guidelines issued to doctors ON
DIAGNOSIS AND MANAGEMENT OF LEPTOSPIROSIS

What is the clinical  importance  of Leptospirosis ?

Leptospirosis   had been on the increase after every monsoon.  It is a detectable and treatable disease.It is  important to differentiate leptospirosis from other febrile conditions & to identify who will develop Multi Organ Dysfunction (MOD).

Clinical manifestations of leptospirosis ?

Icteric leptospirosis is the commonest   presentation in and around Cochin.. This is characterised by fever, headache, myalgia, maculopapular rash, conjunctival congestion jaundice, renal failure, hypotension, hemorrhage, hemorrhagic pneumonitis.  Anicteric Leptospirosis is another presentation ,which is biphasic  characterized by reappearance of fever along with aseptic encephalitis after a febrile period of two  weeks

What are the clinical differential diagnosis ?

 Typhoid,  Malaria, and septicemia are  are detectable and treatable conditions.Others which mimic lepto are Viral fever, Viral hepatitis,Dengue ,Hanta and other viral infections .There is no specific treatment available.With supportive and symptomatic treatment many recover.

What routine tests favour Lepto?

 Severe thrombocytopenia,(<50000/mm), raised CPK (more than 2 fold),  increase in liver enzymes less  than fourfold, presence of urinary abnormalities like albuminuria, microhaematuria and leukocyturia. These are not confirmatory.

      How do you confirm ?

By demonstration of antibodies  by ELISA - High titere or a rise in titre.

IgM antibodies become detectable in about 7 days after the onset of the disease, remain high for 6 weeks and gradually fade . Early treatment with steroid therapy is known to blunt the antibody response. LEPTO  DRIDOT TEST   Cards contains dried latex particles coated with leptospiral antigens. When mixed  gently with serum for 30 seconds, agglutination  seen  with naked eyes confirms the presence of the antibody in the serum tested.  This is a qualitative test.

What are the complications?

Acute renal failure – oliguric & non oliguric                                    Thrombocytopenia

Makedly raised CPK (Rhabdomyolysis)                                            Hepatitis / Congestion

Encephalopathy  - encephalitis / + metabolic encephalopathy

Haemorrhagic Alveolitis / Pneumonitis/ ARDS                               Myocarditis

Pancreatitis / Cholecystitis / Uveitis                                                  Refractory Hypotension

Systemic Inflammatory Response Syndrome                                   Capillary Leak

What is the treatment?

Penicillin is the antibiotic of choice. Ampicillin,  Doxycycline, Erythromycin (useful in out-patients), 3rd/4th generation cephalosporins and quinolones are found to be effective both in vivo and in vitro studies.  Early antibiotic therapy has been shown to shorten the duration of illness.  Simple analgesics and antipyretics like acetaminophen, tepid sponging etc are adequate for the myalgia and fever.  NSAID’s are better avoided due to the potential nephrotoxicity . based on the symptoms and with the limited lab parameters pointing to leptospirosis should be treated at the earliest.

What is the course of disease?

80-90% patients have a mild clinical  illness like any other viral fever with or without early mild internal organ dysfunction.  A subset of patients may become seriously ill with internal organ dysfunction progressing into multi organ failure complicating the picture.  They have to be admitted in a critical care unit.

Which complications can be effectively trated ?

Dehydration is the commonest cause for  hypotension and benefits with appropriate I.V fluids. A hypervolaemic hypotensive patient will require ionotropic support.  Hypoxia (Pao2 < 70mm Hg) in leptospirosis is due to ARDS, (haemorrhagic pneumonitis). Renal failure patients (non-oliguric in 55%) would require dialysis support early to have better results.  Platelet transfusions decrease  active bleeding when platelets are < 20000 -  50,000/ mm3.

Tab Doxycycline 200 mgs   2times/week has been found to be effective in preventing leptospirosis in endemic areas.