Intensive Care Med

DOI 10.1007/s00134-017-4917-7

CORRESPONDENCE

Severe leptospirosis inMorocco:

comparative data fromthe Amazonian area
LocEpelboin1,2* , PaulLeTurnier1, EmilieMosnier1,2,3, RoxaneSchaub2,4, ErwannFontaine5,
StphanieHoucke6, AnneJolivet7, MagalieDemar1,2,8, MathieuNacher2,4 andFlixDjossou1,2

2017 Springer-Verlag GmbH Germany and ESICM

Dear Editor, Patients for whom no clinical information was avail-

able, < 15 years of age, MAT of 100 or no significant
We read with interest the article by Abidi and colleagues
IgM were excluded. Confirmed and probable cases were
on severe leptospirosis in Morocco that was recently
included in the analysis. Patients were then separated
published in Intensive Care Medicine [1]. Leptospirosis
into two groups: those with non-severe disease and
is a cosmopolitan zoonosis caused by Leptospira sp. and
those with severe disease; the latter were defined by the
is associated with significant mortality in tropical regions
presence of acute renal failure requiring dialysis, shock
[2]. It has rarely been studied in the Amazonian area and
treated with vasopressor agents, respiratory distress
was considered to be anecdotic until recently in French
requiring mechanical ventilation and/or death during
Guiana, a French overseas department in South America
hospitalization. We first compared patients with severe
[3]. The aim of our study was to determine the variables
disease to those with non-severe disease. In a second
associated with the evolution of the disease towards a
analysis we compared severe patients hospitalized in
severe form at admission and to compare severe cases
ICUs in French Guiana and Morocco, respectively.
from both countries.
A total of 72 patients were included in the analysis,
A retrospective study was conducted which involved
among whom 12 (16.6%) presented severe forms of the
patients admitted to either of the two main hospitals of
disease. Mortality was 4.2% (three cases). Results of the
French Guiana between 1 January 2007 to 30 September
bivariate analysis are presented in Table1. Acute respira-
2014. Leptospirosis was confirmed based on: (1) posi-
tory failure was more frequent among patients admitted
tive PCR assay result in the blood, urine or cerebrospinal
to the intensive care units (ICUs) in French Guiana, while
fluid, or positive biopsy findings; and/or (2) seroconver-
jaundice and hemorrhage were more frequent among
sion based on the microscopic agglutination test (MAT),
admitted to ICUs in Morocco. Surprisingly, irrespective
with a MAT titer of 200; and/or (3) a fourfold increase
of ICU mortality, vasopressor, mechanical ventilation
of the MAT titer in paired sera; and/or (4) a MAT titer
and renal replacement therapy were applied more sys-
of 400. Patients with probable leptospirosis had at
tematically in French Guiana than in Morocco.
least one serology test with a MAT=200 and/or a posi-
This is the first description of patients with severe
tive MAT titer (=100) with or without MAT seroconver-
Leptospirosis from the Amazonian area. The results
sion, with immunoglobulin M (IgM) seroconversion in
vary widely from previous studies because of the het-
a screening test or a significant positive IgM titer (80).
erogeneity of the inclusion criteria, study populations
and severity criteria [4]. Patient fatality rate was globally
*Correspondence: epelboincrh@hotmail.fr
1
lower than that in other Latin American countries [5].
Infectious andTropical Diseases Department, Centre Hospitalier Andre
Rosemon, Avenue des Flamboyants, 97300Cayenne, French Guiana
One partial explanation for this difference may be asso-
Full author information is available at the end of the article ciated with French Guiana being a French territory with
Takehome message: Leptospirosis is a potentially life-threatening
human and material resources that are closer to Euro-
bacterial disease associated with a high frequency of severe cases and pean norms than those of neighboring countries with
death despite modern intensive care procedures as found in French far fewer resources, especially in terms of intensive care
Guiana. Acute respiratory failure is more frequent in French Guiana while
jaundice and hemorrhage are more frequent in Morocco.
procedures, such as dialysis, mechanical ventilation and
Table1 Comparison ofsevere versusnon-severe forms ofleptospirosis inFrench Guiana, andof severe forms inFrench
Guiana versusthose inMorocco
Variables Severe Not severe Bivariate analysis (not severe ICU patients Bivariate analysis (severe cases
(n=12) (n=60) vs. severe inFrench Guiana) inMorocco French Guiana vs. Morocco)
(n=100)
Odds 95% P Odds ratioa Odds 95% P
ratioa Confidence ratioa Confidence
interval interval

Male gender 11/12 (91.7%) 51/60 (85%) 0.54 92/100 (92%) 1

Age60years 3/12 (25.0%) 6/60 (10.0%) 0.15
Age (years) 46.817.2 39.113.2 0.15 3615 0.022
Professional exposureb 8/9 (88.9%) 23/39 (58.9%) 0.09
Time between first 3/10 (30.0%) 14/55 (25.5%) 0.76
symptoms and biological
diagnosis >5days
Time since symptoms 4 [45.75] 4 [45.5] 0.79 8.5 [715] NA
onset (days)
Antibiotherapy prior to 1/12 (8.3%) 7/54 (13.0%) 0.66
first emergency room
admission
Antibiotic regimen in the 12/12 (100.0%) 44/57 (82.6%) 0.07 100/100 (100) 1
emergency room
Underlying comorbiditiesc 3/11 (27.3%) 11/58 (19.0%) 0.53
Headache 5/12 (41.7%) 44/58 (75.9%) 0.23 0.501.00 0.019
Diarrhea 8/12 (66.7%) 16/58 (27.6%) 5.3 1.226.5 0.009
Nausea or vomiting 5/12 (41.7%) 28/56 (50.0%) 0.6 55/100 (55%) 0.54
Abdominal pain 10/12 (83.3%) 16/57 (28.1%) 12.3 2.3127.7 <0.001 25/100 (25%) 14.6 2.8145.6 <0.001
Jaundice 3/12 (25.0%) 8/56 (14.3%) 0.36 99/100 (99%) 0.0042 0.00010.0126 <0.001
Oliguria 5/8 (62.5%) 1/10 (10.0%) 15 0.9785.6 0.019
Bleeding signs 2/12 (16.7%) 2/53 (3.8%) 5.1 0.3275.4 0.093 76/100 (76%) 0.065 0.00650.335 <0.001
Neurological signsd 2/12 (16.7%) 5/56 (8.9%) 0.59 17/100 (17%) 0.98
Biological meningitidis 0/3 (0%) 6/11 (54.5%) 0.21 16/33 (50%) <0.001
Conjunctival hemorrhage 0/12 (0%) 4/55 (7.3%) 1 11/100 (11%) <0.001
SBP<90mmHg 3/12 (25%) 1/52 (1.9%) 17 1.1908.9 0.003
Temperature38.5C 6/12 (50.0%) 34/55 (61.8%) 0.45 26/100 (26%) 2.8 0.711.6 0.1
Pulse>90/min 11/12 (91.7%) 35/52 (67.3%) 5.3 0.65243.2 0.091
Pulmonary involvemente 6/12 (50.0%) 11/53 (20.8%) 3.81 0.8217.2 0.037 42/100 (42%) 0.75
Acute respiratory failure 5/12 (41.7%) 0/60 (0%) <0.001 12/100 (12%) 5.1 1.1-22.5 0.018
Leukocyte count (G/L) 12.110.1 7.83.8 0.01 18.89.9 0.029
PMN count>7.5 G/L 7/12 (58.3%) 18/57 (31.6%) 3 0.7013.7 0.08
Lymphocyte count0.5 6/11 (54.5%) 14/51 (27.5%) 3.17 0.6715.2 0.08
G/L
Platelet count<100G/L 7/12 (58.3%) 13/59 (22.0%) 4.9 1.1122.8 0.11 66/100 (66%) 0.75
Platelet count (G/L) 146.8142.4 157.794.1 0.74 111123 0.35
Hemoglobin<12g/dL 6/12 (50.0%) 10/58(17.2%) 4.8 1.0221.8 0.014
Hemoglobin (g/dL) 11.93 13.71.8 0.007 11.12.7 0.34
Creatinine (mol/L) 339.2256.4 127.886.7 0.004 531.9265.5 0.019
Creatinine>110M 11/12 (91.7%) 23/59 (38.9%) 17.1 2.16760.9 0.001
ASAT and/or ALAT>10N 2/12 (16.7%) 2/59 (3.4%) 5.7 0.3684.0 0.069
Total bilirubin>50mol/L 6/12 (50.0%) 6/57 (40.5%) 8.5 1.643.3 0.001
Bilirubin (mol/L) 101.7163.5 25.531.0 0.0014 383313 0.0028
LDH>500 UI/L 3/7 (42.9%) 1/19 (5.3%) 13.5 0.7746 0.018
CRP (mg/L) 298 [138329] 152 [82.5218] 0.014
Table1 continued
Variables Severe Not severe Bivariate analysis (not severe ICU patients Bivariate analysis (severe cases
(n=12) (n=60) vs. severe inFrench Guiana) inMorocco French Guiana vs. Morocco)
(n=100)
Odds 95% P Odds ratioa Odds 95% P
ratioa Confidence ratioa Confidence
interval interval
CRP>150mg/L 9/12 (75.0%) 30/60 (50.0%) 3 0.6218.6 0.11
Microscopic hematuria 6/9 (66.7%) 24/47 (51.1%) 0.39
MAT>800 3/11 (27.8%) 15/52 (28.8%) 0.92
Icterohaemorrhagiae vs. 5/9 (55.6%) 14/41 (34.2%) 0.23
other serogroups
Confirmed vs. probable 10/12 (83.3%) 45/60 (75.0%) 0.54
case
Vasopressors 10/12 (83.3%) 0/60 (0%) <0.001 11/100 (11%) 38.0 6.9399.2 <0.001
Dialysis 7/12 (58.3%) 0/60 (0%) <0.001 4/100 (4%) 31.0 5.8202.1 <0.001
Mechanical ventilation 9/12 (75.0%) 0/60 (0%) <0.001 11/100 (11%) 23.0 4.9152.3 <0.001
ICU mortality 3/12 (25%) 0/60 (0%) <0.001 23/100 (23%) 1

Data in table are presented as the number with the percentage in parenthesis, as the mean standard deviation or as the median with the interquartile range in
square brackets, as appropriate
SBP Systolic blood pressure, PMN polymorphonuclear leukocytes, ASAT aspartate aminotransferase, ALAT alanine aminotransferase, LDH lacticodeshydrogenase, CRP
C-reactive protein, MAT microscopic agglutination test, NA not available
a
Odds ratio was calculated with Fischers exact test for qualitative variables
b
Professional exposure in Morocco: vegetables, poultry or fish merchants, dustmen or plumbers, laborers, or farmers. Professional exposure in French Guiana: jobs
with regular contact with animals or with water, such as gold lining, building, veterinary, forest commando soldiers, gardening
c
Underlying comorbidities reported by the patients were epilepsy (n=2); high blood pressure (n=2); immunosuppressive therapy (n=2), chronic alcohol intake
(n=7) and human immunodeficiency virus infection (n=1)
d
Neurological signs in French Guiana: mental confusion and/or stroke; in Morocco:stupor
e
Cough or dyspnea or crackles on pulmonary auscultation or hemoptysis and lung infiltrates on chest X-ray

vasopressor management. To the contrary, ICU mortal- Acknowledgements

ity was comparable to that in Morocco. Despite its ret-
rospective design and small sample size, with subsequent
wide confidence intervals, the study shows that emer-
gency department physicians need to recognize patients
that require a critical care environment early in the dis-
ease course due to the risk of these patients developing
severe disease. The clinical presentation of severe lepto-
spirosis differs between North Africa and the Amazonian
area, possibly due to different strains of infectious agent.
The large contrast in intensive care procedures between
both ICUs raises a number of questions.
Author details
1
Infectious andTropical Diseases Department, Centre Hospitalier Andre
Rosemon, Avenue des Flamboyants, 97300Cayenne, French Guiana. 2Equipe
EA 3593, Ecosystmes Amazoniens et Pathologie Tropicale, Universit de la
Guyane, Cayenne, French Guiana. 3Centres Dlocaliss de Prvention et de
Soins, Centre Hospitalier Andre Rosemon, Cayenne, French Guiana. 4Centre
dInvestigation Clinique, CIC INSERM 1424, Centre Hospitalier Andre Rose-
mon, Cayenne, French Guiana. 5Emergency Department, Centre Hospitalier
Andre Rosemon, 97300Cayenne, French Guiana. 6Intensive Care Unit, Centre
Hospitalier Andre Rosemon, Cayenne, French Guiana. 7Public Health Depart-
ment, Centre Hospitalier Franck Joly, SaintLaurent Du Maroni, French Guiana.
8 MS, Stein C, Abela-Ridder B, Ko AI (2015) Global morbidity and
Laboratoire Hospitalouniversitaire de Parasitologie Mycologie, Centre
Hospitalier Andre Rosemon, Cayenne, French Guiana.
The authors thank Matthieu Picardeau and Pascale Bourhy, from the French
National Reference Center of Leptospirosis, for kindly providing leptospirosis
biological results of our facilities.
Author contribution
All the authors have contributed substantially to the conception and design of
the study, the acquisition of data or the analysis and interpretation of the data,
have drafted or provided critical revision of the article and have provided final
approval of the version submitted for publication.
Compliance with ethical standards
Conflicts of interest
All authors declare that they have no conflict of interest.
Accepted: 19 August 2017
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