LEPTOSPIROSIS

Tropical and Infectious Diseases Division Internal Medicine Department Saiful Anwar General Hospital / Faculty of Medicine Brawijaya University Malang

Introduction
Leptospirosis is an acute anthropozoonotic infection It occurs in tropical, subtropical and temperate zones

Weil Disease, Hemorrhagic Jaundice, Mud Fever, Swineherd Disease,Canicola Fever, seven-day fever found commonly in Japan, Cane cutters disease in Australia, Rice field Leptospirosis in Indonesia , Fort Bragg fever in U.S, Andaman haemorrhagic fever(AHF)

Introduction
Spirochetal disease, finely coiled, motile, 0.1 m x 6 20 m Systemic infection manifested as widespread vasculitis Zoonosis L. interogans 23 serogroups and 200 serovars L. biflexa : non-pathogenic, saprophyte

Classification
Classification:
Phylum Class Order Species Family : : : : : Spirochaetes Spirochaetes Spirochaetales Leptospira Leptospiraceae

Leptospirosis
Facts about the bacteria. The bacteria themselves cannot survive for very long unless immersed in fresh water or urine. Unlike viruses, bacteria are rarely airborne. They must exist immersed in water, and so except in very high vapour situations airborne infection is not a risk

Leptospirosis
Facts about the bacteria There are over 200 variations of leptospira bacterium that can cause the disease. There are numerous types which are known to cause ONLY mild infection. All infections are classified into Icteric or Anicteric forms

Leptospirosis
The infection Types The Anicteric is the most common type of infection. This type is generally not Fatal, though simultaneous infections or unrelated infections may prove fatal The Icteric Weils infection is comparatively rare; can be fatal in severe cases, and accounts for 5 to 13% of all recorded cases

Leptospirosis
Features of Human Infection. The infection follows a biphasic course, for the first 3 to 7 days , the septic phase, the bacterium spreads throughout the blood, CSF and most body tissues. Early symptoms are fever, chills, muscular aches and pains, loss of appetite, and nausea when lying down. Every infection has identical initial dynamics.

Leptospirosis
Features of Human Infection.
From 10 to 30 days the Immune phase sees the removal of the bacterium from the blood and CSF, but remains in the urine. During this stage many of the body systems show detriment(kerusakan)

Leptospirosis
Features of Human Infection
Later symptoms include bruising of the skin, anemia, sore eyes, nose bleeds and in severe cases jaundice, this is know as Weils Disease.

Recovery from an infection, once the serious stages are passed is usually within 6 to 12 weeks.

Leptospirosis
Getting infected?
In order to become infected, a quantity of the leptospira bacteria must enter our body.
The main routes for any bacteria to enter a human are through ingestion, inhalation, or through broken skin.

Acquiring a leptosprial infection is not as easy as other infections, and a great deal harder than contracting some viral infections such as the common cold

Leptospirosis
Other Facts
An infection from one strain will provide immunity but only to that strain.
Exposure to other strains will still cause infection. It is usual for more than one strain to exist within a specific population of infected animals. Immunity to one type is no great advantage to reducing your risk

Leptospirosis
Urban myths the facts:
Human to human transfer is almost unheard of. Saltwater, or freshwater treated with chlorine or UV sterilised, is generally safe. Any surface or object dried out completely for over an hour even if it gets wet once more, the bacteria will remain dead. Rats are the most common carriers, but all mammals are susceptible to the illness. Almost every routine disinfectant methods will kill the bacteria. There is no human vaccine licensed for use in Europe, Asia or the USA

A microscopic view of LeptospiraI bacteria stained apple green with a fluorescent dye (from the CDCs Public Health Image Library)

Epidemiology
Leptospirosis is an important zoonosis with a worldwide distribution that affects at least 160 mammalian species In 1999, more than 500,000 cases were reported from China, with case-fatality rates ranging from 0.9 -7.9%

In Brazil, more than 28,000 cases were reported in the same year In a study in the Netherlands, 14% of patients with confirmed leptospirosis had acquired the infection while traveling in tropical countries, mostly in Southeast Asia

Reservoire of Infection
Rats Dogs Live stocks Rodents including rabbits Wild animals Cats

Sources of Human Infections

Contaminated Water or soil from infected urine Direct animal contacts Occupational exposure : farmers, vets, abattoire workers Recreational exposure : campers(kemah), swimmers, visiting graveyards

Routes of Infection
Contact with water or soil contaminated animals Direct contact with the by urine from infected source, farmer, vets, butchers, recreational activities

Rodents carry EH fever, scrub typhus, paratyphus, leptospirosis

Factors for high incidence : rain during harvest time, carrier rate in rodents Spirochetes survive longer in wet swampy conditions

Pathogenesis
Entry sites : skin wounds or abrasions in hand and feet and mucous membranes, conjunctiva, nasal, oral Bacteremia involving the entire body including eye, CSF Systemic effect and vasculitis due to endotoxin (hyaluronidase) and burrowing motility Hemorrhagic necrosis esp. in liver, lung, and kidneys jaundice, ARF, hemorrhages

Biphasic nature of leptospirosis and relevant investigations at different stages of disease. Specimens 1 and 2 for serology are acute-phase serum samples; specimen 3 is a convalescentphase serum sample that may facilitate detection of a delayed immune response; and specimens 4 and 5 are follow-up serum samples that can provide epidemiologic information, such as the presumptive infecting serogroup. [Reprinted as adaptedby Levett (from Turner LH: Leptospirosis.

BMJ 1:231, 1969)

Clinical types
Types 1986 1987

Pneumonitis Rash type Weils disease

Renal failure Flue-like Acute Hepatitis Combination

33% 17% 15% 13% 15% 8%

57.7%

53.8% 13.5% 86.5%

Phase I (Septicemia)
Following incubation period of 7-10 days High spiking fever, headaches, myalgia, arthralgias Lasting 4 7 days Proteinuria and increased creatinnine Organism detectable but serologic diagnosis not possible

Phase II (Immune)
Much more variable Induction of IgM Antibodies 1- 3 day freedom recurrence of symptoms Lower fever, CNS signs Maybe cultured from urine but not from blood or CSF

Weils Disease
Less common but severe form Mild phase I, initially Followed by severe Jaundice, Azotemia, and Hemorrhage from Lungs, GI tract, and other organs (3-6 day) Oliguric renal failure and Liver dysfunction dominate the clinical picture

Conjunctival hemorrhage in leptospirosis

Clinical Signs of Leptospirosis

Pulmonary infiltrates, pneumonitis, hemorrhages Conjunctival injection Jaundice Muscle tenderness Abdominal tenderness CVA tenderness Abnormal auscultation Erythema, petechiae, neck stiffness, adenopathy

Lab. Diagnosis
Microbiologic identification : Blood or CSF first 10 days Urine second week (Fletchers, EMJH Medium) Serology : screening Microscopic Slide Agglutination (MST), titration & serogroup identification Microscopic Agglutination (MAT), detection of IgM (ELISA)

Differential Diagnosis
EH fever Rickettsial disease : Scrub typhus, murine typhus Acute viral hepatitis Sepsis Influenza Aseptic Meningitis If with jaundice during or after an acute febrile illness (Malaria, septicemia, alcoholic hepatitis and typhoid fever)

Complications
Azotemia Oliguria Hemorrhage Purpura Hemolysis Gastrointestinal bleeding Hypoprothrombinemia and Thrombocytopenia

Treatment
Early anti-microbial therapy is important shorten the course and prevent carrier state Choice : Penicillin G, Ampicillin May cause Jarish-Huxheimer type reaction Mild cases oral Doxycycline or

Amoxicillin

Prognosis
Most patients with leptospirosis recover Mortality is highest among patients who are elderly and those who have Weils syndrome Leptospirosis during pregnancy is associated with high fetal mortality Long-term follow-up of patients with renal failure and hepatic dysfunction has documented good recovery of renal and hepatic function

Prevention
Vaccination of domestic animals Rodent control Protective gloves and boots Avoid swimming in contaminated waters Vaccination in endemic region