Clinical manifestation of severe leptospirosis

in Dr. Soetomo Hospital Surabaya,

Indonesia

Usman Hadi
Dr. Soetomo Hospital-Airlangga University,
Surabaya, Indonesia
INTRODUCTION
Weil’s syndrome
is defined as severe leptospirosis
consist of liver and kidney disease,
which is characterized by jaundice, hematuria
People get the
disease by either
Widespread digesting
contaminated
zoonosis Indirect contact
food or water or
caused by (soil,water,feed)
by broken skin
pathogenic with infected
and mucous
spirochetes of urine from an
membrane
the animal with
(eyes,nose,sinus
Leptospira leptospira
es,mouth)
spp contact with
contaminated
water or soil.
In Indonesia
Leptopsirosis incidence reported
(2008) was 0.5 / 100,000 population,
- still endemic,  out break in several area,
- in Dr. Soetomo Hospital in the year 2014
 34 cases suspected having leptospirosis
 with mortality rate 50%.
Oligouris
Diagnosis of leptospirosis

WHO recommendations
diagnostic score (Faine’s criteria)

suspected when the score is 20,

strong presumption when the score is 24.
Modified Faine’s Criteria

 PART – A Score  PART – B Score

• Headache 2 • Rainfall 5
• Fever 2 • Contact with 4
• Temp >39C 2 contaminated
• Conjunctival 4 environment
suffusion • Animal contact 1
• Meningism 4
• Myalgia 4  PART – C
• Conj.suffusion, 10 • ELISA IgM + 15
myalgia, • SAT + 15
meningism • MAT- Single +titer 15
• Jaundice 1 • MAT – rising titer / 25
• Albuminuria/ 2 seroconversion
nitrogen retention
Treatment

 Mild leptospirosis  Doxycycline 100mg BD /

 Ampicillin 500-
750mg QID /
 Amoxicillin 500mg QID

 Severe leptospirosis  Penicillin G 1.5 million untis IV

QID /
 Ampicillin 1g IV QID /
 Amoxicillin 1g IV QID /
 Ceftriaxone 1g IV OD /
 Cefotaxime 1g IV QID /
 Erythromycin 500 mg IV QID

Chemoprofilaksis
Doxycycline 200 mg OD once a week
CASE 1.
Mr. A. 47 years old, construction worker admitted to the Hospital
with complaint of fever. His fever started 6 days before admission
His other complaint were pain especially in his lower extremities
and abdomen, headache, red eye and pain, the colour of his urine
was dark.

Physical examination
His condition at the time of hospital admission looks weak
Laboratory examination: HGB: 9.9 g/dl, WBC 18,400/cmm, HCT
28.4%, PLT 30.000/cmm, creatinin serum 3.0 mg/dl, SGOT 379 IU,
SGPT 86 IU. Hematuria (+)
He was suspected of having Weil’ disease
He was treated with Ceftriaxon 1 x 2 gram, paracetamol 3x 500
Progress of the disease
• On the third day, he became dyspnea, decrease of conciousness, and
blood pressure 80/50 mmHg, pulse 120/minute, Respiratory rate
34x/minute.
• On the chest examination: rales was (+) in all pulmonary field.
• Haemoglobin 6.8 g/dl, trombosite 45,000/cmm,
• Blood gas analysis showed metabolic acidosis and oxygen saturation
was 84%.
• chest X-ray revealed an extensive bilateral alveolar shadowing
 He was assesed as acute respiratory distress syndrome with
pulmonary haemorrhage.
Then he was referred to the ICU and supported by a respirator, blood
transfusion, and antibiotic.
 His condition became better and on the day 5 the respirator was
turn of.
• chest X-ray revealed an extensive bilateral alveolar shadowing
Lab. result after day 5:
IgM leptospira/Leptotek (+),
Blood and urin culture was positive for leptospira

He was discharge from the hospital with good

condition on 14th day
DISCUSSION
• Diagnosis of leptospirosis can be defined in accordance with
WHO recommendations with diagnostic score
suspected when the score is 20,
strong presumption when the score is 24.
• Pulmonary involvement is as a result of hemorrhage but not
of inflammation
 cough, dyspnea, chest pain & blood stained
sputum
Sometimes hemoptysis / resp failure / ARDS
• Invasion of skeletal muscles results in swelling, vacuolation
of myofibrils & focal necrosis.
• In severe infection,
 vasculitis impairs the microcirculation & increased
capillary permeability results in fluid leakage
& hypovolemia.
 Case: 2
Mr. M 50 years old, gardener.
He came to hospital with chest pain on the left side
nausea +, vomiting +, dyspnea and fever +,
fever started 3 days before admission,
urin redness since 2 days before admission.

Physical examination
His condition at the time of hospital admission looks
weak blood pressure 80/50 mmHg., pulse rate
120/minute,
resp. rate 28 x/minute, axiler temperature 38.5º C.
Icteric and conjunctival bleeding
Extremities: petechiae (+)
Abnormal Laboratory examination
leucocyte 14,200/cmm., trombocyte 18,000/cmm., creatinin
serum 3.7 mg/dl, Blood Urea Nitrogen (BUN) 9,8 mg/dl,
SGOT 261 U/l, SGPT 82 U/l, total bilirubun 10,8 mg/dl,
direct bilirubin 6.8 mg/dl., LDH 979 U/L, CKMB 170 U/L
Electrocardiography:
sinus tachycardia 118 x/minute, elevation of ST in lead I,
AVL, V5- V6.
Echocardiography: showed tricuspid regurgitation trivial,
Obtained hyper echoic of pericard, and pericardial
thickness 1,15 cm (normal 0.5 cm).
Diagnosis:
Acute myopericarditis and suspect leptospirosis.
Therapy:
Nasal oxygen, infus normal saline 1500 cc/24 H.
Ceftriaxone 1x2gram iv,
ibuprofen 3 x 200 mg.
Progress of the disease
Day 12 of admission:
There was no complaint of the patient, Blood pressure
120/70 mmHg. RR 20x/mnt. Urin production 6000 cc/24 H,
ECG within normal limit.
Laboratory examination:
Hemoglobin 8.5 g/dl, leucocyte 8490/cmm,
trombocyte 599.000/cmm,
SGPT 61 U/L, bilirubn total 8.16 mg/dl, bilirubin direct 5.56
mg/dl, BUN 12,8, creatinin serum 0.97 mg/Dl,
IgM antileptospira positif, CRP 8 mg/DL
 DIAGNOSIS OF MYOPERICARDITIS

REFERENCES PATIENT

Dyspneu + +

Palpitation + +

Chest pain + +

ECG : arrhytmya, evolution + +

of pericarditis
Lab : cardiac enzym + +

Echocardiography : echoic + +
& thickening pericard

Leptospirosis with myopericarditis complication

Summary
Leptospirosis is an important zoonotic disease and distributed worldwide,
rhodent and other wildlife animal commonly considered to be important
epidemiological carriers. In Indonesia leptopsirosis still endemic, some time
appear out break in several area, while in the Dr. Soetomo Hospital in the year
2014 there were 34 cases suspected having leptospirosis with mortality rate
50%. Indonesian ministry of health reported the incidence of this disease
around 0.5 / 100,000 population in the year 2008.

In this paper have been reported 2 cases of severe leptospira with

complications, with cardiac involvement in the form of myocarditis and in the
other patient revealed pulmonary haemorrhage and acute respiratory distress.
Both patients can be cured with antibiotics and supportive therapy.