Leptospirosis

Question 1

How does leptospirosis present?

Answer 1

Initially non-specific symptoms of fever, lethargy and may get gastrointestinal upset.
Most infections are self resolving but a small percentage (10%) progress to disease which needs treatment and/or organ support.

Typically complications include:

• AKI
• hepatitis and jaundice
• pulmonary involvement/pulmonary haemorrhage/ARDS
• Weil’s disease

Other complications include

• CNS - headaches, photophobia, meningitis
• GI - N&V, abdo pain, pancreatitis

Question 2

What are your differentials of someone presenting with jaundice and AKI?

Answer 2

Divided into pre-existing liver disease and non-preexisting liver disease.

Pre-existing liver disease:

• HRS
• SBP
• Any cause of AKI on CLD: NSAIDs, loop diuretics, ACEi, steroids, UTI, sepsis

No pre-existing liver disease:

• Viral infection: EBV, CMV, viral hepatitides, HIV
• bacterial infection/sepsis
• Fungal infection with hepatic toxicity from antifungals
• Autoimmune hepatitis
• obstructive biliary disease
• Extra luminal IBD complications
• Pregnancy
• vasculitis

Question 3

What is the recommended management for leptospirosis in critical care?

Answer 3

1. Resuscitate ABCDE approach, correcting abnormalities as they are found
2. Supportive care: Fluid resuscitation, renal support, ventilatory support.
3. Send microbiological cultures, urine, blood, sputum +/- CSF
4. IgM antibodies (present from day 7-10)
5. Antibiotics once confirmed:
   i) IV Penicillin G (oral doxycycline may be used in milder disease)
   ii) Amoxicillin and azithromycin used in pregnancy.
   iii) Often 3rd gen cephalosporins (ceftriaxone) used in ITU

Watch for Jarisch-Herxheimer reaction