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leyla swafe

on 25 June 2013

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Transcript of Leptospirosis

"His" story
The importance of "His" story
A case presentation
Leyla Swafe, F1

Literature review
Take home message
73 year old man
4/7 fever diarrhoea, nausea
Abdominal pain
Bilateral leg weakness, myalgia
No recent travel, no family members affects, no association with food
His story of presenting complaint
Past medical history
Psoriatic arthritis 1994 on methotrexate for 2 years
Left total nephrectomy 1979 for hydronephrosis 1978
No known drug allergies
Drug history
Methotrexate 20 mg once/week
Folic acid 5 mg once/week
Omeprazole 20 mg OD
Lives with wife
Ex-smoker: 10 pack yearsNo alcohol
Social history
General examination
Pyrexial 38.8 C BP 110/70, HR 85: Sats 97% on air, RR 16,
Icteric sclera
Abdomen soft, epigastric pain on deep palpation
No hepatomegaly/splenomegaly
CNS: GCS 15/15, power upper 4/5, lower 4/5, normal sensation, downgoing plantars, areflexia
Tender thighs, no joint inflammation
Blood results
Urine diptick +++ blood +++ proteins
ABG: compensated metabolic acidosis
lactate 1.59
CT chest
Abdominal ultrasound
Commenced on broad spectrum antibiotics
Became anuric
Developed pulmonary oedema
Admitted to ICU for haemofiltration
Stool cultures negative
Bloods: CMV negative
Hepatitis B, C negative
ANCA, ANA, anti-GBM negative
Specialist input
Low platelets, normal fibrinogen, not likely to be DIC
Blood film: reactive picture, not due to methotrexate toxicity

Myopathy/myositis with possible polyradiculopathy/neuropathy to account for areflexia on background of systemic infection

Not a picture of methotrexate related lung injury
Vasculitis unlikely
Expanding on "His" story
Differential diagnosis?
?Toxicity following use of pesticides/antifungal treatment
Leptospiral serology sent
Commenced on doxycycline
Day 9: Transferred to medical ward
Stable vital signs
Weakness and myalgia resolved
Daily bloods
Transfer to NNUH for liver biopsy
Leptospira serology
IgM EIA Positive titre 1:640
MAT Positive titre 1:320
Important zoonosis of worldwide distribution, predominantly involving tropical and rural areas
High risk areas: Brazil, Carribean, Malaysia, Sri Lanka, Thailand

Worldwide nr of cases estimated
0.1-1 / 100,000 population / year in temperate climates to
10 or more / 100,000 population per year in humid tropics.
Who is at risk?
Signs and symptoms
Incubation period 2 days – 3 weeks (usually 5-14 days)
Biphasic pattern
Clinical spectrum ranges from
Anicteric leptospirosis: influenza-like presentation of fever and myalgia
Weil’s disease: jaundice, renal dysfunction, major bleeding complications
Pulmonary symptoms: cough (60%) , haemoptysis (13-40%)

Diffuse alveolar haemorrhage

Syndrome consists of :
bilateral airspace opacification
decreased hematocrit

Typical patterns:
Small ‘snowflake-like’ nodular densities
Large confluent consolidations
Diffuse, ill-defined ground-glass pattern
Pulmonary involvement
Supportive treatment

Role of antibiotics
World Health Organization (WHO) guidelines: early antibiotic treatment
Cochrane review: 7 RTCs
Pre-exposure chemoprophylaxis available
MTX found to inhibit the humoral and cellular immune response in several animal models

MTX does reduce the antibody response following pneumococcal vaccination

Adverse effects:
ulcerative stomatitis, low white blood cell count
nausea, abdominal pain, fatigue, fever, dizziness,
acute liver enzyme elevations
pulmonary toxicity: acute pneumonitis , pulmonary fibrosis
Heavy rainfull and flooding increases incidence
Leptospires survival better in wet season with higher moisture and humidity
Leptospira infection of rodents higher in wet season than dry season
Infection from environmental sources
Fever, Chills, Headache During Rainy Season? It Could be Leptospirosis!

Consider Leptospirosis in patients with pulmonary haemorrhage and paraparesis

MTX– greater time for antibody response?
Take home messages
Animal hosts harbour bacteria
Bacteria excreted in urine
Transmission to humans: penetration through mucous membranes/skin or soil/fresh water contaminated with urine
Measures to reduce rodent populations, such as clearing rubbish and preventing rodent access into buildings

Cover cuts, scratches or sores with a waterproof plaster and thoroughly clean cuts or abrasions received during activities

Wear appropriate protective clothing, gloves or protective footwear

Wash or shower promptly after water sports, especially if you fall in

Avoid capsize drill or rolling in stagnant or slow moving water

Wear thick gloves when handling rats

Wash hands after handling any animal, and before eating
Neurological involvement

CNS : encephalitis, coma, convulsions, hemiplegia, myelitis and movement disorders

PNS: transient lower, limb weakness, areflexia, paraesthesiae, neuropathies and the Guillain-Barre syndrome
Full transcript