that is harmful to the host resulting in multi-organ dysfunction, which is potentially offset by the nonspecific immunosuppression of high dose steroids. We conducted a systematic review of studies that have assessed the use of high dose corticosteroids in patients with severe leptospirosis by searching MEDLINE and Scopus SciVerse without any language or time restrictions. We identified five studies, including one open randomized clinical trial, which had assessed the use of high dose steroids in severe leptospirosis. Four studies demonstrated a benefit of corticosteroids in treating severe disease with pulmonary involvement when administered early in the course of the disease, but these studies had several methodological constraints as highlighted in the text. Only the randomized controlled trial study showed that corticosteroids are ineffective and may increase the risk of nosocomial infections. There is no robust evidence to suggest that high dose corticosteroids are effective in severe leptospirosis, and a well-designed randomized clinical trial is needed to resolve this.