Leptospirosis

update
Dr.T.V.Rao MD

Dr.T.V.Rao MD

Scientific Beginning
It was first described by Adolf Weil in 1886 when he reported an "acute infectious disease with enlargement of spleen, jaundice and nephritis". Leptospira was first observed in 1907 from a post mortem renal tissue slice.
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Leptospirosis - Zoonosis
Leptospirosis is an acute arthropod-zoonotic infection of worldwide significance caused by spirochete Leptospira interregna's which has 23 serogroups and >200 serovars. Various factors influencing the animal activity, suitability of the environment for the survival of the organism and behavioural and occupational habits of human beings can be the determinants of incidence and prevalence of the disease.
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What is leptospirosis?
Leptospirosis, also known as canicola fever, haemorrhagic jaundice, infectious jaundice, mud fever, spirochetal jaundice, swamp fever, swineherd's disease, caver's flu or sewerman's flu, is a bacterial infection resulting from exposure to the Leptospira interrogans bacterium.
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Leptospirosis also called as Weils Disease after its inventor

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Weils disease signifies

Leptospirosis
There is an acute form of human infection known as Weil's disease, where the patient suffers from jaundice, though this term is often (incorrectly) used to describe any case of infection..
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Leptospirosis 2011

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Synonyms
Mud / Swamp fever Japanese 7 day fever Rice Field Fever Spirochete Jaundice

Canicola Fever

Leptospiral Jaundice

Autumn Fever

Swineherds Disease

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The Causative Bacterium

Order Spirochaetales Treponema, Borrelia, Leptospira Family Leptospiraceae, susceptible to heat, cl, acid

Genus Leptospira, 26 serogroups, 250 serovars

interrogans, biflex, ictero hemorrhagica, hebdomidis Corkscrew shaped, delicate, flexible spirochete, Gram -ve

6 to 20

long & 0.1

thick, coiled, flagellate, actively motile

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Reservoirs
Wild and domestic animals rodents, livestock (cattle, horses, sheep, goats, swine), canines, and wild mammals are the reservoir for leptospirosis. Many animals have prolonged leptospiruria without suffering from the disease themselves.
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Classification:
Phylum: Spirochaetes Class: Spirochaetes Order: Spirochaetales Species: Leptospira Family: Leptospiraceae

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What causes Leptospirosis

Leptospirosis is a bacterial disease that affects humans and animals. Leptospira bacteria are found worldwide and there are many different types or serovars capable of causing disease. Disease caused by Leptospira bacteria is most common in temperate or tropical climates and appears to be rare in North America.
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Morphology
The Leptospira appear tightly coiled thin flexible Spirochetes 5 15 microns long. Fine spiral of 0.1 0.2 microns One end appears bent forms a hook. Actively motile Seen best with dark field Microscopy.
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Greater Understanding with Electron Microscopy

Electron Microscopy show thin axial filament and a delicate membrane In dark field it may appear as chain of miniature cocci.
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Resistance and Disinfection

Leptospira species can be inactivated by 1% Sodium hypochlorite 70%ethanol, glutaraldehyde, formaldehyde, detergents and acid.
This organism is sensitive to moist heat (121 C for a minimum of 15 min))and is also killed by pasteurization.
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Leptospirosis A Major Zoonotic Infection

Weil's disease is comparatively rare, though 'mild' cases of leptospirosis happen everywhere there are carriers, and it is believed that leptospirosis is one of the most common zoonotic infections in the world. Millions of people are infected each year, but information and treatment can be limited, especially in the developed world where cases are considered 'rare' by the medical community.
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Animals spread Leptospirosis

Rats, Mice, Wild Rodents, Dogs, Swine, Cattle are principle source of infection The above animals excrete Leptospira both in active infection and Asymptomatic stage The Leptospira survive and remain viable for several weeks in stagnant water.
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Modes of Transmission
1. Direct contact with urine or tissue of infected animal Through skin abrasions, intact mucus membrane

2. Indirect contact
Broken skin with infected soil, water or vegetation Ingestion of contaminated food & water 3. Droplet infection
Dr.T.V.Rao MD Inhalation of droplets of infected urine 19

Transmission
Urine Tissue Feces

Contam

Survive

Infection

Animal Source

Environment

Human

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Pathogenic Strains x Non pathogenic Leptospirosis

There are several species of Leptospira only few are pathogenic to Humans, rest to some Animals and Many in Nature as saprophytes Leptospira Interrogans is Pathogenic there are 200 serovars. Leptospira biflexa Non Pathogenic there are 60 serovars Further classifications are made on shared antigens
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Genomic based classification

DNA DNA hybridization studies proved more specific The traditional serologic classification has limitations at Molecular level, but useful at Epidemiological studies.
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Comparative Morphology of Spirochetes

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Culturing of Leptospira
Leptospira grows best under aerobic conditions at 280 to 300c best demonstrated in Semisolid agar media Optimal Media Fletchers Media Stuarts Media Optimal growth after 1 2 weeks
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Growth requirements
Leptospira derive energy from oxidation of long chain fatty acids, and cannot use or carbohydrates or amino acids as major energy source.
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Antigenic structure
All isolates of L.inttterogans from different parts of the world are serologically related and exhibit cross reactions in serologic tests. Overlapping of Antigens do occur in different species. Outer envelop contains large amount of Lipopolysaccharides ( LPS ) Antigenic structure varies from one strain to other This variation forms the basis of serologic classification
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Genome of Leptospira
L. interrogans serogroups Icterhaemorrhagiae consists of a 4.33 mega base large chromosome and a 359 kilo base small chromosome, totalling 4,768 predicted genes. A series of genes have been discovered that could potentially be related to adhesion. This genome differs from the two other pathogenic spirochete (Treponema palladium and Borrelia burgdorferi), though some similar genes are visible (CHGC, 2004).
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PATHOGENESIS
leptospira skin,mucosa Initial stage leptospiremia toxic symptoms
(1~3days) three symptoms: fever,myalgia,fatigue; three signs: conjunctival suffussion; muscle tenderness; enlargement of lymphonodes;
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Pathogenesis
Leptospira are present in the water bodies
Enter through breaks in the skin ( cuts and abrasions ) and mucous membranes

Enters through Mouth Nose Conjunctive Rarely enters though ingestion. Incubation period 1 2 weeks When multiples blood stream produces fever. May establish organ involvement in Kidney and Liver, May produce hemorrhage and necrosis in the tissues and initiates dysfunction of these organs

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Sequence of Leptospira Infection

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Clinical Illnesses
Types

Anicteric (common 95% recover)

Icteric ( Weils Syndrome) (rare, fatal)

Hepato-renal syndrome
Hemorrhagic syndrome with ARF Atypical pneumonia syndrome Aseptic meningo-encephalitis Myocarditis, Chronic uveitis

Clinical Presentation
90% of Cases

Anicteric
Common, mild < 2% Mortality

Icteric
Rare, Severe 15% Mortality

10% of Cases

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May present with

Jaundice Hemorrhage Nitrogen retention The Illness is Biphasic with initial temperature when the second phase comes with raise of IgM titers raise Aseptic meningitis initial headache, stiffness of neck, pleocytosis of Cerebro spinal fluid
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Pathogenesis of Severe Disease

Damage to small blood vessels Vasculitis

Leptospira

Massive migration of fluid from Intravascular to interstitial compartment

Direct cytotoxic injury Immunological injury

Renal dysfunction, vascular Injury to internal organs

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Presenting with Jaundice is significant and Important, Serious Manifestation

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May present with Major Complications

Nephritis Hepatitis. Manifestations in eye Muscular lesions Many infections are mild and subclinical
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Weils Syndrome
Weil's syndrome is a severe form of leptospirosis that causes a continuous fever, stupor, and a reduction in the blood's ability to clot, which leads to bleeding within tissues. Blood tests reveal anaemia. By the third to sixth day, signs of kidney damage and liver injury appear. Kidney abnormalities may cause blood in the urine and painful urination. Liver injury tends to be mild and usually heals completely.
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May present as Atypical Pneumonia

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Hepatitis - Leptospirosis
Hepatitis is the frequent complication Elevation of serum creatine phospholipase enzyme raise differentiates from Viral hepatitis where the enzyme is not raised

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Nephritis - Leptospirosis
Kidney involvement in animals produce chronic disease of the kidney and the infected animal starts shedding large number of Leptospira and main source of environmental contamination of bacteria and results I human infections Human urine also contain Spirochetes in the second and third week of infection

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Complications
Azotemia Oliguria Hemorrhage Purpura Hemolysis Gastrointestinal bleeding Hypoprothrombinemia and Thrombocytopenia
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Fever

Differential Diagnosis

Viral fever, Malaria, Typhus

Jaundice
Malaria, Viral hepatitis, Sepsis

Renal Failure
Malaria, Hanta virus, Sepsis

Meningitis
Bacterial / Viral causes

Hemorrhagic Fever
Dengue, Hanta virus, Typhus

Early and Prompt Diagnosis is Highly Essential

The development of simpler, rapid assays for diagnosis has been based largely on the recognition that early initiation of antibiotic therapy is important in acute disease but also on the need for assays which can be used more widely.
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Laboratory Tests
TC / DC / ESR / Hb / Platelet count Serum Bilirubin / SGOT/ SGPT Blood Urea, Creatinine & Electrolytes Chest X-Ray; ECG Tests for diagnosis of Leptospirosis

Culture for Leptospira: Positive MAT; Sero conversion or 4 fold rise/ high titer ELISA / MSAT : positive MAT: Microscopic agglutination test (M)SAT: Microscopic slide agglutination Test

Approach to Diagnosis
Clinical Features

Leptospiremic phase < 7days

Immune 7d

phase >

Blood

Culture

PCR

ELISA

MSAT

Repeat
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MAT
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Laboratory Diagnosis
Specimens
1 Blood

to be collected in a heparin tube 2 CSF, Tissues Microscopic examination 3 Urine to be collected with great care to avoid contamination 4 Serum for agglutination tests
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Leptospira under the Microscope

Dark Field Microscopy FL

Long, Thin, Highly Coiled

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Culturing Leptospira
Blood and Urine be cultured in Fletchers semisolid agar or other media chemically defined protein-free media for the growth of leptospires have been proposed.
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Time Relationship of Tests

MAT

1 week

1 month

2 months

1 year

5 years

ELISA or SAT

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WHO Guide - Faines Criteria

2
2 2 4 4 4 1 1
Headache Fever Temp > 39 F Conjn. suffusion Meningism Muscle pain

5
4 1 15 15 15 25
Definite

Rain fall Contaminate H20 Animal contact ELISA IgM + ve SAT positive MAT high titer

Jaundice
Alb, creatinine

MAT rising titer

Culture positive

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Serology based Testing

Variety of serological tests other than MAT have been developed for the diagnosis of leptospirosis. Among them are the complement fixation test , several enzymelinked Immuno-Sorbant assay formats , the macroscopic slide agglutination test , the microcapsule agglutination test , the indirect Haemagglutination assay , the dipstick assay , and other methods . Each assay has its own advantages, drawbacks, and limitations
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Serology
Agglutinating antibodies raise to very high titers 1 : 10,000 or higher occurs 5 10 weeks after onset of infection
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What is MAT Testing

Each serum sample was tested against 21 or as specified different serovars by MAT by the standard procedure . Agglutination was examined by dark-field microscopy at a magnification of 100. The reported titer was calculated as the reciprocal of the highest dilution of serum that agglutinated at least 50% of the cells for each serovar used.
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What is MAT Confirmed Test

A MAT-confirmed case was defined as a fourfold increase in antibody titer or a single titer 1:200, according to the case definition of the Centres for Disease Control and Prevention

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Serology - ELISA
Several Immunoassays are available as commercial kits Detection of IgM and razing titers of IgG will guide in association with clinical history will help in Diagnosis

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Newer and Rapid Methods in Diagnosis

Several rapid tests are evolved for the diagnosis of leptospirosis. They are easy to perform and read, although needs to be scientifically evaluated with respect to sensitivity and specificity.
Dri-Dot test gave considerable sensitivity (67.7%)along with good specificity (78%)by Ig M ELISA.
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Treatment
Antibiotic of choice is Benzyl Penicillin given by injection in doses of 5 mega units in a day, for 5 days. If the patients are genuinely hypertensive to Penicillin opted with Erythromycin 250mgs four times a day for a period of 5 days.
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Preferred treatment
Penicillin 6 million units daily I.V (10-14 days) Amoxicillin, Erythromycin, & Doxycycline Patients with MOF(Multi organ failure) to be observed and treated in intensive care unit
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Treatment - Other alternatives

The leptospirosis can be effectively treated with Doxycycline Ampicillin Amoxicillin Severe patients need administration Intravenous Penicillin or Amoxicillin
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Epidemiology
Rainfall; Contaminated environment Poor Sanitation; Inadequate drainage facilities Presence of rodents, cattle & stray dogs Walking/ working bare foot poses high risk Difficult to pinpoint the source of infection

Any person can get infected, if exposed to contaminated and environment

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Epidemiology
Leptospirosis causes several animal infections Most wide spread zoonotic infection in Nature Human infections are accidental associated with contamination of water, other materials contaminated with excreta and animal flesh. Animal carriers often excrete upto 100million leptospirosis per ml of urine

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Epidemiology - Occupation
Certain occupational groups such as agriculture workers in rice and cane fields, miners and sever cleaners are potential victims
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Leptospirosis Indias Concern

The first of its kind in India was reported in the 1920s from Andaman and Nicobar Islands. In 1993, a serosurvey of conservancy workers in Madras (using MAT) revealed a prevalence rate of 32.9%. In 1994, an increase in the number of individuals with uveitis was noted at Aravind Eye hospital, Madurai, India after an epidemic of leptospirosis in South India; the epidemic followed severe flooding of the Tamil Nadu District in the autumn of 1993 In 1995, a seroprevalence rate of 12% leptospirosis was found among febrile and jaundice patients in Pondicherry

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How Man gets Infected

Water the great source Drinking Swimming Bathing, as the urine of Rodents chronically infected contaminate water sources

Children get infected when in contact with infected Dogs

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Control of Leptospirosis
Rodent control is most important. Humans should avoid contact with water contaminated with animal contact.
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Chemoprophylaxis
Doxycycline 200 mg orally once a week is simple effective measure. When heavy exposure is anticipated
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Vaccination in humans
Vaccination for humans is justified where they cannot be separated from animal sources or where the animals cannot be immunized successfully Necessity of human vaccinated will arise where people live and work in proximity to rodents in wet, tropical conditions, in wet rice planting and harvesting, in military operations, or working in sewers. Yet no universally accepted vaccine is available for humans
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Vaccination of Animals
Vaccinating animals have a dual purpose 1 Protecting animals 2 Protecting humans who may contract leptospirosis from them It is probably true as that immunization of animals will prevent leptospirosis in people in contact with them. It proved true in 1980 when extensive vaccination of dairy cows in New Zealand lead to marked decreased incidence in Humans. Animals immunized experimentally with polysaccharide derived from Leptospira LPS linked to diphtheria Toxoid were protected against challenges Several other vaccines in use to suit local needs.
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New Vaccine trails - Leptospira

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Walking in Flood Waters can Infect

With the rats comes the threat of illnesses such as Weil's Disease, which is transmitted to humans via contaminated water and is carried by up to 30 per cent of the rodent population.

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Prevention
Prevention is difficult due to wild animal infection Good sanitation, Immunization of live stock

Personal hygiene, PPE, Water treatment

No useful human vaccines multiple serovars Doxycycline 200 mg weekly for at risk groups

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Created for Health Awareness on Leptospirosis

Email

doctortvrao@gmail.com

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