Leptospirosis_Smt7.ppt

7/27/2019 Leptospirosis_Smt7.ppt

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LEPTOSPIROSISTropicalandInfectiousDiseasesDivision

InternalMedicineDepartment

SaifulAnwarGeneralHospital/Facultyof

MedicineBrawijayaUniversity

Malang


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Introduction

Leptospirosis is an acute anthropo-

zoonotic infection

It occurs in tropical, subtropical andtemperate zones

Weil Disease, Hemorrhagic Jaundice, MudFever, Swineherd Disease,Canicola Fever,seven-day fever found commonly in

Japan, Cane cutters disease in Australia,Rice field Leptospirosis in Indonesia , FortBragg fever in U.S, Andamanhaemorrhagic fever(AHF)


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Introduction

Spirochetal disease, finely coiled,motile, 0.1 m x 6 20 m

Systemic infection manifested as

widespread vasculitis Zoonosis

L. interogans 23 serogroups and

200 serovars

L. biflexa : non-pathogenic,

saprophyte


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ClassificationClassification:

Phylum : Spirochaetes

Class : Spirochaetes

Order : Spirochaetales

Species : Leptospira

Family : Leptospiraceae


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Leptospirosis

Facts about the bacteria. The bacteria themselves cannot survive

for very long unless immersed in fresh

water or urine.

Unlike viruses, bacteria are rarelyairborne. They must exist immersed in

water, and so except in very high vapour

situations airborne infection is not a risk


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Leptospirosis

Facts about the bacteria

There are over 200 variations of

leptospira bacterium that can causethe disease. There are numerous

types which are known to cause

ONLY mild infection. All infections are classified into

Icteric or Anicteric forms


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Leptospirosis

The infection Types The Anicteric is the most common type

of infection. This type is generally not

Fatal, though simultaneous infectionsor unrelated infections may prove

fatal

The Icteric Weils infection iscomparatively rare; can be fatal in

severe cases, and accounts for 5 to

13% of all recorded cases


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Leptospirosis

Features of Human Infection.

The infection follows a biphasic course, for

the first 3 to 7 days , the septic phase, the

bacterium spreads throughout the blood, CSF

and most body tissues.

Early symptoms are fever, chills, muscular

aches and pains, loss of appetite, and nausea

when lying down.

Every infection has identical initial dynamics.


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Leptospirosis

Features of Human Infection.

From 10 to 30 days the Immune phasesees the removal of the bacterium from

the blood and CSF, but remains in the

urine.

During this stage many of the body

systems show detriment(kerusakan)


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Leptospirosis

Features of Human Infection

Later symptoms include bruising of

the skin, anemia, sore eyes, nosebleeds and in severe cases jaundice,this is know as Weils Disease.

Recovery from an infection, once theserious stages are passed is usuallywithin 6 to 12 weeks.


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Leptospirosis

Getting infected? In order to become infected, a quantity of

the leptospira bacteria must enter our body.

The main routes for any bacteria to enter ahuman are through ingestion, inhalation, orthrough broken skin.

Acquiring a leptosprial infection is not aseasy as other infections, and a great dealharder than contracting some viralinfections such as the common cold


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Leptospirosis

Other Facts An infection from one strain will provide

immunity but only to that strain.

Exposure to other strains will still causeinfection. It is usual for more than onestrain to exist within a specific populationof infected animals.

Immunity to one type is no greatadvantage to reducing your risk


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Leptospirosis

Urban myths the facts: Human to human transfer is almost unheard

of. Saltwater, or freshwater treated with chlorine

or UV sterilised, is generally safe. Any surface or object dried out completely for

over an hour even if it gets wet once more,the bacteria will remain dead.

Rats are the most common carriers, but all

mammals are susceptible to the illness. Almost every routine disinfectant methodswill kill the bacteria.

There is no human vaccine licensed for use inEurope, Asia or the USA


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A microscopic view ofLeptospiraI bacteria stained applegreen with a fluorescent dye (fromthe CDCs Public Health ImageLibrary)


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Epidemiology

Leptospirosis is an important

zoonosis with a worldwide

distribution that affects at

least 160 mammalian species

In 1999, more than 500,000

cases were reported from

China, with case-fatality rates

ranging from 0.9 -7.9%


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In Brazil, more than 28,000

cases were reported in thesame year

In a study in the

Netherlands, 14% of

patients with confirmed

leptospirosis had acquiredthe infection while traveling

in tropical countries, mostly

in Southeast Asia


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Reservoire of Infection

Rats

Dogs

Live stocks Rodents including rabbits

Wild animals

Cats


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Sources of Human Infections

Contaminated Water or soilfrom infected urine

Direct animal contacts

Occupational exposure :farmers, vets, abattoire

workers

Recreational exposure :

campers(kemah), swimmers,

visiting graveyards


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Routes of Infection

Contact with water or soil contaminated

animals

Direct contact with the by urine frominfected source, farmer, vets, butchers,recreational activities

Rodents carry EH fever, scrub typhus,paratyphus, leptospirosis

Factors for high incidence : rain duringharvest time, carrier rate in rodents

Spirochetes survive longer in wet swampyconditions


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Pathogenesis

Entry sites : skin wounds or

abrasions in hand and feet andmucous membranes, conjunctiva,nasal, oral

Bacteremia involving the entire

body including eye, CSF Systemic effect and vasculitis due

to endotoxin (hyaluronidase) andburrowing motility

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


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Biphasic nature of leptospirosis and relevant investigations at different stages of disease.

Specimens1and2forserologyareacute-phaseserumsamples;specimen3isaconvalescent-

phaseserumsamplethatmayfacilitatedetectionofadelayedimmuneresponse;andspecimens

4and 5are follow-up serumsamples thatcan provideepidemiologic information,suchasthe

presumptiveinfectingserogroup.[ReprintedasadaptedbyLevett(fromTurnerLH:Leptospirosis.BMJ1:231,1969)


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Clinical types

Types 1986 1987Pneumonitis 33% 57.7%Rash type 17%Weils disease 15%Renal failure 13% 53.8%Flue-like 15% 13.5%Acute Hepatitis 8%Combination 86.5%


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Phase I (Septicemia)

Following incubation period of 7-10days

High spiking fever, headaches,

myalgia, arthralgias Lasting 4 7 days

Proteinuria and increased

creatinnine

Organism detectable but serologic

diagnosis not possible


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Phase I I (Immune)

Much more variable

Induction of IgM Antibodies

1- 3 day freedomrecurrence of symptoms

Lower fever, CNS signs

Maybe cultured from urinebut not from blood or CSF


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Weils Disease

Less common but severe form

Mild phase I, initially

Followed by severe Jaundice,

Azotemia, and Hemorrhagefrom Lungs, GI tract, and otherorgans (3-6 day)

Oliguric renal failure and Liverdysfunction dominate theclinical picture


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Conjunctival hemorrhage

in leptospirosis


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Clinical Signs of Leptospirosis

Pulmonary infiltrates,

pneumonitis, hemorrhages Conjunctival injection

Jaundice

Muscle tenderness

Abdominal tenderness

CVA tendernessAbnormal auscultation

Erythema, petechiae, neck

stiffness, adenopathy


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Lab. Diagnosis

Microbiologic identification :

Blood or CSF first 10 daysUrine second week(Fletchers,EMJH Medium)

Serology : screeningMicroscopic Slide Agglutination

(MST), titration & serogroupidentification MicroscopicAgglutination (MAT), detection

of IgM (ELISA)


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Differential Diagnosis

EH fever

Rickettsial disease : Scrub typhus,murine typhus

Acute viral hepatitis

Sepsis

Influenza

Aseptic Meningitis

If with jaundice during or after anacute febrile illness (Malaria,septicemia, alcoholic hepatitis and

typhoid fever)


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Complications Azotemia

Oliguria

Hemorrhage

Purpura

Hemolysis

Gastrointestinal bleeding

Hypoprothrombinemia and

Thrombocytopenia


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Treatment

Early anti-microbial therapy isimportant shorten the courseand prevent carrier state Choice : Penicillin G, Ampicillin May cause Jarish-Huxheimer

type reaction Mild cases oral Doxycycline or

Amoxicillin


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Prognosis Mostpatientswithleptospirosisrecover

Mortalityishighestamongpatientswho

areelderlyandthosewhohaveWeils

syndrome

Leptospirosisduringpregnancyis

associatedwithhighfetalmortality

Long-termfollow-upofpatientswithrenal

failureandhepaticdysfunctionhasdocumentedgoodrecoveryofrenaland

hepaticfunction


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Prevention

Vaccination of domesticanimals

Rodent control

Protective gloves and boots

Avoid swimming in

contaminated waters Vaccination in endemic region

Leptospirosis_Smt7.ppt

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