Cavite State University Indang, Cavite

Patricia Marie R. Mojica BSN4-1

Leptospirosis

first described by Adolf Weil in 1886 when he reported an acute a disease that is caused by pathogenic spirochetes of the genus

infectious disease with enlargement of spleen, jaundice and nephritis

Leptospira Interrogans. It is a bacterial infection passed from animals to humans by way of contaminated urine. The bacteria penetrate mucous membranes or breaks in the skin, multiply in the bloodstream and carried to all parts of the body. Alternative Names Weil disease Icterohemorrhagic fever Swineherd's disease

 Rice-field fever Cane-cutter fever Swamp fever Mud fever Hemorrhagic jaundice Stuttgart disease Canicola fever Causative Agent:

Leptospira-genus bacteria was isolated in 1907 from post mortem commonly found: Leptospira pyrogenes, Leptospira manilae, & other

renal tissue slice

species like L. icterohemorrhagiae, L. canicola, L. batavia, L. Pomona, L. javinica

in animals often is subclinical; an infected animal may appear healthy

even as it sheds leptospires in its urine; humans are dead-end hosts for the leptospire Incubation Period The incubation period usually 7 to 12 days, with a range of 2 to 29 days. Source of Infection Infection comes from contaminated food and water, and infected wild life and domestic animals especially rodents. 1. Rats ( L. leterohemoragiae) are the source of Weils disease frequently observed among miners, sewer, and abattoir workers.

2. Dogs (L. canicola) can also be the source of infection among veterinarians, breeders, and owners of dogs.
3. Mice (L. grippotyphosa) may be a source of infection that attacks

farmers and flax workers.

4. Rats (L. bataviae) are the source of infection that attacks rice field

workers. Clinical Manifestations: 1st stage: Septicemic/ Leptospiremic Phase (4 7 days) onset of high remittent fever, chills, headache, anorexia, nausea &

vomiting, abdominal pain, joint pains, muscle pains, myalgia, severe prostration, cough, respiratory distress, eye redness bloody sputum. 2nd stage: Immune/ Toxic Phase (4 30 days) if severe, death may occur between the 9th & 16th day

Abdominal pain, Abnormal lung sounds, Bone pain, Conjunctivitis, Enlarged lymph glands, Enlarged spleen or liver, Joint aches, Muscle rigidity, tenderness, Skin rash, Sore throat and Jaundice of the body and eyes. 2 types:

Anicteric (without jaundice) return of fever of a lower degree with

rash, conjunctival infection, headache, meningeal manifestations like disorientation, convulsions & signs of meningeal irritations (with CSF finding of aseptic meningitis)

Icteric (with jaundice) Weil syndrome; hepatic & renal manifestations:

hemorrhage, hepatomegaly, hyperbilirubinemia, oliguria, anuria with progressive renal failure; shock, coma & congestive heart failure in severe cases 3rd stage: Convalescence Phase Relapses may occur during 4th or 5th week

Precipitating Factors:

Occupational exposure -- farmers, ranchers, slaughterhouse workers, trappers, veterinarians, loggers, sewer workers, rice field workers, and military personnel

Recreational activities -- fresh water swimming, canoeing, kayaking, and trail biking in warm areas Household exposure -- pet dogs, domesticated livestock, rainwater catchment systems, and infected rodents

Predisposing Factors:

age: < 15 years of age sex: male season: rainy months geographic: prevalent in slum areas

Incidence:

The largest recorded U.S. outbreak occurred in 1998, when 775 people were exposed to the disease. Of these, 110 became infected. In the Philippines as of January 6 2012 the outbreak of leptospirosis was in northern Mindanao cities of Cagayan de Oro and Iligan that were devastated by flood and reported almost 300 cases and 15 deaths according to Cagayan de Oro City Health Office. Diagnosis Leptospirosis can be diagnosed by its clinical manifestation culture of the organism examination of blood and CSF during the first week of illness and urine after the 10 day. Generally, it is not necessary to confirm the diagnosis or wait for the result of the tests before starting treatment. The clinical assessment and epidemiologic history are more important. Early recognition and treatment is MORE important to prevent complications of the severe disease and mortality.

Exams and Tests The blood is tested for antibodies to the bacteria. Other tests that may be done:

Complete blood count (CBC) Creatine kinase Liver enzymes Urinalysis SAT and ELISA

Management:
Medical Management: Supportive Therapy: IV Fluids Analgesics Dialysis

Medications to treat leptospirosis include:

Ampicillin Ceftriaxone Penecilins and other B- lactam antibiotics(PCN at 2M units q6H IM/IV) Teracycline(Doxycycline at 100mg q12H PO) Erythromycin (500mg q12H PO)- if allergic to Penicillin Nursing Management: Provide education to clients telling them to avoid swimming or wading in potentially contaminated water or flood water.

Electrolyte and protein restriction diet in cases of renal insufficiency

Use of proper protection like boots and gloves when work requires exposure to contaminated water. Drain potentially contaminated water when possible. Control rats in the household by using rat traps or rat poison, maintaining cleanliness in the house. Proper sanitation measures Isolate the patient and concurrent disinfection of soiled articles. Stringent community-wide rat eradication program. Remove rubbish from work and domestic environment to reduce rodent population. Report all cases of leptospirosis. Investigation of contacts and source of infection Chemoprophylaxis can be done in a group of high risk infected hosts. Complete bed rest Advice to eat light easily digestable foods Drink plenty oral fluids Causes of Leptospirosis Leptospirosis is not only acquired from absorbing contaminated flood waters through cuts in the skin but also by swallowing the bacteria directly from water or through food. Although the disease is commonly associated with rat urine, infection can also come from animals like cattle, pigs, horses, dogs, and wild animals. Complication: Renal failure Hemorrhage Acute hepatic failure Pneumonia Meningitis

Acute cardio vascular failure Jarisch-Herxheimer reaction when penicillin is given Severe bleeding

Serology: A minimum volume of 250l of serum is required. Initial samples should be taken 5 - 7 days after the onset of symptoms. For isolation of leptospires (where appropriate) CSF Blood cultures: Ideally, blood cultures should be taken within the first 5 days after the onset of symptoms and before the administration of antibiotics and sent directly to the LRU. Since the optimal incubation temperature for leptospires is 29 - 30 oC, retaining blood cultures at room temperature until despatch to the LRU will be the most advantageous for the recovery of leptospires. Blood should be taken into blood culture (BacT/ALERT, BacTec) or mycobacterial blood culture (BacT/ALERT MB) AEROBIC bottles, or an aliquot from one of the above. Hold at 29 oC or at room temperature until dispatched to the LRU. Immunofluorescence Fixed or unfixed post mortem tissue is only accepted after prior discussion with consultant staff. N.B. Urine samples are not suitable for the isolation of leptospires due to the presence of other contaminating bacteria and the poor viability of leptospires in urine. Tests offered by the Leptospira Reference Unit Leptospira serology Two tests are offered by the LRU for the serological diagnosis of leptospirosis. An 'in house' ELISA is used to screen all sera, with positive results confirmed by the standard reference method, the Microscopic Agglutination Test (MAT). A. Leptospira IgM ELISA Leptospira IgM antibodies may be detectable 5 days after the onset of symptoms, but not usually before this. In cases where antibiotic treatment has been initiated, this period may be increased. Once a patient has produced IgM antibodies, they can remain detectable for months, or even years. IgG antibodies may only be detected for a short period, if at all. An IgM titre of 1:320 is considered suggestive of leptospiral infection and further samples will be required to confirm a diagnosis in conjunction with the MAT. Low IgM titres of 1:80 to 1:160 may be indicative of early infection, or with possible cross-reaction with other conditions, e.g. EBV or Hepatitis A. Further samples will be required to confirm results. The IgM ELISA test has a 90% sensitivity and 93% specificity (J Clin Pathol, 2001; 54: 25-30). B. Microscopic Agglutination Test (MAT) The MAT may be positive from about day 10 after onset of symptoms. To determine the presumptive infecting serogroup in acute leptospiral infection it may be necessary to examine samples taken over a period of several weeks. Frequency of testing in the laboratory Routine serological analyses are undertaken in batches on a twice weekly basis. Results will be issued at the earliest opportunity, usually 7 working days. Water testing There is little point in testing fresh surface water for Leptospira. The test only detects Leptospira in a small volume of the water and at a single point in time. It is also expensive and lengthy (6 weeks). A different area of the surface water body could have Leptopspira present, or there could be leptospires present shortly after

the sample was taken. Leptospires are sensitive to chlorination of domestic water supplies. The simple precautions outlined in the Q&A should minimise the risk to water users.