Leptospirosis natural history, complications and prognosis: Difference between revisions
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== Overview == | == Overview == | ||
Leptospirosis is transported by the natural carriers such as feral, semi-domestic and farm and pet animals.<ref name="pmid11292640">{{cite journal| author=Levett PN| title=Leptospirosis. | journal=Clin Microbiol Rev | year= 2001 | volume= 14 | issue= 2 | pages= 296-326 | pmid=11292640 | doi=10.1128/CMR.14.2.296-326.2001 | pmc=88975 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11292640 }} </ref> Incubation period for leptospirosis varies between 3-20 days. The disease can cause wide range of symptoms from mild flu-like symptoms to severe disease with multi organ failure causing death. The first phase resolves and the patient is asymptomatic briefly before the second phase begins that is characterized by meningitis, liver damage (causing jaundice), and renal failure.<ref name="VCNA">{{cite journal|author=Heuter, Kerry J.,Langston, Cathy E.|title=Leptospirosis: A re-emerging zoonotic disease|journal=The Veterinary Clinics of North America|year=2003|volume=33|pages=791-807}}</ref> The disease leptospirosis is poorly known and unaware of its natural history is mainly due to the wide range of non specific symptoms, subclinical nature of the disease in animals, and non specific laboratory tests making the disease difficult to diagnose.<ref name="pmid16600656">{{cite journal| author=Vieira ML, Gama-Simões MJ, Collares-Pereira M| title=Human leptospirosis in Portugal: A retrospective study of eighteen years. | journal=Int J Infect Dis | year= 2006 | volume= 10 | issue= 5 | pages= 378-86 | pmid=16600656 | doi=10.1016/j.ijid.2005.07.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16600656 }} </ref> Outcome of the patient depends upon the pathogenic serovar and immunological status. | Leptospirosis is transported by the natural carriers such as feral, semi-domestic and farm and pet animals.<ref name="pmid11292640">{{cite journal| author=Levett PN| title=Leptospirosis. | journal=Clin Microbiol Rev | year= 2001 | volume= 14 | issue= 2 | pages= 296-326 | pmid=11292640 | doi=10.1128/CMR.14.2.296-326.2001 | pmc=88975 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11292640 }} </ref> Incubation period for leptospirosis varies between 3-20 days. The disease can cause wide range of symptoms from mild [[flu]]-like symptoms to severe disease with multi [[organ failure]] causing death. The first phase resolves and the patient is asymptomatic briefly before the second phase begins that is characterized by [[meningitis]], [[liver]] damage (causing [[jaundice]]), and [[renal failure]].<ref name="VCNA">{{cite journal|author=Heuter, Kerry J.,Langston, Cathy E.|title=Leptospirosis: A re-emerging zoonotic disease|journal=The Veterinary Clinics of North America|year=2003|volume=33|pages=791-807}}</ref> The disease leptospirosis is poorly known and unaware of its natural history is mainly due to the wide range of non specific symptoms, subclinical nature of the disease in animals, and non specific laboratory tests making the disease difficult to diagnose.<ref name="pmid16600656">{{cite journal| author=Vieira ML, Gama-Simões MJ, Collares-Pereira M| title=Human leptospirosis in Portugal: A retrospective study of eighteen years. | journal=Int J Infect Dis | year= 2006 | volume= 10 | issue= 5 | pages= 378-86 | pmid=16600656 | doi=10.1016/j.ijid.2005.07.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16600656 }} </ref> Outcome of the patient depends upon the pathogenic [[serovar]] and [[immunological]] status. | ||
==Natural History== | ==Natural History== | ||
Natural history of leptospirosis varies with each patient. It might be mild or asymptomatic, and go unrecognized or in some patients the illness may progress to kidney or liver failure, aseptic meningitis, life-threatening pulmonary hemorrhage and other syndromes. | Natural history of leptospirosis varies with each patient. It might be mild or asymptomatic, and go unrecognized or in some patients the illness may progress to [[kidney]] or [[liver failure]], [[aseptic meningitis]], life-threatening pulmonary hemorrhage and other syndromes. | ||
===Acute Phase=== | ===Acute Phase=== | ||
* Also known as Septicemic phase or leptospiremic phase. | * Also known as Septicemic phase or leptospiremic phase. | ||
* Begins abruptly | * Begins abruptly | ||
* Bacteria are present in the blood and CSF of the patient | * Bacteria are present in the [[blood]] and [[CSF]] of the patient | ||
* Characterized by wide spectrum of nonspecific signs and symptoms such as fever, chills, headache and conjunctival suffusion making it very difficult to diagnose.<ref name="pmid16333189">{{cite journal| author=Bal AM| title=Unusual clinical manifestations of leptospirosis. | journal=J Postgrad Med | year= 2005 | volume= 51 | issue= 3 | pages= 179-83 | pmid=16333189 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16333189 }} </ref> | * Characterized by wide spectrum of nonspecific signs and symptoms such as [[fever]], [[chills]], [[headache]] and conjunctival suffusion making it very difficult to diagnose.<ref name="pmid16333189">{{cite journal| author=Bal AM| title=Unusual clinical manifestations of leptospirosis. | journal=J Postgrad Med | year= 2005 | volume= 51 | issue= 3 | pages= 179-83 | pmid=16333189 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16333189 }} </ref> | ||
* Associate with severe myalgia | * Associate with severe [[myalgia]] | ||
* Other less common findings include: Photophobia, lymphadenopathy, abdominal pain, nausea, vomiting, a transient rash, sore throat, coughing or chest pain | * Other less common findings include: [[Photophobia]], [[lymphadenopathy]], [[abdominal pain]], [[nausea]], [[vomiting]], a transient [[rash]], [[sore throat]], [[coughing]] or [[chest pain]]. | ||
* Characterestic of this phase also includes: Mild form of leptospirosis in ~90% cases which lasts several days to a week, followed by a brief remission, during which the temperature drops and the symptoms disappear | * Characterestic of this phase also includes: Mild form of leptospirosis in ~90% cases which lasts several days to a week, followed by a brief remission, during which the temperature drops and the symptoms disappear | ||
===Immune phase=== | ===Immune phase=== | ||
* It is also known as leptospiruric phase. | * It is also known as leptospiruric phase. | ||
* Circulating (IgM) antibodies are produced and leptospires are present in the urine | * Circulating ([[IgM]]) antibodies are produced and leptospires are present in the [[urine]]. | ||
* Characterestic findings that differentiate from other febrile illnesses are myalgia and conjunctival suffusion.<ref name="pmid22843698">{{cite journal| author=Forbes AE, Zochowski WJ, Dubrey SW, Sivaprakasam V| title=Leptospirosis and Weil's disease in the UK. | journal=QJM | year= 2012 | volume= 105 | issue= 12 | pages= 1151-62 | pmid=22843698 | doi=10.1093/qjmed/hcs145 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22843698 }} </ref> | * Characterestic findings that differentiate from other febrile illnesses are [[myalgia]] and conjunctival suffusion.<ref name="pmid22843698">{{cite journal| author=Forbes AE, Zochowski WJ, Dubrey SW, Sivaprakasam V| title=Leptospirosis and Weil's disease in the UK. | journal=QJM | year= 2012 | volume= 105 | issue= 12 | pages= 1151-62 | pmid=22843698 | doi=10.1093/qjmed/hcs145 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22843698 }} </ref> | ||
* Myalgia often involves in calf muscles, less commonly involves abdominal and para-spinal muscles. | * Myalgia often involves in [[Calf muscle|calf]] muscles, less commonly involves abdominal and para-spinal muscles. | ||
====Anicteric leptospirosis==== | ====Anicteric leptospirosis==== | ||
* More common but serious illness is uncommon | * More common but serious illness is uncommon. | ||
* Most of cases present either subclinical or of very mild severity | * Most of cases present either subclinical or of very mild severity. | ||
* Few cases present with a febrile illness of sudden onset | * Few cases present with a febrile illness of sudden onset. | ||
* May progress to aseptic meningitis in ≤25% of patients and more common in younger age group than the patients with icteric leptospirosis | * May progress to [[aseptic meningitis]] in ≤25% of patients and more common in younger age group than the patients with icteric leptospirosis. | ||
* Mortality is very less when compared to icteric leptospirosis | * Mortality is very less when compared to icteric leptospirosis. | ||
====Icteric leptospirosis==== | ====Icteric leptospirosis==== | ||
* Rapidly progressive and severe form of leptospirosis(Weil's disease) | * Rapidly progressive and severe form of leptospirosis([[Weil's disease]]) | ||
* In the severe form of leptospirosis renal failure, hepatic failure and pulmonary haemorrhage can occur and associate with Icterohaemorrhagiae.<ref name="pmid11692294">{{cite journal| author=Katz AR, Ansdell VE, Effler PV, Middleton CR, Sasaki DM| title=Assessment of the clinical presentation and treatment of 353 cases of laboratory-confirmed leptospirosis in Hawaii, 1974-1998. | journal=Clin Infect Dis | year= 2001 | volume= 33 | issue= 11 | pages= 1834-41 | pmid=11692294 | doi=10.1086/324084 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11692294 }} </ref> | * In the severe form of leptospirosis [[renal failure]], [[hepatic failure]] and pulmonary haemorrhage can occur and associate with Icterohaemorrhagiae.<ref name="pmid11692294">{{cite journal| author=Katz AR, Ansdell VE, Effler PV, Middleton CR, Sasaki DM| title=Assessment of the clinical presentation and treatment of 353 cases of laboratory-confirmed leptospirosis in Hawaii, 1974-1998. | journal=Clin Infect Dis | year= 2001 | volume= 33 | issue= 11 | pages= 1834-41 | pmid=11692294 | doi=10.1086/324084 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11692294 }} </ref> | ||
* Less common form of leptospirosis with incidence of 5%-10% | * Less common form of leptospirosis with incidence of 5%-10% | ||
* Jaundice is not associate with hepatocellular injury, eventually LFT returns to normal after recovery | * [[Jaundice]] is not associate with hepatocellular injury, eventually [[Liver function tests|LFT]] returns to normal after recovery. | ||
* High mortality rate with a range of 5%-15% | * High mortality rate with a range of 5%-15%. | ||
==== Severe leptospirosis ==== | ==== Severe leptospirosis ==== | ||
Sever form of leptospirosis with organ failure including | Sever form of leptospirosis with [[organ failure]] including [[liver]] and [[kidney]] involvement is known as [[Weil's disease]]. | ||
* Hepatic: Mild to severe form of jaundice developed within 4-7 days after the initial clinical presentation that can progress to hepatic failure or hepatic encephalopathy. | * [[Hepatic]]: Mild to severe form of [[jaundice]] developed within 4-7 days after the initial clinical presentation that can progress to [[hepatic failure]] or [[hepatic encephalopathy]]. | ||
* Renal: Very common presentation involving kidneys is acute interstitial nephritis, with cola colored urine, oliguria or anuria. | * [[Renal]]: Very common presentation involving [[kidneys]] is [[acute interstitial nephritis]], with cola colored [[urine]], [[oliguria]] or [[anuria]]. | ||
* Pulmonary: Milder form of leptospirosis presents with cough, chest pain and blood tinged sputum, where as in severe form present with cough, hemoptysis, rapidly increasing breathlessness which may lead to respiratory failure and death. Hemorrhagic pneumonitis with interstitial and intra alveolar hemorrhage is the commonest cause of death in leptospirosis with case fatality rate of 0%-15%. | * [[Pulmonary]]: Milder form of leptospirosis presents with [[cough]], [[chest pain]] and blood tinged sputum, where as in severe form present with [[cough]], [[hemoptysis]], rapidly increasing [[breathlessness]] which may lead to [[respiratory failure]] and death. Hemorrhagic [[pneumonitis]] with [[interstitial]] and intra alveolar hemorrhage is the commonest cause of death in leptospirosis with case fatality rate of 0%-15%. | ||
* | * [[Cardiovascular]]: [[Arrhythmias]] present with [[syncope]] and [[palpitations]]. | ||
* Nervous system: Meningitis, encephalitis, focal | * [[Nervous system]]: [[Meningitis]], [[encephalitis]], focal defecits, spasticity, paralysis, peripheral neuropathies, nerve palsies and radiculopathies. | ||
===Complications=== | ===Complications=== | ||
Complications of leptospirosis are associated with localization of pathogen(Leptospires) within the tissues during the immune phase, eventually present during the second week of the illness. | Complications of leptospirosis are associated with localization of pathogen (Leptospires) within the tissues during the immune phase, eventually present during the second week of the illness. | ||
'''Life threatening complications''' | '''Life threatening complications''' | ||
* Acute kidney injury | * [[Acute kidney injury]] | ||
* Disseminated intravascular coagulation | * [[Disseminated intravascular coagulation]] | ||
* Gastrointestinal hemorrhage | * [[Gastrointestinal hemorrhage]] | ||
* Hemorrhagic shock | * [[Hemorrhagic shock]] | ||
'''Common Complications''' | '''Common Complications''' | ||
* Pulmonary: Pulmonary hemorrhage<ref name="pmid16333187">{{cite journal| author=Salkade HP, Divate S, Deshpande JR, Kawishwar V, Chaturvedi R, Kandalkar BM et al.| title=A study of sutopsy findings in 62 cases of leptospirosis in a metropolitan city in India. | journal=J Postgrad Med | year= 2005 | volume= 51 | issue= 3 | pages= 169-73 | pmid=16333187 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16333187 }} </ref> | * [[Pulmonary]]: Pulmonary hemorrhage<ref name="pmid16333187">{{cite journal| author=Salkade HP, Divate S, Deshpande JR, Kawishwar V, Chaturvedi R, Kandalkar BM et al.| title=A study of sutopsy findings in 62 cases of leptospirosis in a metropolitan city in India. | journal=J Postgrad Med | year= 2005 | volume= 51 | issue= 3 | pages= 169-73 | pmid=16333187 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16333187 }} </ref> | ||
* Hematological: Thrombocytopenic purpura, Disseminated intravascular coagulation | * [[Hematological]]: [[Thrombocytopenic purpura]], [[Disseminated intravascular coagulation]]. | ||
* Neurological: Mild meningitis, encephalitis, radiculopathies, transverse myelitis, cranial nerve palsies and | * [[Neurological]]: Mild [[meningitis]], [[encephalitis]], radiculopathies, [[transverse myelitis]], [[cranial nerve palsies]] and [[Guillain-Barre syndrome]].<ref name="pmid16333189">{{cite journal| author=Bal AM| title=Unusual clinical manifestations of leptospirosis. | journal=J Postgrad Med | year= 2005 | volume= 51 | issue= 3 | pages= 179-83 | pmid=16333189 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16333189 }} </ref> | ||
* Cardiac: Myocarditis, pericarditis<ref name="pmid2355200">{{cite journal| author=Watt G, Padre LP, Tuazon M, Calubaquib C| title=Skeletal and cardiac muscle involvement in severe, late leptospirosis. | journal=J Infect Dis | year= 1990 | volume= 162 | issue= 1 | pages= 266-9 | pmid=2355200 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2355200 }} </ref><ref name="pmid18262280">{{cite journal| author=Chakurkar G, Vaideeswar P, Pandit SP, Divate SA| title=Cardiovascular lesions in leptospirosis: an autopsy study. | journal=J Infect | year= 2008 | volume= 56 | issue= 3 | pages= 197-203 | pmid=18262280 | doi=10.1016/j.jinf.2007.12.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18262280 }} </ref> | * [[Cardiac]]: [[Myocarditis]], [[pericarditis]]<ref name="pmid2355200">{{cite journal| author=Watt G, Padre LP, Tuazon M, Calubaquib C| title=Skeletal and cardiac muscle involvement in severe, late leptospirosis. | journal=J Infect Dis | year= 1990 | volume= 162 | issue= 1 | pages= 266-9 | pmid=2355200 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2355200 }} </ref><ref name="pmid18262280">{{cite journal| author=Chakurkar G, Vaideeswar P, Pandit SP, Divate SA| title=Cardiovascular lesions in leptospirosis: an autopsy study. | journal=J Infect | year= 2008 | volume= 56 | issue= 3 | pages= 197-203 | pmid=18262280 | doi=10.1016/j.jinf.2007.12.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18262280 }} </ref> | ||
**Conduction abnormalities: First degree atrioventricular block, widespread T-wave inversion<ref name="pmid18262280">{{cite journal| author=Chakurkar G, Vaideeswar P, Pandit SP, Divate SA| title=Cardiovascular lesions in leptospirosis: an autopsy study. | journal=J Infect | year= 2008 | volume= 56 | issue= 3 | pages= 197-203 | pmid=18262280 | doi=10.1016/j.jinf.2007.12.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18262280 }} </ref><ref name="pmid20790602">{{cite journal| author=Parsons M| title=Electrocardiographic Changes in Leptospirosis. | journal=Br Med J | year= 1965 | volume= 2 | issue= 5455 | pages= 201-3 | pmid=20790602 | doi= | pmc=1846500 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20790602 }} </ref> | **[[Conduction System|Conduction]] abnormalities: [[First degree atrioventricular block]], widespread [[T-wave inversion]]<ref name="pmid18262280">{{cite journal| author=Chakurkar G, Vaideeswar P, Pandit SP, Divate SA| title=Cardiovascular lesions in leptospirosis: an autopsy study. | journal=J Infect | year= 2008 | volume= 56 | issue= 3 | pages= 197-203 | pmid=18262280 | doi=10.1016/j.jinf.2007.12.007 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18262280 }} </ref><ref name="pmid20790602">{{cite journal| author=Parsons M| title=Electrocardiographic Changes in Leptospirosis. | journal=Br Med J | year= 1965 | volume= 2 | issue= 5455 | pages= 201-3 | pmid=20790602 | doi= | pmc=1846500 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20790602 }} </ref> | ||
**Rhythm abnormalities: Atrial fibrillation | **[[Rhythm]] abnormalities: [[Atrial fibrillation]]. | ||
* Renal: Myositis '''→''' Rhabdomyolysis '''→''' Interstitial nephritis '''→''' Renal failure | * [[Renal]]: [[Myositis]] '''→''' [[Rhabdomyolysis]] '''→''' [[Interstitial nephritis]] '''→''' [[Renal failure]] | ||
* Pregnancy: Miscarriages, active leptospirosis in fetus<ref name="pmid8399874">{{cite journal| author=Shaked Y, Shpilberg O, Samra D, Samra Y| title=Leptospirosis in pregnancy and its effect on the fetus: case report and review. | journal=Clin Infect Dis | year= 1993 | volume= 17 | issue= 2 | pages= 241-3 | pmid=8399874 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8399874 }} </ref><ref name="pmid7650320">{{cite journal| author=Carles G, Montoya E, Joly F, Peneau C| title=[Leptospirosis and pregnancy. Eleven cases in French Guyana]. | journal=J Gynecol Obstet Biol Reprod (Paris) | year= 1995 | volume= 24 | issue= 4 | pages= 418-21 | pmid=7650320 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7650320 }} </ref> | * [[Pregnancy]]: [[Miscarriages]], active leptospirosis in [[fetus]]<ref name="pmid8399874">{{cite journal| author=Shaked Y, Shpilberg O, Samra D, Samra Y| title=Leptospirosis in pregnancy and its effect on the fetus: case report and review. | journal=Clin Infect Dis | year= 1993 | volume= 17 | issue= 2 | pages= 241-3 | pmid=8399874 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8399874 }} </ref><ref name="pmid7650320">{{cite journal| author=Carles G, Montoya E, Joly F, Peneau C| title=[Leptospirosis and pregnancy. Eleven cases in French Guyana]. | journal=J Gynecol Obstet Biol Reprod (Paris) | year= 1995 | volume= 24 | issue= 4 | pages= 418-21 | pmid=7650320 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7650320 }} </ref> | ||
'''Less Common Complications''' | '''Less Common Complications''' | ||
* Cerebrovascular accidents | * [[Cerebrovascular accident|Cerebrovascular]] accidents | ||
* Rhabdomyolysis | * [[Rhabdomyolysis]] | ||
* Acute acalculous cholecystitis | * Acute [[acalculous cholecystitis]] | ||
* Erythema nodosum | * [[Erythema nodosum]] | ||
* Aortic stenosis | * [[Aortic stenosis]] | ||
* Kawasaki syndrome | * [[Kawasaki syndrome]] | ||
* Reactive arthritis | * [[Reactive arthritis]] | ||
* Epididymitis | * [[Epididymitis]] | ||
* Nerve palsy | * [[Nerve palsy]] | ||
* Male hypogonadism | * Male [[hypogonadism]] | ||
===Prognosis=== | ===Prognosis=== | ||
The prognosis of leptospirosis depends upon several known and unknown factors, among which the type of pathogenic serovar and the host’s immune status are the important factors which determines the outcome.<ref name="pmid11292640">{{cite journal| author=Levett PN| title=Leptospirosis. | journal=Clin Microbiol Rev | year= 2001 | volume= 14 | issue= 2 | pages= 296-326 | pmid=11292640 | doi=10.1128/CMR.14.2.296-326.2001 | pmc=88975 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11292640 }} </ref> Most patients recover completely from leptospirosis, but the duration of recovery varies from months to years with or without late sequelae. The late sequelae may include neuropsychiatric problems such as paresis, paralysis, mood swings and depression etc. The major causes of death include renal failure, cardiopulmonary failure, and haemorrhage. Patients with risk factors such as old age and multiple underlying co-morbid conditions are often associated with more severe leptospirosis and increased mortality. | The prognosis of leptospirosis depends upon several known and unknown factors, among which the type of pathogenic serovar and the host’s immune status are the important factors which determines the outcome.<ref name="pmid11292640">{{cite journal| author=Levett PN| title=Leptospirosis. | journal=Clin Microbiol Rev | year= 2001 | volume= 14 | issue= 2 | pages= 296-326 | pmid=11292640 | doi=10.1128/CMR.14.2.296-326.2001 | pmc=88975 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11292640 }} </ref> Most patients recover completely from leptospirosis, but the duration of recovery varies from months to years with or without late sequelae. The late sequelae may include [[neuropsychiatric]] problems such as [[paresis]], [[paralysis]], [[mood swings]] and [[depression]] etc. The major causes of death include [[renal failure]], [[cardiopulmonary]] failure, and [[haemorrhage]]. Patients with risk factors such as old age and multiple underlying co-morbid conditions are often associated with more severe leptospirosis and increased mortality. | ||
==References== | ==References== | ||
Revision as of 03:08, 8 March 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [2]
Overview
Leptospirosis is transported by the natural carriers such as feral, semi-domestic and farm and pet animals.[1] Incubation period for leptospirosis varies between 3-20 days. The disease can cause wide range of symptoms from mild flu-like symptoms to severe disease with multi organ failure causing death. The first phase resolves and the patient is asymptomatic briefly before the second phase begins that is characterized by meningitis, liver damage (causing jaundice), and renal failure.[2] The disease leptospirosis is poorly known and unaware of its natural history is mainly due to the wide range of non specific symptoms, subclinical nature of the disease in animals, and non specific laboratory tests making the disease difficult to diagnose.[3] Outcome of the patient depends upon the pathogenic serovar and immunological status.
Natural History
Natural history of leptospirosis varies with each patient. It might be mild or asymptomatic, and go unrecognized or in some patients the illness may progress to kidney or liver failure, aseptic meningitis, life-threatening pulmonary hemorrhage and other syndromes.
Acute Phase
- Also known as Septicemic phase or leptospiremic phase.
- Begins abruptly
- Bacteria are present in the blood and CSF of the patient
- Characterized by wide spectrum of nonspecific signs and symptoms such as fever, chills, headache and conjunctival suffusion making it very difficult to diagnose.[4]
- Associate with severe myalgia
- Other less common findings include: Photophobia, lymphadenopathy, abdominal pain, nausea, vomiting, a transient rash, sore throat, coughing or chest pain.
- Characterestic of this phase also includes: Mild form of leptospirosis in ~90% cases which lasts several days to a week, followed by a brief remission, during which the temperature drops and the symptoms disappear
Immune phase
- It is also known as leptospiruric phase.
- Circulating (IgM) antibodies are produced and leptospires are present in the urine.
- Characterestic findings that differentiate from other febrile illnesses are myalgia and conjunctival suffusion.[5]
- Myalgia often involves in calf muscles, less commonly involves abdominal and para-spinal muscles.
Anicteric leptospirosis
- More common but serious illness is uncommon.
- Most of cases present either subclinical or of very mild severity.
- Few cases present with a febrile illness of sudden onset.
- May progress to aseptic meningitis in ≤25% of patients and more common in younger age group than the patients with icteric leptospirosis.
- Mortality is very less when compared to icteric leptospirosis.
Icteric leptospirosis
- Rapidly progressive and severe form of leptospirosis(Weil's disease)
- In the severe form of leptospirosis renal failure, hepatic failure and pulmonary haemorrhage can occur and associate with Icterohaemorrhagiae.[6]
- Less common form of leptospirosis with incidence of 5%-10%
- Jaundice is not associate with hepatocellular injury, eventually LFT returns to normal after recovery.
- High mortality rate with a range of 5%-15%.
Severe leptospirosis
Sever form of leptospirosis with organ failure including liver and kidney involvement is known as Weil's disease.
- Hepatic: Mild to severe form of jaundice developed within 4-7 days after the initial clinical presentation that can progress to hepatic failure or hepatic encephalopathy.
- Renal: Very common presentation involving kidneys is acute interstitial nephritis, with cola colored urine, oliguria or anuria.
- Pulmonary: Milder form of leptospirosis presents with cough, chest pain and blood tinged sputum, where as in severe form present with cough, hemoptysis, rapidly increasing breathlessness which may lead to respiratory failure and death. Hemorrhagic pneumonitis with interstitial and intra alveolar hemorrhage is the commonest cause of death in leptospirosis with case fatality rate of 0%-15%.
- Cardiovascular: Arrhythmias present with syncope and palpitations.
- Nervous system: Meningitis, encephalitis, focal defecits, spasticity, paralysis, peripheral neuropathies, nerve palsies and radiculopathies.
Complications
Complications of leptospirosis are associated with localization of pathogen (Leptospires) within the tissues during the immune phase, eventually present during the second week of the illness.
Life threatening complications
- Acute kidney injury
- Disseminated intravascular coagulation
- Gastrointestinal hemorrhage
- Hemorrhagic shock
Common Complications
- Pulmonary: Pulmonary hemorrhage[7]
- Hematological: Thrombocytopenic purpura, Disseminated intravascular coagulation.
- Neurological: Mild meningitis, encephalitis, radiculopathies, transverse myelitis, cranial nerve palsies and Guillain-Barre syndrome.[4]
- Cardiac: Myocarditis, pericarditis[8][9]
- Conduction abnormalities: First degree atrioventricular block, widespread T-wave inversion[9][10]
- Rhythm abnormalities: Atrial fibrillation.
- Renal: Myositis → Rhabdomyolysis → Interstitial nephritis → Renal failure
- Pregnancy: Miscarriages, active leptospirosis in fetus[11][12]
Less Common Complications
- Cerebrovascular accidents
- Rhabdomyolysis
- Acute acalculous cholecystitis
- Erythema nodosum
- Aortic stenosis
- Kawasaki syndrome
- Reactive arthritis
- Epididymitis
- Nerve palsy
- Male hypogonadism
Prognosis
The prognosis of leptospirosis depends upon several known and unknown factors, among which the type of pathogenic serovar and the host’s immune status are the important factors which determines the outcome.[1] Most patients recover completely from leptospirosis, but the duration of recovery varies from months to years with or without late sequelae. The late sequelae may include neuropsychiatric problems such as paresis, paralysis, mood swings and depression etc. The major causes of death include renal failure, cardiopulmonary failure, and haemorrhage. Patients with risk factors such as old age and multiple underlying co-morbid conditions are often associated with more severe leptospirosis and increased mortality.
References
- ↑ 1.0 1.1 Levett PN (2001). "Leptospirosis". Clin Microbiol Rev. 14 (2): 296–326. doi:10.1128/CMR.14.2.296-326.2001. PMC 88975. PMID 11292640.
- ↑ Heuter, Kerry J.,Langston, Cathy E. (2003). "Leptospirosis: A re-emerging zoonotic disease". The Veterinary Clinics of North America. 33: 791–807.
- ↑ Vieira ML, Gama-Simões MJ, Collares-Pereira M (2006). "Human leptospirosis in Portugal: A retrospective study of eighteen years". Int J Infect Dis. 10 (5): 378–86. doi:10.1016/j.ijid.2005.07.006. PMID 16600656.
- ↑ 4.0 4.1 Bal AM (2005). "Unusual clinical manifestations of leptospirosis". J Postgrad Med. 51 (3): 179–83. PMID 16333189.
- ↑ Forbes AE, Zochowski WJ, Dubrey SW, Sivaprakasam V (2012). "Leptospirosis and Weil's disease in the UK". QJM. 105 (12): 1151–62. doi:10.1093/qjmed/hcs145. PMID 22843698.
- ↑ Katz AR, Ansdell VE, Effler PV, Middleton CR, Sasaki DM (2001). "Assessment of the clinical presentation and treatment of 353 cases of laboratory-confirmed leptospirosis in Hawaii, 1974-1998". Clin Infect Dis. 33 (11): 1834–41. doi:10.1086/324084. PMID 11692294.
- ↑ Salkade HP, Divate S, Deshpande JR, Kawishwar V, Chaturvedi R, Kandalkar BM; et al. (2005). "A study of sutopsy findings in 62 cases of leptospirosis in a metropolitan city in India". J Postgrad Med. 51 (3): 169–73. PMID 16333187.
- ↑ Watt G, Padre LP, Tuazon M, Calubaquib C (1990). "Skeletal and cardiac muscle involvement in severe, late leptospirosis". J Infect Dis. 162 (1): 266–9. PMID 2355200.
- ↑ 9.0 9.1 Chakurkar G, Vaideeswar P, Pandit SP, Divate SA (2008). "Cardiovascular lesions in leptospirosis: an autopsy study". J Infect. 56 (3): 197–203. doi:10.1016/j.jinf.2007.12.007. PMID 18262280.
- ↑ Parsons M (1965). "Electrocardiographic Changes in Leptospirosis". Br Med J. 2 (5455): 201–3. PMC 1846500. PMID 20790602.
- ↑ Shaked Y, Shpilberg O, Samra D, Samra Y (1993). "Leptospirosis in pregnancy and its effect on the fetus: case report and review". Clin Infect Dis. 17 (2): 241–3. PMID 8399874.
- ↑ Carles G, Montoya E, Joly F, Peneau C (1995). "[Leptospirosis and pregnancy. Eleven cases in French Guyana]". J Gynecol Obstet Biol Reprod (Paris). 24 (4): 418–21. PMID 7650320.