Leptospirosis 817.

e7

2. Immune stage: heralded by the produc-
BASIC INFORMATION tion of antibodies, occurs a few days
after first stage with similar symptoms
DEFINITION and may include kidney disease, jaun-
Leptospirosis is a zoonosis caused by the spiro- dice, pneumonitis, hemorrhage, cardiac
arrhythmias, headache, and lethargy;
chete Leptospira interrogans.
hallmark is aseptic meningitis.
SYNONYMS ICTERIC LEPTOSPIROSIS (WEIL’S SYNDROME):
Weil’s disease 1. Denotes severe cases, with symptoms of he-
patic, renal, and vascular dysfunction.
2. Biphasic course: persistence of fever, jaun-
ICD-10CM CODES dice, and azotemia.
A27.9 Leptospirosis, unspecified 3. Complications: oliguria or anuria, hemor-
A27.0 Leptospirosis icterohemorrhagica rhage, hypotension, vascular collapse.
A27.81 Aseptic meningitis in leptospirosis
A27.89 Other forms of leptospirosis ETIOLOGY
Caused by a spirochete, L. interrogans.
EPIDEMIOLOGY & • Infects a variety of animals, including most
DEMOGRAPHICS mammals.
• Specific serotypes associated with different
INCIDENCE (IN U.S.):
hosts—L. pomona in livestock, L. canicola in
• 0.05 cases/100,000 persons.
• Significant underestimation because of dogs, and L. icterohaemorrhagiae in rodents.
• Organism penetrates skin or mucous mem-
underreporting.
branes through exposure to animal urine or
• Hawaii consistently has the highest reported
infected water.
annual incidence rate in the United States.
• The most important reservoir for the bacteria
PEAK INCIDENCE: Summer months, into the
fall. is rats.
PREDOMINANT SEX: Male (4:1).
PREDOMINANT AGE: Teenagers and young adults. DIAGNOSIS
GENETICS: Neonatal infection can occur.
DIFFERENTIAL DIAGNOSIS
PHYSICAL FINDINGS & CLINICAL • Bacterial meningitis.
PRESENTATION (SEE TABLE E1)
• Viral hepatitis.
ANICTERIC FORM: • Malaria.
• Milder and more common presentation of • Dengue fever.
disease. • Hanta virus.
• A self-limited systemic illness with two stages: • Influenza.
1. Septicemic stage: presents abruptly with • Legionnaire’s disease.
fevers, headache, severe myalgias, rigors,
prostration, and sometimes circulatory WORKUP
collapse; conjunctival suffusion is com- Culture of blood, CSF, and urine:
mon; skin rash, pharyngitis, lymphade- • Organism can be isolated from blood or CSF
nopathy, hepatomegaly, splenomegaly. during first 10 days of illness.
• Urine should be cultured after first wk and for
up to 30 days after onset of illness.
• Serology: ELISA. A PCR is available in refer-
ence labs.
LABORATORY TESTS
• Normal or elevated WBCs, at times with leu-
kemoid reactions up to 70,000/mm3.
• Elevated transaminases or bilirubin.
• Anemia, azotemia, hypoprothrombinemia in
those with icteric illness.
• Elevated CK in first phase.
• Meningitis in both phases, but aseptic in
second phase.
IMAGING STUDIES
Chest x-ray may reveal interstitial nonlobar
infiltrates.
TREATMENT
NONPHARMACOLOGIC THERAPY
• Supportive.
• Observation for dehydration, hypotension,
renal failure, hemorrhage.
ACUTE GENERAL Rx
• Severe illness: IV penicillin G 1.5 million units
IV q6h (children: 250,000 to 400,000 units/
kg IV qd in four to six divided doses) or cef-
triaxone 1 to 2 g q24h (children: 80 to 100
mg/kg IV once a day) or doxycycline 100 mg
IV q12h (children ≥8: 2 mg/kg per day in two
equally divided doses). Treatment should last
7 days.
• Mild illness: doxycycline 100 mg PO bid for 7
days or amoxicillin 25 to 50 mg/kg in three
equally divided doses for 7 days or azithro-
mycin 500 mg PO qd for 3 days (children: 10
mg/kg orally on day one then 5 mg/kg per
day for 2 days).

TABLE E1  Signs and Symptoms of Admission in Patients with Leptospirosis in Large Case Series

Puerto Rico, China, 1965 Vietnam, 1973 Korea, 1987 Barbados, Seychelles, Brazil, 1999 Hawaii, 2001 India, 2002
1963 n = 208 n = 168 n = 150 n = 93 1990 n = 88 1998 n = 75 n = 193 n = 353 n = 74
Percent with:
Jaundice 49 0 1.5 16 95 27 93 39 34
Anorexia — 46 — 80 85 — — 82 —
Headache 91 90 98 70 76 80 75 89 92
Conjunctival suffusion 99 57 42 58 54 — 28.5 28 35
Vomiting 69 18 33 32 50 40 — 73 —
Myalgia 97 64 79 40 49 63 94 91 68
Arthralgia — 36 — — — 31 — 59 12
Abdominal pain — 26 28 40 43 41 — 51 —
Nausea 75 29 41 46 37 — — 77 —
Dehydration — — — — 37 — — — —
Cough 24 57 20 45 32 39 — — —
Hemoptysis 9 51 — 40 — 13 20 — 35
Hepatomegaly 69 28 15 17 27 — — 16 —
Lymphadenopathy 24 49 21 — 21 — — — 15
Diarrhea 27 20 29 36 14 11 — 53 —
Rash 6 — 7 — 2 — — 8 12

From Mandell GL et al: Principles and practice of infectious diseases, ed 7, Philadelphia, 2010, Churchill Livingstone.
Downloaded for Andika Ghifari (andikaghifari@yahoo.co.id) at Universitas Tarumanagara from ClinicalKey.com by Elsevier on November 14, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
Leptospirosis 817.e8

• For children ≦8 and pregnant females:
azithromycin or amoxicillin preferred.
• Vitamin K administration if hypoprothrombin-
emia present.
• Possible Jarisch-Herxheimer reaction when
treated with penicillin.
• Icteric leptospirosis, even with supportive doxycycline 200 mg once/week, beginning
therapy, may have a mortality as high as 10%. 1 to 2 days before and continuing throughout
the period of exposure.
REFERRAL
AUTHOR: GLENN G. FORT, M.D., M.P.H.
• If more than mild disease.
• If no response to treatment.

DISPOSITION PROPHYLAXIS
• In anicteric leptospirosis, antibiotics can • Travelers at increased risk for infection may
decrease severity and duration of symptoms. be given weekly chemoprophylaxis with

SUGGESTED READINGS
Haake DA, Levett PN: Leptospirosis in humans, Curr Top Microbiol Immunol
387:65–97, 2015.
Lau C, et al.: Leptospirosis: an emerging disease in travelers, Travel Med Infect
Dis 8(1):33–39, 2010.
Toyokawa T, et al.: Diagnosis of acute leptospirosis, Expert Rev Anti Infect Ther
9(1):111–121, 2011.

Downloaded for Andika Ghifari (andikaghifari@yahoo.co.id) at Universitas Tarumanagara from ClinicalKey.com by Elsevier on November 14, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.