A Case

Of
Leptospirosis
Group V-A
Bhele Jusay Kang Kasti Katuwal Khatri Kurra Laingo Lama
Binos, Dangal, Dongol, Diones
THE CASE

A 26 year old female came in at the emergency room due to fever and jaundice.
Five days prior to days admission, patient started to have fever, headache and
calf pains. Over the next few days, the patient noticed to have decreasing urine
output and jaundice. Past medical and family history were unremarkable.
The patient reported that 2 weeks prior to admission, she waded in the flood
along Taft avenue. She also said that she sustained a wound on her left toe after
having a pedicure a day before the flood wading .
THE CASE

At the ER, vital signs are Bp 90,60, HR 110. RR 24, T 38.4 c.

Physical examination showed icteric, conjunctival suffusion,
jaundice, clear breath sounds, tachycardia with regular
rhythm, slight abdominal tenderness, calf tenderness and
normal neurologic examination.
CHIEF COMPLAINT
Jaundice
HISTORY OF
PRESENT ILLNESS
2 weeks prior to admission, she waded in the flood along Taft
avenue. She also said that she sustained a wound on her left toe
after having a pedicure a day before the flood wading
Five days prior to days admission, patient started to have fever,
headache and calf pains
Over the next few days, the patient noticed to have decreasing urine
output and jaundice.
Persistence prompt to consult at ER.
PAST MEDICAL HISTORY
Unremarkable
FAMILY HISTORY
Unremarkable
PHYSICAL EXAMINATION
General Survey: Awake ,Coherent , Conscious, Oriented and
not in cardio-respiratory distress.

Vital signs:
BP: 90/60
HR:110
RR: 24
Temp: 38.4 C
 PHYSICAL EXAMINATION
Skin: (+) Jaundice, Warm to touch, dry, good turgor, no rashes
HEENT: icteric, conjunctival suffusion, , no aural discharge, no nasal discharge
Chest: Symmetrical chest expansion, no retraction, clear breath sounds,
tachypniec
Heart: Adynamic Precordium, tachycardic , regular rhythm; no murmurs
Abdomen: Flat, normoactive bowel sounds, soft, slight abdominal tenderness
Extremities: Grossly normal with full and equal pulses; with full range of motion,
Calf tenderness, no cyanosis, no edema
Normal neurologic examination
SALIENT FEATURES
26years
Female
(5 days PTC) History of fever, headache, calf pain
(2 weeks PTC) History of wading in the flood with an open wound on
her left toe
Decreasing urine output
On PE, noted: tachycardic, tachypneic, Icteric sclerae, conjunctival
suffusion, slight abdominal tenderness, and calf tenderness.
INITIAL IMPRESSION
Severe Leptospirosis ( Weils Syndrome)
Differential Diagnosis
 Would likely consider due to:
Dengue Hemorrhagic Fever Fever
Headache
Abdominal tenderness
Tachycardic
Tachypniec
(+) conjunctival suffusion
(+) history of wading in the flood
Would not likely consider
due to:
(+)Jaundice
(+) icteric sclera
(+) calf tenderness
(-) severe back pain or muscle
pain break bone fever

Malaria Fever (+) Icteric sclera

Headache (+) calf tenderness
(+) Jaundice
Typhoid Fever Fever (+) Jaundice
Headache (+) Icteric sclera
Abdominal tenderness (+) tachycardic
(+) Calf tenderness
Final Diagnosis

Severe Leptospirosis
( Weils Syndrome)
Case Discussion
 WEILS DISEASE (LEPTOSPIROSIS)
Is a form of bacterial infection which is caused by a spirochete
Leptospira interrogans and is carried by animals, most commonly in
rats (rodents) and cattle.
This bacterial infection can be caught by humans through contact
with rat or cattle urine, most commonly occurring through
contaminated fresh water.
Weils disease is a secondary phase of a form bacterial infection also
known as Leptospirosis. Secondary symptoms include jaundice
(yellowish skin and eyes), red eyes, abdominal pain and diarrhea.
Severe cases can also cause acute kidney failure and liver failure.
LEPTOSPIRES

These are coiled, thin, highly motile organisms that have

hooked ends and two periplasmic flagella, with polar
extrusions from the cytoplasmic membrane (motility)
6-20 um long and 0.1 um wide; they stain poorly but can be
seen microsopically by dark-field examination.
Leptospires require special media and condition for
growth; it may take weeks to months for cultures to
become positive.
A microscopic view of LeptospiraI bacteria
stained apple green with a fluorescent dye
(from the CDCs Public Health Image Library)
EPIDEMIOLOGY
Has a worldwide distribution but occur most
commonly in tropics and subtropics .
Most cases occur in men, peak incidence in the
summer.
Approximately 1 million cases occur per year, with a
mean case-fatality of nearly 10%.
Leptospires establish a symbiotic relationship with
their host and can persist in the urogenital tract for
years.
Leptospirosis in
Philippine floods
A re-emerging endemic zoonosis in the
Philippines with an average of 680
leptospirosis cases and 40 deaths from the
disease reported every year and a prevalence
of 10/100,000
Peak is during the rainy season (July-October)
2009- Leptospirosis outbreak
2 weeks after the heavy rainfall typhoon
Ketsana last September 26, 2009. As of 13
November 2009 a total of 2,292 suspected
cases of leptospirosis were recorded with 178
deaths (8%) in 15 hospitals in Metro Manila.
Leptospirosis CPG 2010
Leptospirosis CPG 2010
TRANSMISSION
Transmission may follow direct contact with urine, blood or tissue from an
infected animal, or more commonly, exposure to environmental
contamination.
Human-to-human transmission is very rare.
Due to Leptospires ability to survive in a humid environment for many
months, water is an important vehicle in their transmission.
Inhalation of droplet aerosols of contaminated fluids can occasionally occur
Outbreaks may occur with or without floods, and floods often occur
without outbreaks.
 TRANSMISSION
The incubation period is usually 2-26 days, but usually (7 12 days) days.
Period of Communicability or Infectious Period: Humans with leptospirosis usually
excrete the organism in the urine for 4-6 weeks and occasionally for as long as 18
weeks.
Person-to-person transmission is considered extremely rare.
Vast majority of infections with Leptospira cause no or only mild disease in humans.
A small percentage of infections (1%) lead to severe, potentially fatal complications.
The proportion of leptospirosis that are mild is unknown because patients neither
seek nor do not have access to medical care or because non-specific symptoms are interpreted
as an influenza-like illness.
TRANSMISSION
Recreational exposure and domestic animal contact are prominent
sources of Leptospirosis.
Recreational freshwater activities such as canoeing, windsurfing,
swimming, and waterskiing place people at risk for infection.
Leptospirosis is a travelers disease. Large proportions of patient
acquire the infection while traveling in tropical countries, during
adventurous activities such as whitewater rafting, jungle trekking,
and caving.
May also be acquired through unanticipated immersion in
contaminated water and animal bite.
SIGNS AND SYMPTOMS
Anicteric Leptospirosis Severe Leptospirosis (Weils
Syndrome
Fever Jaundice
Chills Renal dysfunction
Severe headache (frontal or retroorbital) Hemorrhagic diathesis
Nausea Hepatomegaly
Vomiting Splenomegaly
Myalgias Hypovolemia
Muscle pain (calves, back, abdomen) Pulmonary involvement: cough, dyspnea,
Cough chest pain, blood-tinged sputum,
Chest pain hemoptysis or respiratory failure
Hemoptysis Hemorrhagic manifestations: epistaxis,
petechiae, purpura and ecchymosis
Less common:
Sore throat
Rash
SIGNS AND SYMPTOMS
Anicteric Leptospirosis Severe Leptospirosis (Weils Syndrome
ON PE: ON PE:
Fever with conjunctival suffusion Plus:
Muscle tenderness RUQ tenderness
Lymphadenopathy Crackles on chest auscultation
Pharyngeal injection Yellowish discoloration of the skin
Rash (macular, maculopapular, (Jaundice)
erythematous, urticarial, hemorrhagic) Icteric sclera
Hepatomegaly
Splenomegaly
Pathogenesis of the Disease
Pathophysiology
Organism gains entry in the body through
Skin abrasions
Intact mucosa: conjunctiva, oro/nasopharynx, gut

After entry, it multiplies in the blood and tissues including CSF

Leptospires can damage the wall of small blood vessels causing
vasculitis
Vasculitis is responsible for the most important manifestations of
the disease
The most important known pathogenic properties of leptospires
are adhesion to cell surfaces and cellular toxicity
Pathophysiology
Kidneys
Penetrate basement membrane of proximal renal tubule Adherent to proximal renal
tubule brush boarder interstitial nephritis and tubular necrosis Low urine output

Liver
Disruption of cellular cohesion Plugging of bile canaliculi Serum hyperbilirubin
Hepatitis creatinine kinase Calf pain

Pulmonary
Involvement is the result of hemorrhage and not of inflammation

Skeletal muscle
Invasion of leptospires results in swelling, vacuolation of the myofibrils and focal necrosis
Pathophysiology
Platelets
Platelet consumption in the activated endothelial surface
thrombocytopenia bleeding
Eye
Dilated conjunctival blood vessels conjunctival
manifestation