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 Table of Contents  
ORIGINAL ARTICLE
Year : 2012  |  Volume : 2  |  Issue : 1  |  Page : 30-37

Clinical profile and outcome of leptospirosis at tertiary care centre in western Maharashtra


1 Department of Medicine, Krishna Institute of Medical Sciences, Karad, Satara, Maharashtra, India
2 Department of Microbiology, Krishna Institute of Medical Sciences, Karad, Satara, Maharashtra, India

Date of Web Publication3-Dec-2012

Correspondence Address:
Harsha V Patil
Department of Microbiology, Krishna Institute of Medical Sciences, Karad - 415 110, Dist. Satara, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4855.104013

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  Abstract 

Background: Leptospirosis is an emerging spirochetal zoonosis world wide. Leptospirosis is common zoonosis that is under reported and under diagnosed in India. The aim of this study was to study the clinical profile outcome and prognostic factors in human leptospirosis at tertiary care centre.
Settings and Design: This was a retrospective study of leptospira positive patients who were admitted in tertiary care centre. The study was conducted in 2010, over a period of 6 month from July to December.
Materials and Methods: All patients who presented with clinical features and tested IgM positive for leptospirosis were taken into the study and analyzed based on modified Faine's criteria.
Results: Out of total 23 patients there were 21 males and 2 females, with mean age was 32 years. Maximum incidence of cases was found in month of July and August. Out of total 23 patients, 18 (78.26%) were farmers and 5 (21.73%) were laborers. Predominant complaints were fever, jaundice, myalgia, and headache. All 23 had positive results for IgM against leptospira. Liver function tests were deranged in 16 (69.56%) and renal functions were deranged in 12 (52.17%). Total 7 (30.43%) patients had Weil's syndrome and 7 (30.43%) had acute respiratory distress syndrome (ARDS). Total 7 (30.43%) patients had neuroleptospirosis, out of which 5 (21.73%) had aseptic meningitis, one had paraparesis secondary to lumbar radiculopathy and one had meningoencephalitis. Hyperkalemia was present in 6 (26.08%) patients, 7 (30.43%) patients had hypokalemia. Total 11 (47.82%) patients had metabolic acidosis (pH<7.3) on arterial blood gas analysis. Two (8.69%) patients had disseminated intravascular coagulation and 3 (13.04%) patients had thrombocytopenia. There was one death due to meningoencephalitis with multiorgan failure with overall case fatality rate of 4.34%. Total nine patients with oliguric renal failure were treated with daily dialysis and seven patients with ARDS were on artificial ventilator. Applying modified Faine's criteria, all 23 were positive for leptospirosis. All patients responded ceftriaxone.
Conclusions: Leptospirosis was unexpectedly found to be positive in many of our patients who were having pyrexia with multiorgan dysfunction during the monsoons. Hepatic dysfunction, acute renal failure, ARDS, and neuroleptospirosis in decreasing frequency were the commonest complication. Daily dialysis, ventilatory support and intensive care management has definitely reduced morbidity and mortality associated with leptospirosis with multi-organ failure.

Keywords: Acute oliguric renal failure, acute respiratory distress syndrome, leptospirosis, meningoencephalitis, Weil′s syndrome


How to cite this article:
Patil VC, Patil HV, Agrawal V. Clinical profile and outcome of leptospirosis at tertiary care centre in western Maharashtra. J Acad Med Sci 2012;2:30-7

How to cite this URL:
Patil VC, Patil HV, Agrawal V. Clinical profile and outcome of leptospirosis at tertiary care centre in western Maharashtra. J Acad Med Sci [serial online] 2012 [cited 2019 Dec 10];2:30-7. Available from: http://www.e-jams.org/text.asp?2012/2/1/30/104013


  Introduction Top


Leptospirosis is a worldwide public health problem. The magnitude of the problem in tropical and subtropical regions can be largely attributed to climatic and environmental conditions. There is also a greater likelihood of contact with a Leptospira-contaminated environment such as local agricultural practices and poor housing and waste disposal, all of which give rise to many sources of infection. Certain occupational groups such as agricultural laborers, sewage workers, animal handlers etc. constitute high risk groups. The disease is presently endemic and deeply entrenched in Gujarat, Maharashtra, Karnataka, Kerala, Tamil Nadu, and Andaman and Nicobar Islands. High risk areas include Goa, Andhra Pradesh, Orissa and West Bengal. [1] Despite this knowledge, the information about the existing status of the disease in the country is lacking and we do not have an accurate estimate of disease burden in the country. [2] Probably the disease is underreported in humans. All available evidences suggest that the Leptospirosis is now emerging in India as an important public health problem. [3] Hyperbilirubinemia is the most frequently noted laboratory abnormality followed by oliguric renal failure. Meningoencephalitis, jaundice, pulmonary hemorrhage, disseminated intravascular coagulation (DIC), and renal failure are considered as bad prognostic factors with high mortality rate. [4]

The disease has also been a diagnostic enigma for the microbiology laboratories across the country. Since isolation rate of the causative organism from clinical specimens is low due to prior indiscriminate use of antibiotics and also difficult and expensive isolation techniques, currently, serological techniques remain the cornerstone of diagnostics. [5] The aim of this study was to study the clinical profile, outcome, and prognostic factors in human leptospirosis in western Maharashtra. We included 23 febrile patients with clinical features and ELISA IgM positive for leptospirosis during the monsoon and postmonsoon period.


  Materials and Methods Top


This was a retrospective, observational study conducted at Krishna Institute of Medical Sciences, Karad that is one of the tertiary referral institute. This study is approved by ethical committee KIMS Karad. Patients with age more than 18 were included in this study presenting with febrile illness and proven on investigations to be ELISA IgM positive for leptospirosis between July to December 2010. Patients with febrile illness presenting with hepatorenal failure, electrolyte disturbance, neurological features, and ARDS explained by other etiology other than leptospirosis by doing relevant investigations were excluded from this study. Associated co-infection with dengue and or malaria was excluded from this study.

Their presenting complaints, age, sex, address, duration of pyrexia, degree of temperature rise, conjunctival suffusion, headache, meningismus, myalgias, jaundice, contact with animals or flood water, and titre of IgM positivity were recorded. Patients with leptospirosis were diagnosed by using modified Faine's criteria (score >25). [6] Clinical examination and laboratory findings were recorded and were analyzed using simple statistical methods. All patients were received injection ceftriaxone, supportive care including intravenous fluid infusion, blood component transfusions, vasopressors, dialysis, respiratory support, administration of other medications was provided according to prospectively designed indications and regimens. Patient characteristics, symptoms, and physical findings were recorded at hospital admission by use of standardized sheets. Vital signs were measured every 1-4 h. In addition, urinalysis, chest radiography, biochemical, and hematological tests were performed at admission. Additional laboratory tests were performed as necessary for patient management. The severity of the disease in the first 24 h of hospitalization was assessed by using the modified APACHE II (acute physiology and chronic health evaluation) scoring system with arterial oxygen pressure. [7] Enzyme Immuno-Assay for IgM with value > 20.0 U/mL was considered as positive for leptospirosis. [3]

Statistical analysis done for numerical parameters in the form of mean, percentage standard deviation and correlation by using Microsoft XL spread sheet.

Diagnostic criteria for the organ dysfunction. [7]

  1. Acute renal failure was defined by the presence of the serum creatinine level of >1.5 mg/dL
  2. Oliguria was defined by the presence of a first 24-h urine volume of <400 mL
  3. Pulmonary hemorrhage was defined as frank blood from endotracheal tube with ≥2 of the following characteristics: decrease in the hematocrit of >3% without another explainable source of bleeding, no clinical signs of volume overload (jugular venous pulsation of <5 cm above the sternal angle or central venous pressure of <12 cm), and a chest radiograph revealing unilateral or bilateral alveolar infiltration with normal cardiothoracic ratio
  4. Acute respiratory distress syndrome was defined by the presence of all of the following criteria: no clinical signs of congestive heart failure; arterial gas exchange index of partial pressure of oxygen/fraction of inspired oxygen of <200; a chest radiograph revealing diffuse alveolar process with normal cardiothoracic ratio
  5. Significant jaundice was defined as frank icteric sclera or a total serum bilirubin level of 1.2 mg/dL
  6. Hypotension was defined as a mean arterial blood pressure of <70 mm Hg and the need for vasopressors to maintain blood pressure.

  Results Top


Demographic and Epidemiological Features

A total 23 patients were diagnosed positive for leptospirosis from July to December 2010. Out of total 23 patients 21 (91.30%) were male and 2 (8.6%) were female. Age was from 18-60 years with mean age of 32 years. Total 4 (17.39%) cases were in the month of July, 5 (21.73%) in August, 6 (26.08) in September, 4 (17.39%) in October, 3(13.04%) in November and one (4.34%) in December 2010. Maximum incidence of cases was found in month of July and August. Out of total 23 patients, 18 (78.26%) were farmers and 5 (21.73%) were laborers. There was positive history of contact with animals, rainfall and contaminated environment in 22 (95.65%) patients.

Clinical Profile

Fever was the universal presenting feature in all 23 patients of which 16 (69.56%) had mild to moderate grade fever and 7 (30.43%) had high grade fever. Clinically icterus was present in 16 (69.56%) patients. Conjunctival suffusion was seen in 11 (47.82%) patients. Meningism was found in 4 (17.39%), headache in 12 (52.17%) and vomiting in 8 (34.78%) patients. Myalgia was present in 16 (69.56%). Oliguria was seen in 9 (39.13%), hypotension in 5 (21.73%) and loose motions in 5 patients (21.73%). Three (13.04%) patients had nonoliguric renal failure, breathlessness in 9 (39.13%) and hemoptysis in 5(21.73%) patients. Paraparesis was presenting feature in one patient. Total 16 (69.56%) patients were admitted under intensive care unit and 7 (30.43%) were admitted in general ward. Mean of starting of symptoms and medical treatment of 16 patients was 5.5 days and of 7 was 3.5 days [Table 1].
Table 1: Clinical profile of leptospirosis

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Laboratory Profile

All 23 patients were positive for leptospira by Enzyme Immuno-Assay for IgM with mean titer of 57.89 unit/mL (Negative <15.0; Indeterminate 15.0-20.0; Positive > 20.0 U/mL). There was Leucocytosis in all patients and mean TLC was 13 500/cm. Thrombocytopenia was observed in 3 (13.04%) patients. Renal function tests were deranged in 12 (52.17%) patients (serum creatinine >1.5 mL). The liver function tests were deranged (total bilirubin >1.2 mL/dL.) in 19 (82.60%) patients with total bilirubin more than 15 mL was seen in two patients. Hyperkalemia (>6.5 meq/L) was present in 6 (26.08%) patients out of which one patient had life threatening ventricular tachycardia. Total 7 (30.43%) patients had hypokalemia (<3.5 meq/L). Hyponatremia (<135 meq/L) was seen in 3 (13.04%) patients. Total 11 (47.82%) patients had metabolic acidosis (pH<7.3) on arterial blood gas analysis. Mean and standard deviation of laboratory parameters [Table 2]. Total 9 (39.13%) patients had bilateral infiltrate on chest radiogram [Figure 1]. Cerebrospinal fluid study was suggestive of aseptic meningitis in 5 (21.73%) patients with lymphocytic predominance. Creatinine phosphokinase enzyme (CPK) was raised in 6 (26.08%) patients. One patient had cerebral edema on computerized tomography. One patient had mild papilledema on fundoscopy. Two (8.69%) patients had picture of DIC with positive fibrinogen degradated products (FDP) and thrombocytopenia. On urine examination 15 (65.21%) patients had albuminuria. Using modified Faine's criteria all 23 patients were positive with a score of >25 (Clinical Data+ Epidemiological factors+ Bacteriological and Lab Findings). [6]
Figure 1: Chest radiograph showing bilateral alveolar pulmonary infiltration in a patient with leptospirosis (pulmonary hemorrhage)

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Table 2: Mean and standard deviation of laboratory parameters

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Clinical Presentations and Complications

Total 9 (39.13%) patient required hemodialysis for acute oliguric renal failure. Out of nine patients with oliguric renal failure 7 (30.43%) were with jaundice and 2 (8.6%) were without jaundice. Three (13.04%) patients had acute nonoliguric renal failure. Out of 23 patients 7 (30.43%) patient required artificial ventilation that had diffuse bilateral pulmonary infiltrate, pulmonary hemorrhage and ARDS. Total 16 (69.56%) patient had jaundice of which 2 (8.69%) had total hyperbilirubinemia with total bilirubin was more than 15 mL and developed hepatic encephalopathy. Two patients landed up into the DIC and treated conservatively. Three (13.04%) patients had severe thrombocytopenia which was treated with (single donor platelets) SDP and supportive line of treatment. One patient developed deep venous thrombosis because of prolonged bedridden, paraparesis and ventilator for 12 days. DVT was treated with LMWH [Table 3] and [Table 4].
Table 3: Clinical presentation and complications associated with leptospirosis

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Table 4: Presentation of leptospirosis according to organ dysfunction

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Total 7 (30.43%) patients developed Weil's syndrome. Total 7 (30.43%) patients had neuroleptospirosis, out of which 5 (21.73%) had aseptic meningitis, one had paraparesis secondary to lumbar radiculopathy and one had meningoencephalitis. Aseptic meningitis was documented by clinical features and CSF studies with predominant lymphocytosis. Patient presented with paraparesis had normal MRI spine and brain study with evidence of lumbar radiculopathy on nerve conduction velocity study. One patient who presented with meningoencephalitis had hyperbilirubinemia (17 mL/dL) DIC (thrombocytopenia, positive fibrinogen degradated products), oliguric acute renal failure (serum creatinine: 7.2 mg/dL) and ARDS for which he was on artificial ventilator and hemodialysis. In spite of all intensive critical care management patient succumbed after 48 hours of admission. Patients with hyponatremia, hypokalemia, and hyperkalemia were treated by correction of respective electrolyte by standard protocol. One patient developed sustained ventricular tachycardia with hyperkalemia (serum potassium 7.2 meq/L) that was treated with cardiovesion and correction of hyperkalemia by glucose insulin drip and hemodialysis [Figure 2]. Graph showing clinical syndrome and complications associated with leptospirosis is shown in [Figure 3].
Figure 2: ECG showing tall tented 'T' waves with loss of 'P' wave with broad 'QRS' complexes and sine wave pattern of hyperkalemia

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Figure 3: Clinical syndrome and complications of leptospirosis

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A total 23 patients 22 (95.65%) were recovered clinically and laboratory investigation wise. One patient succumbed within 48 h who presented with meningoencephalitis, hemoptysis, oliguric renal failure, jaundice, and ARDS. The overall case fatality rate for this population was 4.34%

All the patients were received Ceftriaxone for treating leptospirosis. All patients received supportive line of treatment depending on the clinical presentation and associated complication. The severity of the disease in the first 24 h of hospitalization was assessed using the modified APACHE II scoring system with arterial oxygen pressure. Out of total 23 patients 7 patients were managed in general ward with no severe hepato-renal or pulmonary complications and were discharged on the eighth day after admission. Total 16 patients were admitted in intensive care unit with average duration of stay was 17 days. Mean of number of dialysis cycle done for total nine patients with oliguric ARF was eight cycles per patient. Mean duration of ventilator support was 6.5 days. Out of 16 patients admitted in ICU, three (13.04%) have developed central venous catheter associated infection, two (8.69%) have developed urinary tract infection, and one (4.34%) has developed ventilator associated pneumonia (VAP).

The APACHE score was calculated in initial 24 h of admission in16 (69.56%) patient admitted under the intensive care unit. The mean APACHE score was 25 (±4) in 7 (30.43%) patient, 40 (±5) in 8 (34.78%) patient and 52 in one patient.


  Discussion Top


Leptospirosis has protean clinical manifestations. It is classically presents as a biphasic illness both icteric and anicteric form of leptospirosis. The clinical manifestations of leptospirosis ranging from inapparent infection to fulminant disease. The first phase of the disease is commonly referred to as the septicemic phase. It is characterized by fever, headache, myalgia, conjunctival congestion, and a host of nonspecific features that may include mild cough, lymphadenopathy, rash, anorexia, nausea, and vomiting with history of contact with animals are pointers suggestive of leptospirosis. This phase is followed by a brief afebrile period of variable duration that, in turn, is followed by the immune phase of illness. The common organs involved during this phase are the liver, kidneys, and lung. These organ derangements are reversible. [2],[3] The severe form of leptospirosis, also known as Weil's disease, is characterized by a fulminant course with rapid onset of hepatic and renal failure and high mortality. In an endemic area, leptospirosis is often confused with dengue fever and malaria due to the similarities of clinical features. Pulmonary manifestations may mimic like swine flu (H1N1). Therapy should be initiated on the basis of clinical judgment, as laboratory confirmation can be delayed by days and weeks or is unavailable in several regions and early institution of appropriate therapy is known to reduce mortality. In Maharashtra, the serovars isolated were mainly L. icterohemorrhagiae (rats), L. canicola (canines), and L. australis (cattle). In this study, lepto specific IgM antibody was used to establish the diagnosis in the presence of appropriate clinical setting. [4]

Pulmonary manifestations characterized by short course of illness, dyspnoea, chest pain, hemoptysis, and ARDS is a severe complication, which worsens rapidly resulting in death. Other manifestations include those of cardiovascular involvement characterized by ECG abnormalities, arrhythmias, and vasomotor collapse and CNS manifestations, particularly meningo-encephalitis. Myositis characterized by severe myalgia and raised CPK and SGOT is a common manifestation in leptospirosis. Neutrophilic leukocytosis, raised bilirubin, alkaline phosphatase and transaminases, prerenal azotemia, and hypokalemia are laboratory pointers of leptospirosis. A statistically significant reduction in platelet count is seen in fatal cases of leptospirosis. Hyperkalemia, meningism, oliguria, hemoptysis, hyperbilirubinemia above 15 mg%, disorientation, tachycardia, tachypnoea, and muscle tenderness were found to be predictors of mortality. [5]

Common presentations in neuroleptospirosis are asymptomatic meningitis and encephalitis. The other presentations are myeloradiculopathy, myelopathy, Guillain-Barré syndrome-like presentation, meningoencephalitis, intracerebral bleed, cerebellar dysfunction, iridocyclitis, and tremor/rigidity. Paraparesis due to myelitis or radiculopathy is very rare.

The clinical spectrum of renal manifestations are determined by virulence of leptospires, bacterial load and the host defense and varies from subclinical to severe ARF. In the subclinical form patient would have mild proteinuria, sediment, and mild tubular dysfunction. ARF occurs in 10-67% of the cases and are mainly nonoliguric. The prognosis of ARF in leptospirosis is favorable if treated well in time unless complicated by multiorgan failure. The bad prognostic signs are pulmonary complications, hyperbilirubinemia, oligouria, and hyperkalemia, ARF with two or more organ systemic failure and association with pregnancy or other infections. Mortality varies from 12-36%. The differential diagnosis of leptospirosis should include dengue hemorrhagic fever, hanta virus infection, malarial ARF, and bacterial sepsis with jaundice and ARF. [2],[6]

In this study, we have used modified Faine criteria for leptospirosis as the cases of Leptospirosis are reported in the monsoon and post Monsoon seasons. Therefore, factors such as rainfall and contact with contaminated environment have been incorporated with appropriate scores. Laboratory tests are very essential for diagnosis of Leptospirosis. ELISA IgM is simple, sensitive tests and can be used to diagnose current Leptospirosis. Microscopic agglutination tests (MAT) is the Gold standard test, but it is complicated and less sensitive compared to ELISA and SAT. The difficulties in utilizing MAT are due to the antibody titers rise and peak only in 2 nd or 3 rd week, making it a less sensitive test. The high titers of past infection persist for a long time (1-5years) and therefore interfere with the diagnosis of current leptospirosis. [6]

Results of present study cannot be exactly compared with other because of difference in the economic, social, environmental, epidemiological, heathcare facilities, community awareness, rainfall factors, different serovar of leptospira etc.

In present study out of total 23 patients 7 (30.43%) developed Weil's syndrome. Total 12 (52.17%) patients had acute renal failure. Total 7(30.43%) patients had neuroleptospirosis and 7 (30.43%) patient had pulmonary hemorrhage and ARDS. Total 16 (69.56%) patient had jaundice out of which 2 (8.69%) had total hyperbilirubinemia with total bilirubin was more than 15 mL and developed hepatic encephalopathy. Total 12 (52.17%) patients had acute renal failure. One patient succumbed with case fatality rate was 4.34%. The results of present study are comparable with study by Sethi S et al.[2] in their study of 86 cases of leptospirosis renal failure (60.5%), respiratory failure (20.9%), the neuroleptospirosis (11.6%), and disseminated intravascular coagulation (DIC) (11.6%) were the commonest complications with case fatality rate of 5.9%. In this study there is more prevalence of presentation with two or more organ dysfunction. This could be because of study conducted in tertiary referral centre.

Mortality coated by Chawla et al.[8] in leptospirosis patients was 52% that was much higher compared to our study; this could be delay in patients presentation, associated complication, co-morbidities, and different serovar causing leptospirosis. The poor prognostic factors in their study were male sex, alcohol dependence, age group >50 years, MODS, acute respiratory distress syndrome (ARDS), presence of acidosis, and need for mechanical ventilation.

Niwattayakul et al.[9] observed in 148 positive cases of leptospirosis that normal blood pressure at the time of admission associated with less hepato-renal and pulmonary complication; this is comparable with our study. Similar to the finding in this study, Ramachandran et al.[10] stated that a vasculotoxic or hemorrhagic state and oliguric acute renal failure are important causes for mortality in human leptospiral infections.

Seguro et al.[11] reported higher frequency of nonoliguric renal failure with lower morbidity and mortality rates with 45% of the patients were hypokalemic, and no hyperkalemic patients were seen. This is in contrast to the present study where more patients were with oliguric renal failure and more hyperkalemia; the possible reason could be only complicated cases that were referred to the tertiary care centre. Similarly Andrade et al.[12] stated that acute kidney injury typically is nonoliguric and includes hypokalemia. The tubular function alterations precede a decrease in the glomerular filtration rate, which could explain the high frequency of hypokalemia in leptospirosis with renal involvement. In comparison with our study, we had 6 (26.08%) patients with hyperkalemia out of which one patient had life threatening ventricular tachycardia. Total 7 (30.43%) patients had hypokalemia. This can be possible due to delay in presentation, anuria at the time of admission, and different epidemiological scenario including serovar in our population.

Daher et al.[13] in their study concluded that, age >40 years, hyponatremia, elevated serum creatinine, low arterial pH, high levels of AST, crackles and direct bilirubin levels would be useful markers of patients with oliguric AKI in leptospirosis. This is comparable to our results. Panaphut et al.[14] in their study found that the presence of oliguria, hyperkalemia, pulmonary rales, or hypotension on admission in patients with leptospirosis indicated high risk of death. In Dupont et al.[15] 12 (18%) patients died and dyspnea, oliguria, white blood cell count, >12 900/mm 3 , repolarization abnormalities on electrocardiograms and alveolar infiltrates on chest radiographs were associated with high mortality. These findings are similar to this study. Tantitanawat et al.[16] in his study of 362 patients 67(18.50%) died with acute kidney injury and pulmonary complication. Paganin et al.[17] stated that the pulmonary manifestations in leptospirosis are related to a poor prognosis.

According to Abdulkader et al.[18] the mortality in patients with acute renal failure is approximately 15-20% in association with the presence of oliguria, higher levels of creatinine, and older age. Hurst et al.[19] found that the severe AKI (requiring dialysis) can complicate anicteric leptospirosis. These finding are comparable with our population as we had two patients with oliguric renal failure with normal bilirubin. Andrade et al.[20] stated that alternate-day hemodialysis is no longer appropriate for critically ill patients with Weil's disease. Similarly we treated all the seven patients with Weil's syndrome with daily dialysis.

In contrast to our study where we had Weil' syndrome (30.43%) and thrombocytopenia in 3 (13.04%) Pappachan et al.[5] in their study of 282 patient from Kerala, Weil syndrome was present in 69.8% and thrombocytopenia in 65.8%. Vijayachari et al.[21] in their study found that the hepato-renal form and the pulmonary form of leptospirosis is associated with high case fatality rates ranging from 10% to 15%. Tangkanakul et al.[22] coated the case fatality rate was as high as 4.4%, having a predominant association with male farmers aged 15 to 45 years, which is comparable to this study population case fatality rate of 4.34%. Ragnaud et al.[23] stated that the two patients died with acute respiratory failure and meningo-encephalitis with diffuse hemorrhagic syndrome. These findings are comparable with our study where there was one death due to meningoencephalitis with features of multiorgan failure.

In the study by Panicker et al.[24] paraparesis was the initial presentation in 17 patients. Three patients had a lower motor neuron paraparesis. Myelopathy was seen in seven patients, myeloradiculopathy in seven, and Guillain-Barré syndrome-like presentation in three. Similarly in our study we had 7 (30.43%) patients with neuroleptospirosis, out of which 5 (21.73%) had aseptic meningitis and one had paraparesis secondary to lumbar radiculopathy. Mathew et al.[25] in his pathological study of brain in five cases revealed encephalitic features and in addition immune-mediated acute disseminated encephalomyelitis (ADEM) like pathology in two cases. Deep altered sensorium at presentation and raised CSF protein were two poor prognostic indicators. Similarly we had one patient with acute demylinating encephalomyelitis (ADEM) who succumbed within 48 h of admission who had APACHE score of 52.

In this study total 12 (52.17%) patients had acute renal failure. Out of 12 patients 9 (39.13%) had oliguric renal failure that required hemodialysis and 3 (13.04%) patients had nonoliguric renal failure and were treated conservatively. Total 7 (30.43%) patient had Weil's disease, 7 (30.43%) patient had pulmonary complications requiring ventilator support. Hyperbilirubinemia (69.56%) was the commonest laboratory abnormality followed by renal dysfunction (52.17%). One patient developed sustained ventricular tachycardia with hyperkalemia (serum potassium 7.2 meq/L). Amongst neuroleptospirosis commonest presentation was with aseptic meningitis (21.73%). One patient with neuroleptospirosis was presented with meningoencephalitis and had hyperbilirubinemia (17 mL/dL) DIC, oligouric acute renal failure (serum creatinine: 7.2 mg/d:) and ARDS. Total 2 (8.69%) patients had DIC and 2 (8.69%) patients developed hepatic encephalopathy. Three (13.04%) patients had thrombocytopenia. APACHE score was < 25 in 7 patients, >25 in 7 (30.43%) patients, 40 in 8 (34.78%) patients and 52 in 1 patient. Patients with high score succumbed within 48 h of admission. The APACHE score was correlated with the mortality and outcome in our study population admitted under intensive care unit. The overall case fatality rate for this present study population was 4.34%. Multiple organ dysfunctions were noted in present population with fairly good outcome even with high the APACHE score. In this study, there was high prevalence of multiorgan dysfunction compared to uncomplicated leptospirosis.


  Conclusions Top


Leptospirosis is a re-emerging zoonosis of global importance and unique environmental and social correlations. During the first week of illness, the diagnosis of Leptospirosis has to be done only by clinical and epidemiological criteria. After modification of Faine's criteria it become very easy to diagnose leptospirosis as it includes IgM ELISA. In this study there is more prevalence of presentation with two or more organ dysfunction. Clinical manifestations and laboratory abnormalities were protean; severe complicated disease with renal or respiratory failure, neuroleptospirosis and DIC was also observed. Multiorgan dysfunction with leptospirosis carries high mortality however; timely intervention and intensive therapy can save many young lives. Realizing the epidemic potential of leptospirosis, laboratory facilities should be provided in the institution for the confirmatory tests. Leptospirosis was unexpectedly found to be positive in many of our patients who were having pyrexia with multi-organ dysfunction during the monsoons. Hepatic dysfunction, acute renal failure, ARDS and neuroleptospirosis in decreasing frequency were the commonest presentation requiring artificial ventilation, hemodialysis in this study. Intesive and early renal replacement therapy in the form of hemodialysis will definitely reduce the morbidity, mortality, and duration of hospital stay in leptospirosis with oliguric renal failure and multiorgan dysfunction. Leptospirosis is one of the reversible cause of acute renal failure and its early detection and timely management may significantly reduce morbidity and mortality. Pulmonary complications carries high morbidity and longer duration of intensive care management. The seroprevalence studies should be conducted at many centers. The study of possibility of co-infection especially with malaria and dengue is recommended. The physician awareness during mansoon and postmansoon period is equally important. Though the mortality with leptospirosis is high, timely intervention may reduce significant morbidity and mortality of working group population which are mainly affected with this disease.

 
  References Top

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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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1 Leptospirosis in Coastal South India: A Facility Based Study
Ramesh Holla,Bhagwan Darshan,Latika Pandey,Bhaskaran Unnikrishnan,Nithin Kumar,Rekha Thapar,Prasanna Mithra,Vaman Kulkarni
BioMed Research International. 2018; 2018: 1
[Pubmed] | [DOI]



 

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