Leptospirosis 2010

Question 1

What clinical manifestations should alert a health practitioner to suspect leptospirosis among patients presenting with acute fever?

Answer 1

Any individual presenting with acute febrile illness of at least 2 days AND either residing in a flooded area or has high-risk exposure (defined as wading in floods and contaminated water, contact with animal fluids, swimming in flood water or ingestion of contaminated water with or without cuts or wounds) AND presenting with at least two of the following symptoms: myalgia, calf tenderness, conjunctival suffusion, chills, abdominal pain, headache, jaundice, or oliguria should be considered a suspected leptospirosis case. [Grade A]

Question 2

presenting with at least two of the following symptoms:

Answer 2

myalgia, calf tenderness, conjunctival suffusion, chills, abdominal pain, headache, jaundice, or oliguria should be considered a suspected leptospirosis case.

Question 3

mortality may be as high as

Answer 3

15%.

Question 4

Who should be admitted

Answer 4

MODERATE – SEVERE LEPTOSPIROSIS and BEST managed in a HEALTHCARE / HOSPITAL SETTING. [Grade A]

Question 5

incubation period of leptospirosis may range from

Answer 5

2 to 28 days.

Question 6

(most commonly pulmonary) severe manifestation

Answer 6

hemorrhage

Question 7

Weil’s disease is characterized by a triad of

Answer 7

fever, jaundice, and splenomegaly.

Question 8

remains the GOLD standard BUT is time-consuming,
labor-intensive, requires 6 to 8 weeks for the result

Answer 8

Culture and isolation

Question 9

has the advantage of early confirmation of the diagnosis especially during the acute leptospiremic phase (first week of illness) before the appearance of antibodies.

Answer 9

Polymerase Chain Reaction (PCR)

Question 10

a four-fold rise of the titer from acute to
convalescent sera is confirmatory of the diagnosis.

Answer 10

Microagglutination Test (MAT) -

Question 11

LAATS (Leptospira Antigen- Antibody Agglutination Test (Leptospira Serology Bio-Rad)

Answer 11

This is used as a screening test but is NOT sensitive.
A positive result should be confirmed with MAT.

Question 12

occurs during the first stage of the disease, beginning before the onset of symptoms, and ends by the first week of the illness. Thus blood cultures should be taken as soon as possible after the patient’s presentation and before antibiotics.

Answer 12

Leptospiremia

Question 13

Ideal time of collection for Blood with heparin (to prevent clotting)

Answer 13

First 10 days

Question 14

Ideal time of collection for Clotted blood or serum for serology

Answer 14

Collected twice at an interval of several days

Question 15

Ideal time of collection Urine for culture

Answer 15

Inoculated into an appropriate culture medium not more than 2 hours after voiding

Question 16

Ideal time of collection
Fo Cerebrospinal fluid and dialysate for culture

Answer 16

First week of illness

Question 17

IgM antibodies become detectable during the _____ allowing the diagnosis to be confirmed and treatment initiated while it is likely to be most effective

Answer 17

first week of illness

Question 18

For mild leptospirosis, ____ is the drug of choice.

Answer 18

doxycycline 100mg bid (hydrochloride, hyclate)

Alternative drugs include amoxicillin and azithromycin dihydrate. [Grade B]

Question 19

For moderate-severe leptospirosis, _____ remains the drug of choice.

Answer 19

penicillin G 1.5 MU q6-8hrs

Alternative drugs include parenteral ampicillin, 3rd generation cephalosporin (cefotaxime, ceftriaxone), and parenteral azithromycin dihydrate. [Grade A]

Question 20

The recommended regimen for pre-exposure prophylaxis for non-pregnant, non-lactating adults is:

Answer 20

Doxycycline (hydrochloride and hyclate) 200 mg once weekly, to begin 1 to 2 days before exposure and continued throughout the period of exposure [Grade B]

Question 21

Post-exposure prophylaxis for LOW-RISK EXPOSURE is defined as those individuals with a single history of wading in flood or contaminated water without wounds, cuts or open lesions of the skin.

Answer 21

Doxycycline 200 mg single dose within 24 to 72 hours from exposure [Grade B]

Question 22

Post-exposure prophylaxis for MODERATE-RISK EXPOSURE is defined as those individuals with a single history of wading in flood or contaminated water and the presence of wounds, cuts, or open lesions of the skin, OR accidental ingestion of contaminated water.

Answer 22

Doxycycline 200 mg once daily for 3-5 days to be started immediately within 24 to 72 hours from exposure6 [Grade C]

Question 23

Post-exposure prophylaxis for HIGH-RISK EXPOSURE is defined as those individuals with continuous exposure (those having more than a single exposure or several days such as those residing in flooded areas, rescuers and relief workers) of wading in flood or contaminated water with or without wounds, cuts or open lesions of the skin. Swimming in flooded waters especially in urban areas infested with domestic/sewer rats and ingestion of contaminated water are also considered high risk exposures.

Answer 23

Doxycycline 200 mg once weekly until the end of exposure [Grade B]

Question 24

underlying pathology in renal leptospirosis is a combination of

Answer 24

acute tubular damage and tubule-interstitial nephritis.

Question 25

What are the recommended laboratory tests for AKI?

Answer 25

Creatinine, sodium, potassium, urinalysis and chest x-ray, urine or serum neutrophil gelatinase-associated lipocalin (NGAL), are recommended.

Question 26

What are the clinical features of AKI due to leptospirosis?

Answer 26

The features may span from mild proteinuria to severe anuric acute renal failure. Commonly it may present as non-oliguric renal failure with mild hypokalemia. Oliguria with hyperkalemia may reflect the severity of AKI and may connote poor prognosis.

Question 27

Urine or serum NGAL (if available) will increase in ATN ahead of serum creatinine by at least ____ and will help differentiate ATN from pre-renal azotemia

Answer 27

two days

Question 28

What is oliguria and what are the predictors of oliguric AKI

Answer 28

Oliguria is defined as urine output < 0.5 mL/kg/hr or <400mL/day or a self report of decreased or no urine output within the last 12 hours

Question 29

What are the symptoms and signs of hypovolemia?

Answer 29

a. Thirst
b. Dry mucosal membranes and axillae
c. Poor skin turgor especially over the sternum

Question 30

What intravenous fluids should be used for hypovolemic patients?

Answer 30

Plain NSS with K+ incorporation to Maintain serum K+ at 4meq/L.

Question 31

What are the indications for acute renal replacement therapy or dialysis?

Answer 31

Any one of the following is an indication for dialysis : [Grade A]
a. Uremic symptoms – Nausea, vomiting, altered mental status,
seizure, coma
b. Serum creatinine > 3mg /dL
c. Serum K > 5 meq /L in an oliguric patient
d. ARDS, pulmonary hemorrhage
e. pH < 7.2
f. Fluid overload
g. Oliguria despite measures following the algorithm

Question 32

5. What dialysis modality should be used?

Answer 32

Hemodialysis (including its variants) and hemofiltration are preferred over peritoneal dialysis. The latter is a valid option if hemodialysis is not readily available. [Grade A]

Question 33

How frequent should the dialysis be?

Answer 33

Daily dialysis should be done for critically ill patients, especially in those with pulmonary involvement. [Grade B]

Question 34

When would you suspect pulmonary complications of Leptospirosis?

Answer 34

Tachypnea (Respiratory Rate > 30/min) is the first sign of pulmonary involvement in most cases. One should consider lung involvement with the onset of cough, hemoptysis or dyspnea in a patient with a clinical diagnosis of leptospirosis. Pulmonary symptoms usually appear between the 4th and 6th day of disease.8

Question 35

What are the pulmonary complications that can develop in leptospirosis?

Answer 35

Pulmonary hemorrhage and Acute Respiratory Distress Syndrome (ARDS) are the two most common pulmonary complications of leptospirosis. They are usually associated with worse prognosis and high mortality.

Question 36

What is the role of steroids in pulmonary complications in leptospirosis?

Answer 36

Bolus methyl prednisolone given within the first 12 hours of onset of respiratory involvement is life saving in pulmonary leptospirosis, more so in severe disease. It also reduces or delays the need for ventilator support.
• Methylprednisolone should be given at a dose of 1gm IV/day for 3 days followed by oral Prednisolone 1 mg/kg/day for 7 days [Grade C]

Question 37

Which patients will need admission to the intensive care unit?

Answer 37

management-oriented approach based on the patient’s clinical presentation/condition, status of any co-morbid condition, chest x-ray and arterial blood gas or oximetry findings should be utilized in the decision to determine the site of care for patients.

Question 38

Which patients will need admission to the intensive care unit?

Answer 38

Patients who present with tachypnea, chest x-ray findings of localized or multilobar infiltrates or pleural effusion and who develop moderate to severe hypoxemia need to be admitted to the intensive care unit for closer monitoring and/or invasive ventilation.

Question 39

In Weil’s syndrome, prothrombin time may be prolonged yet is remedied by administration of

Answer 39

vitamin K.

Question 40

The most common radiologic picture is that of a _____ corresponding to scattered alveolar hemorrhage.
Such abnormalities frequently affects the ____ in the periphery of the lung fields.

Answer 40

patchy alveolar pattern

lower lobes

Question 41

have been reported in patients with leptospirosis treated with penicillin.1

Answer 41

Jarisch-Herxheimer reactions

Question 42

phase that lasts about a week, usually characterized by fever of sudden onset, chills, severe myalgia, anorexia, conjunctival suffusion, nausea, vomiting, and prostration

Answer 42

septicemic (leptospiremic)

Question 43

After a 3- to 4-day period of relative improvement, illness may recur in the ____ phase, when leptospires cannot be cultured from blood and antibiotic therapy does not appear useful.

Answer 43

immune

Question 44

is often the first sign of pulmonary involvement, patients with a respiratory rate of >30 breaths/minute should be monitored closely as patients with pulmonary involvement have higher mortality.

Answer 44

tachypnea

Question 45

given within the first 12 hours of onset of respiratory involvement is life saving in pulmonary leptospirosis, more so in severe disease. It also reduces or delays the need for ventilator support.

Answer 45

Bolus methyl prednisolone

Methylprednisolone should be given at a dose of 1gm IV/day for 3 days followed by oral Prednisolone 1 mg/kg/day for 7 days