MAJOR ARTICLE

Activation of the Coagulation Cascade in Patients

with Leptospirosis
Wirongrong Chierakul,1,2 Panatsaya Tientadakul,3 Yupin Suputtamongkol,4 Vanaporn Wuthiekanun,2
Kriangsak Phimda,5 Roongrueng Limpaiboon,5 Nisarat Opartkiattikul,3 Nicholas J. White,2,6 Sharon J. Peacock,2,6
and Nicholas P. Day2,6
1
Department of Clinical Tropical Medicine and 2The Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, and
Departments of 3Clinical Pathology and 4Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, and 5 Medical Department,
Udon Thani Regional Hospital, Udon Thani, Thailand; and 6Centre for Clinical Vaccinology and Tropical Medicine, Nuffield Department of Clinical
Medicine, University of Oxford, Churchill Hospital, Oxford, United Kingdom

Background. Disseminated intravascular coagulation (DIC) is common among patients with sepsis. Leptospirosis is an important cause of sepsis in tropical areas, and pulmonary hemorrhage associated with thrombocytopenia is the major cause of death, but the coagulopathy in severe leptospirosis has not been further characterized.
The aim of this study was to evaluate coagulation factors and the presence of DIC in patients with leptospirosis
in northeast Thailand.
Methods. We measured plasma concentrations of fibrinogen, D-dimer, thrombin-antithrombin III complexes,
and prothrombin fragment 1,2 and evaluated the DIC score in 79 patients with culture-confirmed and/or serologically confirmed leptospirosis and in 33 healthy Thai control subjects.
Results. The median concentrations of fibrinogen, D-dimer, thrombin-antithrombin III complexes, and prothrombin fragment 1,2 were significantly elevated in a cohort of 79 patients with leptospirosis, compared with
healthy control subjects (P .001 for all tests). Patients with leptospirosis had significantly longer prothrombin
times, longer activated partial thromboplastin times, and lower platelet counts. Thrombocytopenia was present in
38% of case patients and occurred more frequently among patients with culture-negative leptospirosis; in multivariate analysis, it was the only hemostasis factor independently associated with clinical bleeding. Patients who
were culture-negative for Leptospira species had higher Acute Physiology and Chronic Health Evaluation II and
Sepsis-Related Organ Failure Assessment scores and more bleeding complications. Nearly one-half of patients with
leptospirosis had overt DIC as defined by an International Society on Thrombosis and Hemostasis DIC score.
Conclusions. Activation of the coagulation system is an important feature of leptospirosis. Thrombocytopenia
is an indicator of severe disease and risk of bleeding.
Leptospirosis is a worldwide zoonosis caused by pathogenic members of the genus Leptospira. A variety of
wild and domestic animals excrete the organism in their
urine. Human infection occurs through direct contact
with infected animals or through exposure to fresh water or soil contaminated by infected animal urine. Leptospirosis is recognized as an important emerging infection in many countries, including Thailand, where

Received 24 July 2007; accepted 11 September 2007; electronically published

13 December 2007.
Reprints or correspondence: Dr. Wirongrong Chierakul, Faculty of Tropical
Medicine, Mahidol University, 420/6 Rajvithi Rd., Rajathevi, Bangkok 10400,
Thailand (tmwcr@mahidol.ac.th).
Clinical Infectious Diseases 2008; 46:25460
 2007 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2008/4602-0015$15.00
DOI: 10.1086/524664

254 CID 2008:46 (15 January) Chierakul et al.

a recent major outbreak of the disease has been reported

in the northern and northeastern regions [1, 2].
The clinical manifestations of leptospirosis range
from a mild, often self-limiting flu-like illness to an
acute, life-threatening multisystem disorder. The complications of severe disease include renal failure, abnormal liver function test results, jaundice, hypotension, and pulmonary hemorrhage. The common causes
of death are pulmonary hemorrhage, protracted shock,
and renal failure [3]. The pathophysiological mechanisms responsible for bleeding in leptospirosis are
poorly understood. Thrombocytopenia has been reported to occur in 50%80% of patients and is usually
associated with severe disease with renal failure [4], but
it was not associated with higher mortality in one retrospective study [5]. A prospective study showed that
low platelet count was not a risk factor associated with

mortality in patients with leptospirosis and acute pulmonary

injury [6]. Findings in animal studies have been conflicting, in
that some studies have shown evidence of disseminated intravascular coagulation (DIC) [79], whereas others have not
[10, 11].
The aim of this study was to determine the frequency and
clinical associations of DIC in patients with leptospirosis. Fibrinogen, cross-linked fibrin degradation products (D-dimer),
thrombin-antithrombin III complexes (TAT), and prothrombin
fragment 1,2 (F1+2) were measured in patients with confirmed
disease during an outbreak of leptospirosis in northeast
Thailand.
PATIENTS AND METHODS
Patients and study design. A prospective study was performed from October 2000 through September 2001 to identify
patients with leptospirosis. The study protocol was approved
by the Ethical Committee of the Ministry of Public Health,
Royal Government of Thailand. Consecutive patients (14
years of age) who were admitted with an acute febrile illness
to Udon Thani Regional Hospital in Udon Thani, northeast
Thailand, were recruited after giving informed consent. History
and physical examination findings were recorded on a clinical
record form. Blood samples were taken from all patients for
baseline laboratory testing, including a complete blood count,
renal and liver function tests, and conventional blood cultures.
A 10-mL blood sample was also collected into a sterile tube
containing 250 U of heparin sodium (Heparin Leo; Leo
Pharma) for Leptospira culture on the day of hospital admission. CSF samples from patients with neck stiffness was also
cultured for aerobic bacteria and Leptospira species. Serum samples were obtained at hospital admission, days 3 and 7, and
weekly until discharge from the hospital. If patients were discharged !2 weeks after hospitalization, they were asked to return for a follow-up visit 1 week after discharge from the
hospital.
Culture for Leptospira was performed using EllinghausenMcCullough-Johnson-Harris media supplemented with 3%
rabbit serum and 0.1% agarose, as described elsewhere [12].
Samples with positive culture results were sent to the World
Health Organization/Food and Agriculture Organization of the
United Nations/World Organisation for Animal Health Collaborating Center for Reference and Research on Leptospirosis
(Brisbane, Australia) for serovar identification using the crossagglutinin absorption test [13]. Serological testing for leptospirosis was performed using the microscopic agglutination test
at the National Institute of Health and National Institute of
Animal Health, Ministry of Public Health, Thailand (Bangkok,
Thailand). A diagnosis of leptospirosis was made if CSF or
blood cultures became positive for Leptospira species and/or
when there was a 4-fold increase in titers between acute-

phase and convalescent-phase serum samples or a single titer

of 1:400.
Blood samples were obtained from all patients for coagulation testing at admission to the hospital, to compare with
blood samples obtained from 33 healthy Thai volunteers who
were known to have no illness that could affect hemostasis and
were not currently receiving any medication. Blood samples
were collected into 3.2% sodium citrate tubes (BD Vacutainer
Blood Collection Tube; Becton Dickinson). Plasma was separated into 2 tubes; 1 was used for immediate coagulation testing,
and 1 was stored immediately at 70C until the assays were
performed.
A primary analysis was performed in which results for control subjects and patients with leptospirosis were compared.
Subgroup analysis was performed to compare results from patients with cultures positive for Leptospira species with those
from culture-negative patients and to compare results from
patients with severe disease with those from patients with nonsevere disease. Patients were defined as having severe leptospirosis if 1 of the following were present: renal involvement
(oliguria or a creatinine level 12.5 mg/dL), jaundice (total bilirubin level 12.5 mg/dL), clinical bleeding abnormalities, hypotension (systolic blood pressure !90 mmHg or diastolic
blood pressure !60 mmHg), or the presence of respiratory
distress or respiratory failure. Patients were defined as having
thrombocytopenia if they had a platelet count of 100 10 9
platelets/mL. A DIC score for each patient was also calculated
using the platelet count and the D-dimer, prothrombin time
(PT), and fibrinogen levels according to the algorithm for the
diagnosis of overt DIC recommended by the DIC scientific
subcommittee of the International Society for Thrombosis and
Hemostasis [14]. This DIC score was calculated by assigning 1
point for each of the following: (1) a platelet count of !100
but 150 10 9 platelets/mL, (2) a prolonged PT of 13 s but !6
s, and (3) a fibrinogen level !1.0 g/L. A platelet count
!50 10 9 platelets/mL, a prolonged PT of 6 s, and an elevated
D-dimer 2 times but !5 times the upper limit of normal were
each assigned 2 points, and a D-dimer of 5 times the upper
limit of normal was assigned 3 points. A score 5 was compatible with overt DIC, whereas a score of !5 may be indicative
(but is not affirmative) of nonovert DIC. The algorithm for
nonovert DIC was not applied, because protein C and antithrombin levels were not measured. No follow-up coagulation
tests were performed in this study. Clinical severity was assessed
using the APACHE II score [15] and Sepsis-Related Organ
Failure Assessment (SOFA) score [16].
Assays. PT and activated partial thromboplastin time were
performed at Udon Thani Regional Hospital (Udon Thani,
Thailand) on the day of hospital admission using the Thromborel S and Dade Actin FS Activated PTT reagents (Dade Behring), respectively. Stored citrated plasma was transferred on
Coagulopathy and Leptospirosis CID 2008:46 (15 January) 255

Table 1. Baseline information for 79 patients with leptospirosis, comparing culture-positive and
culture-negative groups.
Patients with leptospirosis

Variable

All
(n p 79)

Culture positive
for Leptospira
species
(n p 48)

Culture negative
for Leptospira
species
(n p 31)

35 (1572)
36 (75)

41 (2067)
22 (71)

NS
NS

Age, years
Male sex, no. (%) of patients

38.5 (1572)
58 (73.4)

Duration of symptoms, days

Mean arterial pressure, mm Hg
Blood urea nitrogen level, mmol/L
Serum creatinine level, mmol/L

4
77
7.9
133

Serum bicarbonate level, mmol/L

Serum potassium level, mmol/L

23 (1131)
3.6 (1.87)

25 (1531)
3.6 (2.54.9)

21 (1129)
3.6 (1.87.0)

Total serum bilirubin level, mmol/L

Direct serum bilirubin level, mmol/L

24 (5397)
14 (3.4243)

19 (5164)
10 (3.4111)

65 (7397)
39 (3.4243)

!.001

Aspartate aminotransferase level, U/L

Alanine aminotransferase level, U/L

61 (13326)
42 (9201)

52 (13213)
49 (9201)

70 (20326)
41 (19142)

.06
NS

(28)
(37113)
(2.536.4)
(62955)

Alkaline phosphatase level, U/L

Albumin level, g/L
Globulin level, g/L
Hemoglobin level, mmol/L

108
36
30
129

(43446)
(2048)
(1954)
(70168)

WBC count, 109 cells/L

Neutrophil percentage

11.0 (5.233.5)
86 (4595)

3
80
6.4
124

96
39
31
134

(28)
(37113)
(2.532.1)
(71636)

(52446)
(2848)
(2344)
(99168)

11.4 (5.828.3)
86 (7095)

5
73
13.9
283

120
30
27
119

(28)
(46112)
(2.936.4)
(62955)

(43391)
(2040)
(1954)
(70145)

10.7 (5.233.5)
86 (4594)

!.001

NS
!.001
!.001
!.001

NS
!.001

NS
!.001
!.001
!.001

NS
NS

NOTE. Data are given as median value (range), unless otherwise idicated. NS, not significant.

dry ice to the hematology laboratory of Siriraj Hospital (Bangkok, Thailand) for testing of the remaining DIC markers. Fibrinogen, F1+2, and TAT were measured by specific ELISAs,
according to the manufacturers instructions (for fibrinogen,
PT-derived fibrinogen method using Thromborel S as the PT
reagent on Behring Coagulation Timer; for F1+2, Enzygnost
F1+2 micro; and for TAT, Enzygnost TAT micro [Dade Behring]). D-dimers were measured using a latex-enhanced turbidimetric test (D-dimer Plus; Dade Behring); the upper limit
of normal recommended by the manufacturer was 246.4 mg/
mL. Monoclonal antibodies specific for each assay were used
in all of the test systems.
Statistical analysis. Data on patient characteristics and laboratory results were compared between different groups using
the Kruskal-Wallis test or Mann-Whitney U test for continuous
variables, as appropriate, and the x2 test or Fishers exact test
for categorical variables. The nonparametric Spearman correlation (r) was used to demonstrate correlations between laboratory test results and APACHE II and SOFA scores. All analyses were performed using the statistical computing package
STATA/SE, version 9.0 for Windows (Stata), and GraphPad
Prism, version 4 for Windows (GraphPad Software).

256 CID 2008:46 (15 January) Chierakul et al.

RESULTS
Patients. A total of 79 consecutive patients with confirmed
leptospirosis were enrolled in the study. Of these, 48 (61%)
had cases that were diagnosed by isolation of Leptospira species
in either blood or CSF samples (45 from blood samples, 2 from
blood and CSF samples, and 1 from CSF samples only), and
31 patients (39%) were culture negative and had cases that
were diagnosed on the basis of microscopic agglutination test
results. The serovar determinations for cultured Leptospira species were as follows: Leptospira interrogans serovar Autumnalis
(32 isolates), L. interrogans serovar Pyrogenes (3), L. interrogans
serovar Javanica (1), L. interrogans serovar Medanensis (2), and
unidentified serovar (10). A summary of baseline clinical features and baseline laboratory results are shown in table 1. There
were 2 deaths (2.5%) due to pulmonary hemorrhage in the
group of patients who were culture positive for Leptospira species. Patients who were not leptospiremic at admission to the
hospital had a longer median duration of symptoms prior to
admission and had more-severe manifestations in terms of
blood chemistry reflecting renal and liver impairment, higher
APACHE II score, and a higher proportion of clinical bleeding
manifestations (tables 1 and 2).

Table 2. Severity of disease and outcome for patients with leptospirosis, comparing culturepositive and culture-negative groups.
Patients with leptospirosis

Variable
Median APACHE II score (IQR)
Median SOFA score (IQR)

All
(n p 79)

Culture positive
for Leptospira
species
(n p 48)

Culture negative
for Leptospira
species
(n p 31)

7 (410)
3 (111)

5 (38)
2 (14)

9 (415)
12 (614)

!.001

18 (23)
10 (13)

5 (10)
2 (4)

13 (42)
8 (26)

.003
.01

7 (9)
4 (5)

1 (2)
2 (4)

6 (19)
2 (7)

.01
.64

1 (1.3)

1 (2)

.001

Bleeding complication
Any
Skin/mucosal bleeding
Gastrointestinal bleeding
Pulmonary hemorrhage
Urinary tract bleeding
Thrombocytopenia

1.00

Platelet count 100 109 platelets/L

Platelet count 50 109 platelets/L
Overt DIC score

30 (38)

10 (21)

20 (65)

!.001

19 (24)

2 (4)

17 (55)

!.001

Median score (IQR)

5
Death

4 (35)
36 (46)
2 (2.5)

4 (35)
16 (33)
2 (4.2)

5 (46)
20 (65)
0

.002
.007
.52

NOTE. Data are no. (%) of patients, unless otherwise indicated. DIC, disseminated intravascular coagulation;
IQR, interquartile range; SOFA, Sepsis-Related Organ Failure Assessment.

Platelets and coagulation tests. Patients with leptospirosis

had a significantly lower median (interquartile range) platelet
count than did the control group (142.5 10 9 platelets/mL [50
211 10 9 platelets/mL] vs. 289 10 9 platelets/mL [228
328 10 9 platelets/mL]; P ! .001). They also had significantly
longer median PTs and activated partial thromboplastin times
and had higher median levels of D-dimer, F1+2, and TAT
(P ! .001) (figure 1). These differences were preserved in subgroup analyses, in which culture-negative and culture-positive
groups were compared separately with the control group.
Coagulation, DIC score, and clinical severity. Forty-five
patients (57%) presented with severe complications of leptospirosis (oliguria or renal failure in 24 patients, jaundice in 26,
abnormal bleeding in 18, hypotension in 23, and respiratory
distress or failure in 6). These patients had a significantly lower
median (interquartile range) platelet count than did patients
with less severe complications (66.5 10 9 platelets/mL [33.5
166 10 9 platelets/mL] vs. 192 10 9 platelets/mL [144
240 10 9 platelets/mL]; P ! .001), but the other coagulation
test results and factors were not different between the 2 groups
(data not shown). The platelet count was correlated negatively
with the APACHE II and SOFA scores (for APACHE II score,
FrF p 0.53 and P ! .001; for SOFA score, FrF p 0.75 and P !
.001), whereas the other coagulation parameters had no significant correlations with APACHE II and SOFA scores. The
median (interquartile range) overt DIC score was significantly

higher for patients with severe leptospirosis than it was for

patients with less severe leptospirosis (6 [56] vs. 4 [35];
P p .003). Thirty-six patients (46%) had an overt DIC score
5, which is compatible with DIC. The proportion of patients
with an overt DIC score 5 was higher among patients who
had severe disease than it was among patients with less severe
disease (27 [60%] of 45 vs. 9 [26%] of 34; P p .003). In a
logistic regression analysis considering platelet count, D-dimer,
F1+2, and TAT, platelet count was the only factor independently
associated with clinical bleeding (P p .003).
Coagulation, DIC score, and clinical bleeding. Eighteen
patients had clinically significant bleeding. The median (interquartile range) APACHE II, SOFA, and overt DIC scores were
higher in patients with abnormal bleeding than in those who
did not have abnormal bleeding, as follows: for APACHE II
score, 10 (715) versus 5 (39) (P p .004); for SOFA score, 14
(1016) versus 2 (16) (P ! .001); and for overt DIC score, 5
(56) versus 4 (35) (P p .001). Patients with clinically significant bleeding had significantly lower platelet counts, compared with the nonbleeding group (median platelet count, 43.5
vs. 162 10 9 platelets/mL; P ! .001 ). The clinical bleeding
group also had a higher proportion of patients with thrombocytopenia (14 [78%] vs. 16 [27%]; P ! .001). The other coagulation test results and markers were not different between
the patients who had bleeding and those who did not (P
.15). There was no difference in mortality between the 2 groups

Coagulopathy and Leptospirosis CID 2008:46 (15 January) 257

Figure 1. Platelet count and coagulation factors in patients with leptospirosis (empty triangles) who were culture negative (black triangles) or culture
positive (black diamonds) for Leptospira species and in healthy Thai control subjects (empty squares).

(1 [5.6%] in the bleeding group and 1 [1.6%] in the nonbleeding group; P p .41). The proportion of patients with an overt
DIC score 5 was higher among patients who had clinical
bleeding than it was among those with no clinically significant
bleeding (14 [78%] of 18 vs. 22 [36%] of 61; P p .002).
DISCUSSION
Abnormal bleeding is not uncommon in leptospirosis, and it
is often present in fatal cases. The most common site is the
lung, and other complications, such as intracerebral hemorrhage, occur only rarely [17]. Immunofluorescence studies performed on infected lung tissue specimens in the experimental
leptospirosis guinea pig model have shown the presence of IgM,
IgG, IgA, and C3 along the alveolar basement membrane, suggesting a possible role for an autoimmune process in fatal pulmonary hemorrhage associated with leptospirosis [10].
Thrombocytopenia is frequently found in leptospirosis but,
to our knowledge, has not previously been correlated directly
with a higher incidence of clinical bleeding [18, 19]. In this
study, patients with clinical bleeding had significantly lower
platelet counts than did other patients. The mechanism of
thrombocytopenia in leptospirosis is not well defined. Some
studies have suggested defects in production caused by a direct
toxic effect of the organism on the bone marrow [20, 21].
Several studies have shown nonimmune platelet destruction to
be an effect of DIC, immune-mediated causes that respond to
treatment with methylprednisolone and hydrocortisone [22],
and increased consumption of platelets secondary to activation
of vascular endothelium [19]. Recent studies involving a guinea
pig model also showed evidence of platelet activation as reflected by increased plasma levels of 11-dehydrogenate thromboxane B2 without significant increases of D-dimer, TAT complexes, and fibrinogen degradation products and lack of platelet
and fibrin thrombi formation, suggesting that, in this animal
model, the mechanism of bleeding was not DIC [11].
Other thrombohemorhagic syndromes, such as hemolytic
uremic syndrome and thrombotic thrombocytopenic purpura,
can cause thrombocytopenia and have been reported rarely in
leptospirosis [23, 24]. Thrombocytopenia and renal impairment, which are characteristic features of these syndromes, were
found commonly in this study (in 38% and 26% of patients,
respectively), but neurological symptoms, such as those seen
in thrombotic thrombocytopenic purpura, were found in !10%
of patients. Unfortunately, peripheral blood films were not performed in this study, so the presence of schistocytes could not
be assessed. Although the patients with thrombocytopenia had
lower hemoglobin concentrations (P p .002 ) and higher bilirubin (P ! .001) and aspartate aminotransferase (P p .004) levels than did those who had normal platelet counts (data not
shown), microangiopathic hemolytic anemia could not be
confirmed.

Fibrinogen is an acute-phase reactant, and plasma levels may

be increased or remain normal during infection, despite ongoing consumption in the process of DIC. Hypofibrinogenemia
occurs infrequently in severe cases of DIC, with a reported
sensitivity of only 28% of a low fibrinogen level as a predictor
of DIC [25, 26].
A recent review of coagulation disorders and the pathogenesis
of leptospirosis concluded that the bleeding tendency results
from an imbalance in the hemostatic equilibrium, caused by
as yet unknown mechanisms. This hemostatic imbalance may
lead to DIC, but this needs to be proven in a prospective study
[27]. DIC is a complex, systemic thrombohemorrhagic syndrome, which is difficult to diagnose and for which there is no
single diagnostic test. However, using the diagnostic algorithm
introduced by the subcommittee on DIC of the International
Society for Thrombosis and Hemostasis in 2001 (with a reported 91% sensitivity and 97% specificity) [14], we found that
nearly one-half of the patients with leptospirosis had a DIC
score 5, indicative of overt DIC. We were unable to evaluate
this DIC score as a predictor of fatal outcome because of the
very low mortality (2.5%) among the study patients.
Patients with blood cultures positive for Leptospira species
presented earlier in the course of their illness than did those
with negative culture results; therefore, antibiotic treatment was
also started earlier. This may explain why, as a group, they had
less severe disease manifestations in terms of lower APACHE
II and SOFA scores, higher platelet counts, fewer cases of
thrombocytopenia, fewer clinical bleeding complications, and
lower DIC scores. These clinically important differences between patients who are culture positive for leptospirosis and
those who are culture negative have not been described
previously.
In summary, activation of the coagulation cascade is common during leptospirosis, and this is often associated with DIC,
which occurred in nearly one-half of study patients. However,
thrombocytopenia was the only hemostasis-related factor independently associated with clinical bleeding, and it should be
considered to be a predictor of disease severity in patients with
leptospirosis.
Acknowledgments
We thank Dr. Rewat Phankingthongkum (Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand),
Naowanit Boonyarueng, Amornwadee Sungkakam, and all of the staff of
the Medical Department, Udon Thani Regional Hospital, Udon Thani,
Thailand.
Financial support. Wellcome Trust and a Wellcome Trust Career Development Award in Clinical Tropical Medicine (to S.J.P.)
Potential conflicts of interest. All authors: no conflicts.

References
1. Disease notification report, Ministry of Public Health, Thailand. Available at: http://epid.moph.go.th/dssur/zoonosis/lepto.htm. Accessed 25
November 2006.

Coagulopathy and Leptospirosis CID 2008:46 (15 January) 259

2. Thaipadungpanit J, Wuthiekanun V, Chierakul W, et al. A dominant

clone of Leptospira interrogans associated with an outbreak of human
leptospirosis in Thailand. PLoS Neglected Trop Dis 2007; 1: e56.
3. Dupont H, Dupont-Perdrizet D, Perie JL, Zehner-Hansen S, Jarrige B,
Daijardin JB. Leptospirosis: prognostic factors associated with mortality. Clin Infect Dis 1997; 25:7204.
4. Edwards CN, Nicholson GD, Everard CO. Thrombocytopenia in leptospirosis. Am J Trop Med Hyg 1982; 31:8279.
5. Raoult D, Jeandel P, Mailloux M, Rougier Y. Thrombocytopenia and
renal failure in leptospirosis. Am J Trop Med Hyg 1983; 32:1464.
6. Marotto PC, Nascimento CM, Eluf-Neto J, et al. Acute lung injury in
leptospirosis: clinical and laboratory features, outcome, and factors
associated with mortality. Clin Infect Dis 1999; 29:15613.
7. da Silva JJ, Netto BA, Lilembaum W, Alvim ME, de Oliveira AV. The
hemorrhagic syndrome of leptospirosis: an experimental study in
guinea pigs. Rev Soc Bras Med Trop 1995; 28:16977.
8. Higgins R, Cousineau G. The pathogenesis of leptospirosis I: hemorrhages in experimental leptospirosis in guinea pigs. Can J Comp Med
1977; 41:17481.
9. Navarro CE, Kociba GJ. Hemostatic changes in dogs with experimental
Leptospira interrogans serovar icterohaemorrhagiae infection. Am J Vet
Res 1982; 43:9046.
10. Nally JE, Chantranuwat C, Wu XY, et al. Alveolar septal deposition of
immunoglobulin and complement parallels pulmonary hemorrhage in
a guinea pig model of severe pulmonary leptospirosis. Am J Pathol
2004; 164:111527.
11. Yang HL, Jiang XC, Zhang XY, et al. Thrombocytopenia in the experimental leptospirosis of guinea pig is not related to disseminated
intravascular coagulation. BMC Infect Dis 2006; 6:19.
12. Wuthiekanun V, Chierakul W, Limmathurotsakul D, et al. Optimization
of culture of Leptospira from humans with leptospirosis. J Clin Microbiol 2007; 45:13635.
13. Stallman N. International committee on systematic bacteriology, subcommittee on the taxonomy of Leptospira: minutes of the meeting,
610 August 1982, Boston, Massachusetts. Int J Syst Bacteriol 1984;
34:2589.
14. Taylor FB Jr, Toh CH, Hoots WK, Wada H, Levi M. Towards definition,
clinical and laboratory criteria, and a scoring system for disseminated
intravascular coagulation. Thromb Haemost 2001; 86:132730.

260 CID 2008:46 (15 January) Chierakul et al.

15. Theilen HJ, Luck C, Hanisch U, Ragaller M. Fatal intracerebral hemorrhage due to leptospirosis. Infection 2002; 30:10912.
16. Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related Organ
Failure Assessment) score to describe organ dysfunction/failure. On
behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med
1996; 22:70710.
17. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a
severity of disease classification system. Crit Care Med 1985; 13:81829.
18. Edwards CN, Nicholson GD, Hassell TA, Everard CO, Callender J.
Thrombocytopenia in leptospirosis: the absence of evidence for disseminated intravascular coagulation. Am J Trop Med Hyg 1986; 35:
3524.
19. Nicodemo AC, Duarte MI, Alves VA, Takakura CF, Santos RT, Nicodemo EL. Lung lesions in human leptospirosis: microscopic, immunohistochemical, and ultrastructural features related to thrombocytopenia. Am J Trop Med Hyg 1997; 56:1817.
20. Nicodemo AC, Del NG, Amato NV. Thrombocytopenia and leptospirosis. Rev Inst Med Trop Sao Paulo 1990; 32:2529.
21. Somers CJ, Al Kindi S, Montague S, et al. Erythroid hypoplasia associated with leptospirosis. J Infect 2003; 47:856.
22. Davenport A, Rugman FP, Desmond MJ, Ganta R. Is thrombocytopenia
seen in patients with leptospirosis immunologically mediated? J Clin
Pathol 1989; 42:43940.
23. Hanvanich M, Moollaor P, Suwangool P, Sitprija V. Hemolytic uremic
syndrome in leptospirosis bataviae. Nephron 1985; 40:2301.
24. Huits RM, van der Werf TS, Zijlstra JG. Clinical reasoning and decisionmaking in practice. A man with jaundice, renal function disorder,
thrombocytopenia, muscular pain and confusion [in Dutch]. Ned
Tijdschr Geneeskd 2004; 148:113741.
25. Levi M, de Jonge E, van der PT, Ten Cate H. Disseminated intravascular
coagulation. Thromb Haemost 1999; 82:695705.
26. Levi M. Disseminated intravascular coagulation. Crit Care Med
2007; 35:21915.
27. Wagenaar JF, Goris MG, Sakundarno MS, et al. What role do coagulation disorders play in the pathogenesis of leptospirosis? Trop Med
Int Health 2007; 12:11122.