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LeptospirosisClinicalPresentation:History,PhysicalExamination

LeptospirosisClinicalPresentation
Author:SandraGGompf,MD,FACP,FIDSAChiefEditor:MichaelStuartBronze,MDmore...
Updated:Apr14,2015

History
Agoodclinicalhistoryisoftenthekeytoaccuratediagnosisinleptospirosis.
Importantfeaturesincludeaplausibleexposurehistoryandaclinicalpicture
consistentwiththedisease.
Theexposurehistorymayrevealdirectcontactwithbodyfluidsororgansofinfected
animals,orindirectly(eg,viacontaminatedsoilorwater).Directexposureoften
occursinoccupationalcases,whileindirectexposureismoretypicalofcases
contractedduringtravelorrecreationalactivitiesrivers(eg,whitewaterrafting).
Onsetofclinicalillnessoccursabruptly,afteranincubationperiodof230days
(typically514d).
Expertconsensusisthatleptospirosisoccursastworecognizableclinical
syndromes:anictericandicteric(theexistenceofathirdsyndromeofasymptomatic
infectionismorecontroversial).Anictericleptospirosisisaselflimited,mildflulike
illness.Ictericleptospirosis,alsoknownasWeildisease,isasevereillness
characterizedbymultiorganinvolvementorevenfailure.
Twodistinctphasesofillnessareobservedinthemildform:thesepticemic(acute)
phaseandtheimmune(delayed)phase.Inictericleptospirosis,the2phasesof
illnessareoftencontinuousandindistinguishable.Atdiseaseonset,clinically
predictingtheseverityofdiseaseisnotpossible.
Anacuteillnessfollowsinfectionwithanyserovarofleptospirosis.Mostofthe
followingsignsandsymptomsmaydevelopinvaryingdegrees:
Headache
Fever(3840C)
Rigors
Musclepain(typicallylocalizedtothecalfandlumbarareas)
Nauseaandvomiting
Anorexia
Diarrhea
Cough
Pharyngitis
Conjunctivitis
Nonpruriticskinrash
Despitereportsoffeverasacardinalsymptom,researchbytheHawaiiDepartment
ofHealthfoundthatthepresenceoffevervaried. [24,33]Inserologicallyconfirmed
cases,5%ofpatientsgavenohistoryoffever,and55%wereafebrileatthetimeof
presentation.Myalgiasandheadachewereuniversallyreportedatthetimeof
presentationandwerethechiefcomplaintin25%ofpatients.
Thenaturalcourseofleptospirosisfallsinto2distinctphases.Theacutephaseof
illnesslasts57daysandisfollowedbya13dayperiodofimprovementinwhich
thetemperaturecurvefallsandthepatientmaybecomeafebrileandrelatively
asymptomatic.Subsequently,leptospirosiseitherregressestoarelatively
asymptomaticillnessorprogressestoamoresevereillness.
Recurrenceoffeverindicatestheonsetofthesecond,immunestage.Nonspecific
symptoms,suchasfeverandmyalgia,maybelessseverethaninthefirststage
andlastafewdaystoafewweeks.Manypatients(77%)experienceheadachethat
isintenseandpoorlycontrolledbyanalgesicsthisoftenheraldstheonsetof
meningitis.
Asepticmeningitisisthemostimportantclinicalsyndromeobservedintheimmune
anictericstage.Meningealsymptomsdevelopin50%ofpatients.Cranialnerve
palsies,peripheralfacialpalsy, [34]encephalitis,andchangesinconsciousnessare
lesscommon.Milddeliriummayalsobeseen.Meningitisusuallylastsafewdays
butoccasionallylasts12weeks.Deathisextremelyrareinanictericcases.
Abdominalpainwithdiarrheaorconstipation(30%),hepatosplenomegaly,nausea,
vomiting,andanorexiaarealsoseen.Acalculouscholecystitismaybeseenrarely
butisclinicallysignificant. [35]
Uveitis(210%)candevelopearlyorlateinthediseaseandhasbeenreportedto
occuraslateasoneyearafterinitialillness.Iridocyclitisandchorioretinitisareother
latecomplicationsthatmaypersistforyears.Thesesymptomsfirstmanifest3
weeksto1monthafterexposure.Subconjunctivalhemorrhageisthemostcommon
ocularcomplicationofleptospirosis,occurringinasmanyas92%ofpatients.
Renalmanifestationsincludehematuria.Oliguricoranuricacutetubularnecrosis
mayoccurduringthesecondweekduetohypovolemiaanddecreasedrenal
perfusion.
Weilsyndrome,thesevereformofleptospirosis,primarilymanifestsasprofound
jaundice,renaldysfunction,hepaticnecrosis,pulmonarydysfunction,and
hemorrhagicdiathesis.Pulmonarymanifestationsincludecough,dyspnea,chest
pain,bloodstainedsputum,hemoptysis,andrespiratoryfailure.

PhysicalExamination
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Thephysicalexaminationfindingsdifferdependingontheseverityofdiseaseand
thetimefromonsetofsymptoms.Patientsmayappearmildlyillortoxic.Earlyin
thedisease,temperaturesashighas40Candtachycardiaarecommon.
Hypotension,oliguria,andabnormalchestauscultationfindingsatpresentationmay
portendsevereillness.Whenfeverissevereandprolonged,hypotensionandshock
duetovolumedepletionmayalsooccur.Thefevertypicallysubsideswithin7days.
Earlyinthedisease,theskiniswarmandflushed.Additionalskinfindingsincludea
transientpetechialeruptionthatcaninvolvethepalate.Laterinseveredisease,
jaundiceandpurpuracandevelop.Theclassicocularfindingofconjunctival
suffusionoccursearlyirrespectiveofdiseaseseverity.Conjunctivalsuffusionis
characterizedbyrednessoftheconjunctivathatresemblesconjunctivitisbutthat
doesnotinvolveinflammatoryexudates.
Uveitisisacommonfeaturefollowingacuteleptospirosis.However,patientswho
receiveantibioticsduringtheacutephaseofillnessmaydeveloponlymilduveitis.
[36]

Muscletendernesscanoccurwiththemyositisofearlyinfection.Thiscanbe
particularlyprominentintheparaspinalandcalfmusclesbutcaninvolveany
muscle.
Neurologicexaminationcanrevealsignsofmeningitis,includingneckstiffnessand
rigidityandphotophobia.Earlyinthedisease,thestiffnessonneckexaminationcan
beconfusedasmuscularinoriginhowever,thissymptommayactuallyrepresent
earlymeningismus.
Lungexaminationresultsmaybenormalinearlyormildillness.Insevereillness,
signsofconsolidationduetoalveolarhemorrhagemaybefound.Inpatientswith
cardiacrelatedpulmonaryedema,ralesandwheezescanbeheard.
Alveolarhemorrhagethatmanifestsasdyspneaandhemoptysisisthemain
pulmonarymanifestation.Thisclinicalmanifestationmaybesevereandcanoccur
intheabsenceoftypicalpresentationsofWeildisease.
Myocarditismayoccurinseveredisease.Allofthephysicalfindingsofbiventricular
heartfailurecanbefound,includingelevatedjugularvenouspulsationsanewS 3
gallopanddysrhythmias,includingatrialfibrillation,heartblocksofvaryingseverity,
andventricularectopy.
Abdominalexaminationmayrevealliverenlargementandtendernessdueto
hepatitis.Acalculouscholecystitis,whichmaybesuggestedbyapositiveMurphy
sign,isafindingofprofoundsystemicillness.Pancreatitishasalsobeendescribed
inseverecases. [37,38,39]Hemepositivestoolandevengrossbloodcanbefound
onrectalexaminationinpatientswithDICandbleeding.
Inseveredisease,deliriummaydevelopeitherasaconsequenceofshockor
independentofit.Deliriummaybeanearlyfindinginseveredisease.Latein
diseaseandintoconvalescence,prolongedmentalsymptomsmaypersist,including
depression,anxiety,irritability,psychosis,andevendementia.
Rashmaypresentasamacularormaculopapulareruptionwitherythematous,
urticarial,petechial,ordesquamativelesions.Adenopathymaybenoted.
DifferentialDiagnoses

ContributorInformationandDisclosures
Author
SandraGGompf,MD,FACP,FIDSAAssociateProfessorofInfectiousDiseasesandInternationalMedicine,
UniversityofSouthFloridaCollegeofMedicineChief,InfectiousDiseasesSection,Director,Occupational
HealthandInfectionControlPrograms,JamesAHaleyVeteransHospital
SandraGGompf,MD,FACP,FIDSAisamemberofthefollowingmedicalsocieties:AmericanCollegeof
Physicians,InfectiousDiseasesSocietyofAmerica
Disclosure:Nothingtodisclose.
Coauthor(s)
JudithGreenMcKenzie,MD,MPH,FACP,FACOEMAssociateProfessor,DirectorofClinicalPractice,
OccupationalMedicineResidencyDirector,UniversityofPennsylvaniaSchoolofMedicine
JudithGreenMcKenzie,MD,MPH,FACP,FACOEMisamemberofthefollowingmedicalsocieties:American
CollegeofPhysicians,AmericanCollegeofPreventiveMedicine,NationalMedicalAssociation,American
CollegeofOccupationalandEnvironmentalMedicine
Disclosure:Nothingtodisclose.
AnaPaulaVelez,MDAssistantProfessorofMedicine,DivisionofInfectiousDiseaseandInternational
Medicine,UniversityofSouthFloridaCollegeofMedicineandJamesAHaleyVeteransAffairsMedicalCenter
AttendingPhysician,MoffittCancerCenter
AnaPaulaVelez,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofPhysiciansAmerican
SocietyofInternalMedicine,AmericanMedicalAssociation,InfectiousDiseasesSocietyofAmerica
Disclosure:Nothingtodisclose.
ChiefEditor
MichaelStuartBronze,MDDavidRossBoydProfessorandChairman,DepartmentofMedicine,StewartG
WolfEndowedChairinInternalMedicine,DepartmentofMedicine,UniversityofOklahomaHealthScience
CenterMasteroftheAmericanCollegeofPhysiciansFellow,InfectiousDiseasesSocietyofAmerica
MichaelStuartBronze,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
MedicalAssociation,OklahomaStateMedicalAssociation,SouthernSocietyforClinicalInvestigation,
AssociationofProfessorsofMedicine,AmericanCollegeofPhysicians,InfectiousDiseasesSocietyofAmerica
Disclosure:Nothingtodisclose.

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Acknowledgements
DeniseDemers,MD,FAAPAssistantProfessorofPediatrics,UniformedServicesUniversityoftheHealth
SciencesAttendingPhysician,DivisionofPediatricInfectiousDiseases,DepartmentofPediatrics,TriplerArmy
MedicalCenter
Disclosure:Nothingtodisclose.
JuanDDiaz,DOFellowinInfectiousDiseases,UniversityofSouthFloridaCollegeofMedicine,TampaGeneral
Hospital,andJamesAHaleyVeteransHospital
Disclosure:Nothingtodisclose.
JosephDomachowske,MDProfessorofPediatrics,MicrobiologyandImmunology,DepartmentofPediatrics,
DivisionofInfectiousDiseases,StateUniversityofNewYorkUpstateMedicalUniversity
JosephDomachowske,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
AcademyofPediatrics,AmericanSocietyforMicrobiology,InfectiousDiseasesSocietyofAmerica,Pediatric
InfectiousDiseasesSociety,andPhiBetaKappa
Disclosure:Nothingtodisclose.
PatrickWHickey,MD,FAAPAssistantProfessorofPediatricsandPreventiveMedicine,UniformedServices
UniversityoftheHealthSciencesConsultingStaff,DepartmentofPediatrics,DivisionofPediatricInfectious
Disease,WalterReedArmyMedicalCenter
PatrickWHickey,MD,FAAPisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
AcademyofPediatrics,AmericanSocietyofTropicalMedicineandHygiene,InfectiousDiseasesSocietyof
America,InternationalSocietyofTravelMedicine,andPediatricInfectiousDiseasesSociety
Disclosure:Nothingtodisclose.
EdmondAHookerII,MD,DrPH,FAAEMAssistantProfessor,DepartmentofEmergencyMedicine,University
ofCincinnatiCollegeofMedicineAssociateProfessor,DepartmentofHealthServicesAdministration,Xavier
University
EdmondAHookerII,MD,DrPH,FAAEMisamemberofthefollowingmedicalsocieties:AmericanAcademyof
EmergencyMedicine,AmericanPublicHealthAssociation,SocietyforAcademicEmergencyMedicine,and
SouthernMedicalAssociation
Disclosure:Nothingtodisclose.
MatthewRJezior,MDFellow,DepartmentofCardiology,WalterReedMedicalCenter
Disclosure:Nothingtodisclose.
MariaDMileno,MDAssociateProfessorofMedicine,DivisionofInfectiousDiseases,TheWarrenAlpert
MedicalSchoolofBrownUniversity
MariaDMileno,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanCollegeof
Physicians,AmericanSocietyofTropicalMedicineandHygiene,InfectiousDiseasesSocietyofAmerica,
InternationalSocietyofTravelMedicine,andSigmaXi
Disclosure:Nothingtodisclose.
JosephTMorris,MDChiefofInfectiousDiseaseService,MadiganArmyMedicalCenterAssistantProfessor,
DepartmentofInternalMedicine,UniformedServicesUniversityoftheHealthSciences
Disclosure:Nothingtodisclose.
GaryJNoel,MDProfessor,DepartmentofPediatrics,WeillCornellMedicalCollegeAttendingPediatrician,
NewYorkPresbyterianHospital
GaryJNoel,MDisamemberofthefollowingmedicalsocieties:PediatricInfectiousDiseasesSociety
Disclosure:Nothingtodisclose.
CecilyKPeterson,MDProgramDirector,ClinicalFaculty,DepartmentofMedicine,MadiganArmyMedical
Center
Disclosure:Nothingtodisclose.
CharlesVSanders,MDEdgarHullProfessorandChairman,DepartmentofInternalMedicine,Professorof
Microbiology,ImmunologyandParasitology,LouisianaStateUniversitySchoolofMedicineatNewOrleans
MedicalDirector,MedicineHospitalCenter,CharityHospitalandMedicalCenterofLouisianaatNewOrleans
ConsultingStaff,OchsnerMedicalCenter
CharlesVSanders,MDisamemberofthefollowingmedicalsocieties:AllianceforthePrudentUseof
Antibiotics,AlphaOmegaAlpha,AmericanAssociationfortheAdvancementofScience,AmericanAssociation
ofUniversityProfessors,AmericanClinicalandClimatologicalAssociation,AmericanCollegeofPhysician
Executives,AmericanCollegeofPhysicians,AmericanFederationforMedicalResearch,AmericanFoundation
forAIDSResearch,AmericanGeriatricsSociety,AmericanLungAssociation,AmericanMedicalAssociation,
AmericanSocietyforMicrobiology,AmericanThoracicSociety,AmericanVenerealDiseaseAssociation,
AssociationforProfessionalsinInfectionControlandEpidemiology,AssociationofAmericanMedicalColleges,
AssociationofAmericanPhysicians,AssociationofProfessorsofMedicine,InfectiousDiseaseSocietyfor
ObstetricsandGynecology,InfectiousDiseasesSocietyofAmerica,LouisianaStateMedicalSociety,Orleans
ParishMedicalSociety,RoyalSocietyofMedicine,SigmaXi,SocietyofGeneralInternalMedicine,
SoutheasternClinicalClub,SouthernMedicalAssociation,SouthernSocietyforClinicalInvestigation,and
SouthwesternAssociationofClinicalMicrobiology
Disclosure:Nothingtodisclose.
WilliamHShoff,MD,DTM&HDirector,PENNTravelMedicineAssociateProfessor,DepartmentofEmergency
Medicine,HospitaloftheUniversityofPennsylvania,UniversityofPennsylvaniaSchoolofMedicine
WilliamHShoff,MD,DTM&Hisamemberofthefollowingmedicalsocieties:AmericanCollegeofPhysicians,
AmericanSocietyofTropicalMedicineandHygiene,InternationalSocietyofTravelMedicine,Societyfor
AcademicEmergencyMedicine,andWildernessMedicalSociety
Disclosure:Nothingtodisclose.
RussellWSteele,MDHead,DivisionofPediatricInfectiousDiseases,OchsnerChildren'sHealthCenter

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ClinicalProfessor,DepartmentofPediatrics,TulaneUniversitySchoolofMedicine
RussellWSteele,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofPediatrics,
AmericanAssociationofImmunologists,AmericanPediatricSociety,AmericanSocietyforMicrobiology,
InfectiousDiseasesSocietyofAmerica,LouisianaStateMedicalSociety,PediatricInfectiousDiseasesSociety,
SocietyforPediatricResearch,andSouthernMedicalAssociation
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment
Jeter(Jay)PritchardTaylorIII,MDComplianceOfficer,AttendingPhysician,EmergencyMedicineResidency,
DepartmentofEmergencyMedicine,PalmettoHealthRichland,UniversityofSouthCarolinaSchoolofMedicine
MedicalDirector,DepartmentofEmergencyMedicine,PalmettoHealthBaptist
Jeter(Jay)PritchardTaylorIII,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
EmergencyMedicine,AmericanCollegeofEmergencyPhysicians,AmericanMedicalAssociation,andSociety
forAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
MaryLWindle,PharmDAdjunctAssociateProfessor,UniversityofNebraskaMedicalCenterCollegeof
PharmacyEditorinChief,MedscapeDrugReference
Disclosure:Nothingtodisclose.

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