Leptospirosis

Sung Chul Hwang

Dept. of Pulmonary and Critical Care Medicine

Ajou University School of Medicine

Introduction• Spirochetal disease, finely coiled, motile, 0.

1 x 6 – 20• Systemic infection manifested as widespre

ad vasculitis

• Zoonosis

• L. interogans 23 serogroups and 187 serovars

• L. biflexa : non-pathogenic, saprophyte

Historical back ground• 1921 : Takaki 창경원 죽은 족제비 – L. ictero

hemorragiae 분리• 1942 : sekiguchi – L. canicola from mouse• 1951 : 미군 , 동경 401 의무 시험소 - 국내

들쥐로부터 ictohemorrhagiae 분리• 1975 : 경기 강원 충북 , “ 출혈성 폐렴양 괴

질”• 1984 년 10 월 : 강원도 원주 , 괴질

환자에서 렙토스피라 균을 분리 동정• 1984 년이후 : 매년 9-11 월 환자 및 야생쥐

-leptospira 균이 동정됨

Epidemiology• Disease of the wild animals

• Incidental human infection by direct or indirect contact with the animal

• 20-40s active males: farmers or soldiers in harvest time

• 9-10 peak into November

• 추수 , 탈곡 , 벌초 , 성묘 , 나무하기 , 훈련 , 등

Reservoires of Infection

• Rats

• Dogs

• Live stocks

• Rodents including rabbits

• Wild animals

• Cats

Sources of Human Infections• Contaminated Water or soil from infected

urine

• Direct animal contacts

• Occupational exposure : farmers, vets, abattoire workers

• Recreational exposure : campers, swimmers, visiting graveyards

Routes of Infection• Contact with water or soil contaminated animals• Direct contact with the by urine from infected sourc

e, farmer, vets, butchers, recreational activities• Rodents carry EH fever, scrub typhus, paratyphus, l

eptospirosis• Factors for high incidence : rain during harvest tim

e, carrier rate in rodents• Spirochetes survive longer in wet swampy conditions

국내 주민의 항체 보유율

• 1985.2 – 1986.7 : 11.69%• 1987.2 – 1987. 7 : 5.9 %• 1985 in febrile patients : 20%• 1986- 1987 in febrile patients :

11.6%

국내 야생쥐의 균 보유율

•1984 : 15.5%•1985 : 14.9%•1986 : 16%•1987 : 30.9% ( 파주 , 여주 )

Microbiology and distribution

•Mainly serogroup ictohemorrhagiae and canicola

•전북 , 서울 , 강원 , 충북 , 충남•CH-48 : 춘천지방 , 혈청형 미상•Serovar : mainly lai

Pathogenesis• Entry sites : skin wounds or abrasions in hand an

d feet and mucous membranes, conjunctiva, nasal, oral

• Bacteremia involving the entire body including eye, CSF

• Systemic effect and vasculitis due to endotoxin (hyaluronidase) and burrowing motility

• Hemorrhagic necrosis esp. in liver, lung, and kidneys jaundice, ARF, hemorrhages

Clinical typesTypes 1986 1987

Pneumonitis 33% 57.7%Rash type 17%Weil’s disease 15%Renal failure 13% 53.8%“Flue-like” 15% 13.5%Acute Hepatitis 8%Combination 86.5%

Phase I (Septicemic)

• Following incubation period of 7-10 days

• High spiking fever, headaches, myalgia, arthralgias

• Lasting 4 – 7 days

• Proteinuria and increased creatinnine

• Organism detectable but serologic diagnosis not possible

Phase II (Immune)

• Much more variable• Induction of IgM Antibodies• 1- 3 day freedom recurrence of sympto

ms• Lower fever, CNS signs• Maybe cultured from urine but not from

blood or CSF

Weil’s Disease• Less common but severe form• Mild phase I, initially• Followed by severe Jaundice , Azotemia,

and Hemorrhage from Lungs, GI tract, and other organs (3-6 day)

• Oliguric renal failure and Liver dysfunction dominate the clinical picture

Clinical Signs of Leptospirosis

• Pulmonary infiltrates, pneumonitis, hemorrhages• Conjunctival injection• Jaundice• Muscle tenderness• Abdominal tenderness• CVA tenderness• Abnormal auscultation• Erythema, petechiae, neck stiffness, adenopathy

Lab. Diagnosis

• Microbiologic identification : Blood or CSF first 10 days Urine second week (Fletcher’s, EMJH Medium)

• Serology: screeningMicroscopic Slide Agglutination (MST), titration & serogroup identification Microscopic Agglutination (MAT), detection of IgM (ELISA)

Chest X-rays

• 33 – 64 % of patientssjows abnormality• Bilateral nodules, rosette densities• Diffuse ill-defined infiltrates• Massive confluent consolidation• Bilateral, Non-lobar, peripheral predominance• Rare pleural reaction• Complete resolution within 5 to 10 days

Treatment

• Early anti-microbial therapy is importantshorten the course and prevent carrier state

• Choice : Penicillin G, Ampicillin• May cause “ Jarish-Huxheimer type reaction” • Mild cases oral Doxycycline or Amoxicillin

Prevention

• Vaccination of domestic animals

• Rodent control

• Protective gloves and boots

• Avoid swimming in contaminated waters

• Vaccination in endemic region

Differential Diagnosis

• EH fever• Rickettsial disease : Scrub typhus, murine

typhus• Acute viral hepatitis• Sepsis• Influenza• Aseptic Meningitis

Conjunctival hemorrhage in leptospirosis