Diagnosis

&
Management of Leptospirosis
Problems in Practice
Dr. S.Shiva Kumar M.D.
HOD & Professor of Medicine,
Stanley Medical College,
Chennai.

Introduction

Most common, underreported and underdiagnosed

zoonosis

India - Cases reported from Kerala , Tamil Nadu,

Karnataka, Maharashtra, Gujarat & Andamans.

Source Animals ( rodents and domestic animals )

Epidemiological factors
 Contaminated environment
 Rainfall
 High risk groups

Introduction

Rural > Urban

Male > Female ( 10 : 1 )

Clinical Features mild to severe life threatening

illness ( may be confused with other diseases )

Diagnosis - difficult to confirm

Treatment effective, if started early ( < 5days)

Epidemiology

Rainfall

Contaminated environment
 Poor Sanitation
 Inadequate drainage facilities
 Presence of Rodents, cattle& stray dogs
 Walking bare foot
 Specific source of infection cannot be pin pointed with

certainty.
 Any person can get infected, if exposed to contaminated

environment

Epidemiology..

Risk groups
 Occupation

Farmers Rice, Sugarcane, Vegetables, Cattle, Pigs

Sewerage workers
Abattoirs, Butchers
Vetenarians , Lab staff
Miners
Fishermen Inland
Soldiers

 Recreational activities

Swimming , Sailing , Marathon runners , Gardening

Transmission
Rodents (Urine)
Contaminated environment

Domestic animals

Humans

Clinical Features

Anicteric

Icteric (Weils Syndrome)

Hemorrhagic fever with renal syndrome

Atypical pneumonia syndrome

Myocarditis

Aseptic Meningoencephalitis

Ocular Manifestations

Anicteric

(>90%)

Leptospiremic Phase
Fever
Myalgia
Conj.suffusion
Headache
Epistaxis
Abdominal pain

Immune Phase
Fever
Meningitis
Uveitis

Anicteric - Mild / Severe

Incubation Period - 7 -14 days (2 21 days)

Icteric Leptospirosis
LIVER

Jaundice - Occurs 4-6 days (2 - 9 days)

Sr.Biliruubin Markedly (20-40 mg/dl)

SGOT / SGPT - Mild elevation

Hepatocellular necrosis / Intra hepatic cholestasis

Death - Not due to Liver Disease

Kidneys

Mild / Severe
Urinalysis : Hematuria / Pyuria /Proteinuria
Renal Failure: Pre renal azotemia
ATN / AIN
Oliguric / Non Oliguric
Mechanism :
Nephrotoxicity - Endotoxin
(Direct )
Bacterial migration
Toxic Metabolites
Hypoperfusion - Hypotension
(Ischaemia) Fluid loss/ Fluid shift
G.I. Bleed
Myocarditis

Haemorrhagic Fever with

Renal Syndrome

Vascular injury

Occurs form Respiratory, Alimentary, Renal &

Genital tracts .

More common in Icteric & with Renal Failure

Reported in Korea, Andamans & Brazil

Atypical Pneumonia Syndrome

Hemorrhagic Pneumonitis

Haemoptysis / Respiratory failure

CXR : Single/ Multiple ill defined

opacities / Consolidation

Occurs 2nd week (As early as 24-48 hrs)

Reported in Korea, Andamans &

Nicaragua

Cardiac

Hemorrhagic Myocarditis
 Arrhythmias / Cardiac failure
 Hypotension / Death

Arrhythmias
 Atrial fibrillation / Conduction defects

ECG changes
 Non Specific ST-T changes
 Low voltage complexes

Reported in Srilanka, Barbados& Portugal

Aseptic MeningoEncephalitis

Occurs in the Immune phase
 CSF proteins , lymphocytes

Rare
 Convulsions, Encephalitis
 Myelitis & Polyneuropathy.

Ocular

Conjunctival suffusion / hemorrhage

Late complication
 Anterior uveal tract inflammation
 Iritis / Iridocyclitis / chorioretinitis

occurs 2 weeks 1 yr (6 months)

Differential Diagnosis

Fever
 Viral fever/Malaria/Typhoid / UTI

Jaundice
 Malaria, Viral hepatitis, Sepsis

Renal failure
 Malaria, Hanta Virus, Sepsis

Meningitis
 Bacterial / Viral

Haemorrhagic Fever
 Dengue, Hanta virus,Typhus

Investigations

TC / DC / ESR / Hb / Platelet count

Sr.Bilirubin / SGOT/ SGPT

Plasma Urea, Creatinine & Electrolytes

Chest X-Ray

ECG

Tests for diagnosis of Leptospirosis

LABARATORY CRITERIA FOR DIAGNOSIS OF

CURRENT LEPTOSPIROSIS

CULTURE : Positive

MAT :
 Seroconversion / 4 fold rise in the titre
 High titre.

ELISA / MSAT : positive.

Problems In Diagnosis

Early Diagnosis (First Week)
 No Reliable test
 Culture Delayed results (weeks / month)
 PCR Valuable

Serologic tests
 Genus specific - SAT / ELISA (>5days)
 Serovar specific - MAT.

Serological Tests

SAT & ELISA
 Simple, Reliable & sensitive for diagnosis of current

inf.

MAT
 Gold Standard
 Complicated, DFM required

 titres occur late, but persist longer

valuable in sero-epidemiologic studies
 less sensitive for current diagnosis

Interpretation of Tests

MAT Titres ( IgM & IgG antibodies)
 >1/80 or >1/400
 Possibilities

Rising titres of Current infection

Declining titres of Past infection
To confirm, second sample essential

ELISA/ SAT (IgM antibodies)

 Valuable for diagnosis of Current infection

Interpretation of Tests
ELISA/SAT

MAT

INTERPRETATION

+
+
NA

+
+
Rising titres

Current Infection
Current Infection
Past infection
Current Infection

0 1 week
ELISA/SAT
MAT

1 month

2 months 1 yr

5 yrs

Approach to Diagnosis of Leptospirosis

Clinical features suggestive of current leptospirosis

Leptospiremic phase < 7days

Blood culture

PCR

Immune phase > 7 days

ELISA / MSAT
Confirm
( if available )

Negative

Repeat ( > 3 days )

Positive

MAT

Approach ..
MAT

Positive

Repeat (if low titre)

High titre

Rising titre

Negative

Repeat

Seroconversion

Treatment

Mild Leptospirosis
 Doxycycline 100 mg bd X 7 10 days
 Amoxycillin 500 mg qid
 Ampicillin 500 750 mg qid

Severe Leptospirosis
 Penicillin 1.5 million units IV qid
 Ampicillin 1 gm IV qid


Supportive Treatment
 IV Fluids
 Analgesics
 Dialysis

Mortality
 Renal failure
 Cardiovascular complications
 Bleeding

Diagnosis of Leptospirosis

WHO guidelines (Faine s criteria)
 Clinical
 Epidemiolgical
 Laboratory

Modified Faine Criteria

 Done for Indian institutions

(Dr.Shivakumar S)

Faine Criteria
Part A: Clinical data
Headache
Fever
Temp > 39
39C
Conjuntival suffusion
Meningism
Muscle pain
Conjuntival suffusion
Meningism
Muscle pain
Jaundice
Albuminuria, Nitrogen,
Retention
Total score

Modified Faine Criteria

Score Part A: Clinical data Score
Headache
2
2
Fever
2
2
Temp > 39
39C
2
2
Conjuntival suffusion
4
4
Meningism
4
4
Muscle pain
4
4
Conjuntival suffusion
10 Meningism
10
Muscle pain
Jaundice
1
1
Albuminuria, Nitrogen,
1
1
Retention
Total score

Faine Criteria

Modified Faine Criteria

Part B: Epidemiological
factors

Part B: Epidemiological
factors
Rainfall
5

Contact with contaminated

Contact with animals or
Contact with known
10 environment
contaminated water

Animal contact
Total

Part C : Bacteriological Lab

findings
Isolation of leptospira in
Culture -Diagnosis
certain

4
1
10

Part C : Bacteriological Lab

findings
Isolation of leptospira
in Culture -Diagnosis
certain

Faine Criteria
Part C : Bacteriological Lab
findings
Positive Serology (MAT)

Modified Faine Criteria

Part C : Bacteriological Lab
findings
Positive Serology

Leptospirosis--Endemic
Leptospirosis
Single positive - Low titre
Single positive - High titre

ELISA IgM - Positive

15
2
SAT - Positive
15
MAT--Single positive in high
MAT
10
15
titre

Leptospirosis Non endemic

Single positive -Low titre

Single positive -High titre

15

Rising titre - (paired sera)

25

Total

Rising titre
(paired sera)

Total

25

Faines Criteria - Score

 Presumptive diagnosis of leptospirosis is
made of 26 or more
 (Part A) or (Part A & Part B Score) : 26 or more
 Part A, B & C (Total)

: 25 or more

 A score between 20 and 25 suggests

 leptospirosis as possible,
but unconfirmed diagnosis.

Example 1
A patient with fever in the post monsoon
season and contact with contaminated
environment is positive by ELISA IgM for
leptospirosis.
SCORE
A. Fever
2
Rain fall+Contact with
B.
9
contaminated environment
C. ELISA IgM positive
15
SCORE
= 2+9+15 = 26
DIAGNOSIS
Leptospirosis (confirmed)
1.

Example 2a
2.

A patient with fever, myalgia and headache in

the month of April (Non-monsoon Period) is
positive for Leptospiral ELISA IgM:

SCORE

A. Fever, Headache, Myalgia

2 +2+4 = 8

No Contact with contaminated

environment
C. ELISA IgM positive
B.

SCORE
DIAGNOSIS

=8+15 = 23
Possible Leptospirosis
( Confirm by MAT raising titres)

0
15

Example 2b
2.

A patient with fever, myalgia and headache in

the month of April (Non-monsoon Period) is
positive for Leptospiral ELISA IgM:

SCORE

A. Fever, Headache, Myalgia

2 +2+4 = 8
Contact with contaminated
B. environment + (eg
(eg..Infected
4+1
dog at home) animal contact
C. ELISA IgM positive
15
SCORE
=8+5+15 = 28
DIAGNOSIS
Leptospirosis (definite)

Example 3
3.

A patient with fever, myalgia and headache in the

monsoon and contact with contaminated
environment is negative by SAT.

SCORE

A. Fever, Headache, Myalgia

2 +2+4 = 8
Rainfall +
B. Contact with contaminated
4+5=9
environment
C. SAT
SAT-- Negative
0
SCORE
8+9 =17
DIAGNOSIS
Leptospirosis-- Negative
Leptospirosis

Conclusion
 Leptospirosis is a mild illness - Probably underreported
 Severe Lepto Early Diagnosis & Appropriate Treatment
 Need for a simple,cheap&easily available diagnostic test
 Rural area Data not available
 Establishment of Reference Laboratories
(National & Regional )
 Early diagnosis Clinical;
 Confirm diagnosis (>5 days) by SAT / ELISA

 Use modified Faine criteria

 Empiric therapy to be started early(<5days)