Emergency)managementof)the) leptospirosis)paentEmergency)managementof)the) leptospirosis)paent...
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Emergency management of the leptospirosis pa3ent Jus3ne A. Lee, DVM, DACVECC, DABT CEO, VetGirl [email protected] www.vetgirlontherun.com
Transcript of Emergency)managementof)the) leptospirosis)paentEmergency)managementof)the) leptospirosis)paent...
Emergency management of the leptospirosis pa3ent
Jus3ne A. Lee, DVM, DACVECC, DABT CEO, VetGirl [email protected] www.vetgirlontherun.com
Financial disclosure
Jus3ne A. Lee, DVM, DACVECC, DABT CEO, VetGirl
Consultant, Merck
Goals of this lecture • Leptospirosis • Pathophysiology: Why do we care? • Clinical signs • Treatment • Preven3on • Zoono3c risk
Leptospirosis • Leptospira spp. Gram-‐nega3ve spirochete with hook ends
• Saprophy3c vs. pathogenic – Saprophy3c: don’t infect animals – Pathogenic: Over 250 serovars
• Geographic regional differences
hTp://wwwnc.cdc.gov/eid/ar3cle/12/3/05-‐0809.htm
Leptospirsosis: E3ology in dogs Species Serogroup Serovar
Leptospira interrogans
Icterohaemorrhagiae Canicola Pomona Australis Sejroe
Autumnalis
Icterohaemorrhagiae Canicola Pomona* Bra3slava
Autumnalis?
Leptospira kirschneri Grippotyphosa Grippotyphosa
Hosts Serovar Reservoir Host L. grippotyphosa L. canicola L. Pomona L. icterohaemorrhagiae
Raccoons, voles, skunks Dogs Raccoons (?), skunks, pigs, caTle (?) Rats, raccoons (?)
Leptospirsosis • Prior to vaccines, most common serovars infec3ng dogs: L. Icterohaemorrhagiae and L. Canicola
• Now: more L. Grippotyphosa, Pomona, Bra9slava, and Autumnalis(?)
Geographic distribu3on • High rainfall; warm tropical loca3ons
• Humans: – Caribbean, La3n America, India, Asia – North America: Hawaii
• Dogs: (based on 3ters > 1,600) – Hawaii – West coast (CA, OR, WA) – Upper midwest – TX, CO, NE, mid-‐Atlan3c, SE
Increasing incidence? • Chronic healthy carriers – 8-‐20%
• Urban areas (Ward JAVMA 2004)
• Smaller dogs < 15 kgs! (Lee JVIM 2013) – Past decade
• Male dogs
How does it spread? • Shed from renal tubules of domes3c & wild animals
• Infec3on through intact mm or abraded skin from urine
– Rarely: via bite wound, inges3on of infected 3ssue, venereal, placental transfer
• Can remain viable in soil for weeks to months
Leptospirosis
• Likes warm (>30°C) • Inac3vated by UV radia3on & freezing • Risk factors: – Slow-‐moving or stagnant water exposure – Outbreaks seen aper higher rainfall – Late fall – Roaming dogs (rural) – Urbanized wild animal exposure – Rodent exposure
Why are we seeing more lepto?
• Global warming? – Warmer – WeTer – Flooding
• Urban growth: – Invasion of humans into wildlife’s environment
Incuba3on • Several days
• Replicates rapidly within 1 day of infec3on
• Incuba3on period: – 7 days, but dependent on dose, strain, geographical loca3on, host immune response
Clinical signs • Malaise, lethargy • Anorexia • Vomi3ng • Febrile • Dehydra3on • PU/PD • Weight loss?
RENAL + HEPATIC SIGNS = LEPTOSPIROSIS!
Clinical signs: Renal
• Renal: 90% of the 3me! – Inappetance – Vomi3ng – Diarrhea – Malaise – PU/PD – Dehydra3on – Abdominal pain – Oliguric/anuria – CKD
Clinical signs: Hepa3c
• Hepa3c: 10-‐20% – Inappetance – Malaise – Vomi3ng – Melena – Icterus – Hepa3c failure – Chronic ac3ve hepa33s
Less common clinical signs • Fever
– Shivering, mm tenderness, not moving
• Ocular – Uvei3s, conjunc3vi3s
• Pulmonary – Pulmonary hemorrhage Leptospiral pulmonary hemorrhage syndrome (LPHS) – Tachypnea – Dyspnea – ARDS – Vasculi3s
Less common clinical signs • Coagulopathy à hepa3c failure, DIC, vascular damage by
spirochetes? – Hemoptysis – Melena – Epistaxis – Petechial hemorrhage – Hematochezia – Hematemesis
Less common clinical signs
• Miscellaneous – Hematuria – Vasculi3s à Peripheral edema, pleural effusion, peritoneal effusion
– ECG altera3ons à myocardial damage (humans?) – Abor3on (caTle)
What about cats? • Yes but rare
• Serologic evidence of exposure – Canicola – Grippotyphosa – Pomona
• Can cause histopathologic changes
• Exposure through rodent contact?
Prognosis for Leptospirosis
• Acute – 80% survival – Fair to good with immediate treatment – $$$
• Chronic – Predisposed to chronic kidney disease – Chronic renal inflamma3on
Darby, 5 yo, MC Papillion, 5 kgs
• PC: 2 day history of vomi3ng and anorexia, ADR X 3 days; pu/pd X 2 days
• PMHX: UTD; on seasonal preventa3ve
• Diet: On The Honest Kitchen diet
• Lives in St. Paul, MN
Darby, 5 yo, MC Papillion, 5 kgs: Physical Examina3on
• 7% dehydrated • Equivocally icteric mm • Moderate pulse quality • CRT = 2 seconds • HR 160 • Splints on abdominal palpa3on • Moderate bladder
Darby, 5 yo, MC, 5 kg Papillion: Plan
• IV catheter • BIG 4 – PCV/TS: 55%/8 – BG: 133 mg/dL – AZO: 50-‐80 mg/dL – Slightly icteric serum
Darby, 5 yo, MC Papillion, 5 kg: Plan
• CBC • Chemistry • UA • Urine culture -‐ hold
Darby: Plan
• Start 150 mls Plyte148 over 30 minutes – 20-‐30 ml/kg bolus – Why not LRS?
• Fluid plan?
Darby: Clinicopathologic findings
• CBC – WBC 18,500 – Platelets: 150,000 – PCV: 55%
• Chemistry: – BUN: 88 – Crea3nine 4.2 – TBILI: 2.6 – AST: 800 – ALT: 1200 – ALP: 522 – TP: 8
Leptospirosis: Clinicopathologic findings
• Neutrophilia • Lep ship • Lymphopenia • Hemoconcentra3on • Non-‐regenera3ve anemia • Hemolysis (caTle) • Thrombocytopenia (58%)
• Azotemia (> 80-‐90%) • é ALT, AST, ALP, TBILI (almost always seen with azotemia)
• Hypokalemia • é CK
Leptospirosis: Clinicopathologic findings
• Isosthenuria • Bilirubinuria • Hematuria • Glucosuria • Proteinuria?
• é fibrinogen, D-‐dimers, FDP
• Prolonged PT/PTT (6-‐50%)
Any other diagnos3cs? • Coagula3on panel: R/O DIC
• Chest radiographs – Nodular inters33al to alveolar paTerns
• Abdominal ultrasound – Renomegaly – Perirenal fluid accumula3on – Pylectasia – Medullary band of increased echogenicity – Increased cor3cal echogenicity – Mild abdominal lymphadenopathy
DIAGNOSING LEPTOSPIROSIS
Microscopic agglu3na3on test (MAT) • Standard test, most frequently used
• Looks for presence of an3bodies to leptospiral an3gens
• Tests for highest serum dilu3on causing agglu3na3on of 50% of the leptospires
• Tests for typically: canicola, icterohaemorrhagiae, pomona, grippotyphosa, hardjo, bra9slava – Highest an3body 3ter = infec3ng serovar
• Some cross-‐reac3vity?
• Poor laboratory quality control
MAT • Interpret results based on:
– Dura3on of disease – Vaccine status of pa3ent
• 1:100-‐1:400, occasionally as high as 1:3200 • Persist for 6 months • May cross-‐react with other serovars (<1:100)
– Prior an3bio3c therapy? à blunt rise of an3body 3ter • Titer of > 1:800 with compa3ble clinical signs and lab tests = Leptospirosis
• Nega3ve 3ters early in course of disease – Typically in 1st week of illness
• Doing convalescent 3ters 2-‐4 weeks later? – 4 fold increase = recent infec3on
Other diagnos3c tests for leptospirosis?
• Darkfield microscopy (dark ages) – Low specificity – Technically difficult
• Silver staining renal biopsy 3ssue – Low sensi3vity & specificity – False nega3ves
• Fluorescent an3body tes3ng & PCR: urine or 3ssue – PCR: affected by an3bio3c therapy!
• Idexx leptospirosis PCR & an3body ELISA in-‐clinic test
Darby’s fluid plan
• 5 kgs X 60 ml/kg/day = 300 mls/day = 13 mls/hr
• 7% dehydra3on X 5 kgs = 350 mls
• Replace dehydra3on over 12 hours: 30 ml/hr
• Ongoing pu/pd?
Treatment • Plyte-‐148 at 50 mls/hr • Goal of assessing hydra3on – Hemodilu3on (PCV/TS 35/5) – Isosthenuria (aim for 1.015-‐1.018) – Drinking water in the cage – Weight gain à weigh q. 6
• Why is weight so important? – 5 kgs + 350 mls of dehydra3on = 5.4 kgs
URINE OUTPUT • Normal: 1-‐2 ml/kg/hour
• Oliguric: 0.5 ml/kg/hour • Decreased renal func3on or your fault? • sp. gr. > 1.018 • Solve with IVF not furosemide (yet!)
• Anuric: < 0.5 ml/kg/hour • Blood-‐3nged urine
Calcula3ng ins and outs • Simple!
• If FUO urinates 160 mls over 4 hours…UOP è 160/4 = 40 ml/hour
• If you gave 80 mls of IV fluids over 4 hours… 80/4 = 20 ml/hour
• In vs. out?
Darby • Treatment: – Blood pressure monitoring – UOP monitoring (UCS) – Polyuric at 6 ml/kg/hour
Day 1 88 4.2
Day 1
Day 2 60 3.1
Day 3 32 1.7
50 ml/hr
50 ml/hr
50 ml/hr
30 ml/hr
BUN mg/dL Creat mg/dL UOP Fluid rate PCV TS kg
55 8
40 7
35 5
34 4.8
Polyuric
Polyuric
Polyuric
Polyuric
5
5.2
5.4
5.4
Treatment: GI support • Suspect uremic ulcers – Omeprazole or pantoprazole 1 mg/kg q 24 or – Famo3dine 1 mg/kg IV q 12
• Phosphate binder PO q. 6-‐8
• Sucralfate 250 mg PO q. 8
• An3-‐eme3cs (e.g., maropitant 1 mg/kg IV q 24)
Treatment: An3bio3c therapy • Goals: – Eliminate leptospiremia – Eliminate organisms from the renal tubular cells and renal carrier state
• An3bio3cs: – Penicillin-‐type
• Penicillin 25,000-‐40,000 U/kg q 12 IV or IM for 14 days) • Ampicillin, amoxicillin, amoxicillin/clavulanic acid X 14 days
– Doxycycline (5-‐10 mg/kg BID PO X 14 days)
Symptoma3c suppor3ve care
• Monitoring – UOP – Blood pressure – Baseline renal panel/PCV/TS/elytes
• Nutri3onal support
Prognosis • Fair to good, but risk for CRF
• Treat aggressively • Why preven3on is impera3ve – Small dogs: 90% rats trapped in inner ci3es were carrying leptospirosis (PCR, Vinetz et al, 1996)
Zoono3c risk • Start appropriate an3bio3cs immediately – Pre-‐treatment blood work!
• Gloves/proper hygiene when handling bodily fluids (e.g., blood, urine, 3ssue)
• Wash hands aper handling pets
• Disinfect with iodine-‐based solu3ons
• Vaccinate other pets in the house
Preven3on! • Discuss zoono3c risk with owners
• Rodent control/fencing from wild animals
• Decrease access to swampy, marshy areas
Preven3on: Vaccines • To vaccinate or not to vaccinate?
• Leptospirosis endemic – yes!
• 2-‐way (old) vs. 4-‐way (new!) – Leptospira Canicola, Grippotyphosa, Icterohaemorrhagiae, Pomona
Vaccines
• Annual vaccina3on with 4-‐serovar vaccines – Regardless of breed – At-‐risk (e.g., urban, backyard, roaming, swimmer, hunters, etc.)
• Wide margin of safety; adequate protec3on and coverage
• Ideally, use a vaccine that: – Protects against disease and mortality – Prevents shedding of leptospires in urine to prevent zoono3c risk and exposure
Special thank you!
• To Merck!
• Free Merck webinars on VetGirl!
• Download Leptospirosis proceedings at: – hTp://vetgirlontherun.com/proceedings-‐publica3ons-‐veterinary-‐con3nuing-‐educa3on-‐podcasts-‐webinars/page/2/
@VetGirlOnTheRun VetGirlOnTheRun @drjus3nelee Dr Jus3ne Lee
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