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Mukesh sah, MD,JI
Virgen Milagrosa University Foundation
Leptospirosis case presentation
 C.R.
 18 yrs old
 Sitio Sagur Pugaro Suit Dagupan city
 Single
 Oct. 7, 1999
 Roman Catholic
 Admitted at R1MC for the first time
 Informant : Mother
 Realiability : 90 %
Chief complaint:
“3 DAY HISTORY OF FEVER”
1 WEEK HISTORY
3 days
DAY 1 ILLNES
• + undocumented fever, + myalgia, Headache
• + Abdominal pain, +Dec appetite and activity
• Took Paracetamol 2X, no consultation done
2 days
DAY 2 ILLNES
•+ persistence of above S/SX
•↓ urine output with yellow orange in color
•+ calf pain
1 WEEK HISTORY OF WADING TO FLOOD
1 day
•+ persistence of above S/SX
•LBM and vomiting
•Last urine output: 12noon < 1ml
Few hrs
•+ anuria
•+DOB
•Sought consult to R1MC
Review of Systems:
• General: (+) body weakness (-) weight loss (+) decrease appetite
(-) chills (-) fatigue
• Skin: (+) Jaundice (-) pallor (-) pruritus
(-) cyanosis (-) rashes (-) hematoma
• Head & neck:(-) nodules (-) stiffness (-) swelling
(-) pain (-) trauma (+) headache
(+) dizziness (-) lightheadedness (-) pain
• Eyes: (-) asymmetry (-) infection
(+) icteric sclera (-) itchiness (-) diplopia
(-)use of glass/lenses (-) lacrimation (-) blurred vision
• Ears: (-) hearing problem (-) itching
• Mouth & throat: (-) hoarseness (-) sore throat (-) dysphagia
• Respiratory: (-) cough (-) colds (-) dyspnea (-) cyanosis (-) hemoptysis
 Cardiac: (-) palpitation (-) chest pain (-) orthopnea (-) paroxysmal nocturnal
dyspnea (-) easy fatigability (-) edema
 GIT: (-) pain (-) anorexia (-) vomiting (-) melena (-)
constipation (-) excessive belching (-) bloated (-) loss of appetite (-) abdominal
pain(-) diarrhea
 Renal: (-) dysuria (-) hematuria (-) nocturia (-) incontinence (-)
polyuria (+) anuria (-) urgency (-) frequency (-) gross hematuria (-) tea-
colored urine
 Genitalia: (-) pain (-) swelling (-) discharge (-) infection
 Musculoskeletal: (-) stiffness (-) numbness (+) joint pain
(+) muscle pain (calf) (-) change in strength (-) backache
 Hematological: (-) pallor (-) hematoma (-) bleeding (-)
anemia
(-) easy bruising
 Endocrine: (-) weight loss (-) edema (-) polyuria (-)
polyphagia
(-) polydipsia (-) heat intolerance (-) cold intoleranc
(-) excessive sweating
 Past medical history:
EPI Completion
No pertinent childhood illnesses
No previous surgical interventions
 Family history:
No history of herediofamilial diseases
No history of TB, asthma, DM and cardiac disease.
 Personal and Social History:
Patient is staying with his father and 2
siblings in a Well- lit, well ventilated
bungalow wooden house with own pour-
flush toilet.
Garbage collected 2-3 times a week
Drinking water is tap water
No history of travel
H- The patient lives with his father with his 2
siblings (his parents are separated)
E- He stop schooling at Grade 10
A- He accompanies his father during fishing and
usually play basketball during free time.
D- No history of illegal drugs. Usually drinks SAN
MIG light with his friends and a smoker as well.
S- No sexual experience
S- No suicidal Ideation
 Awake, conscious, coherent, ambulatory, GCS
15, in cardiorespiratory distress with the
following vital signs:
 BP: 50/30
 PR: 98bpm
 CR: 85bpm
 Temp: 37C
 SKIN:
 Brown in complexion, no pallor, mild jaundice, no
lesions, normal skin turgor, multiple scars on bilateral
lower extremities
 HEENT:
 No areas of balding, no swelling, tenderness
 EYES: pale palpebral conjunctivae, icteric sclera,
conjunctival suffusion, no cataract, no asymmetry
 EARS: at level of lateral canthus of the eyes,
symmetrical, non-tender, with no erythema, no
discharges, no scaling
 NOSE: Nasal mucosa is pink, patent nares, non-
deviated septum and no Nasal discharge, non-
tendersinuses.
MOUTH: pinkish lips, Buccal mucosae is pink,
no ulcer, Dry lips
 CHEST AND LUNGS:Symmetrical chest wall
expansion,No intercostal or subcostal
retraction,no tenderness, normal resonant
breathing sound,
 Heart: Adynamic precordium, Apex beat at 5th
ICS left MCL, , (-) thrills, (-) loud and palpable
P2; normally split S2; (-) S3, (-) S4.normal rate.
(-) murmur, tachycardic.
Abdomen.
Inspection:, no scars, no spider angioma
Auscultation: hypoactive bowel sounds at 6 per minute.
Percussion: Tympanic, liver span 8 cm in right
midclavicular line, non palpable liver edge.
Palpation: (-) tenderness
Musculoskeletal: (+) tenderness Gastrocnemius, No bone
nor joint deformity, no joint swelling
Extremities: full pulses, warm extremities, CRT 2 seconds,
no cyanosis, no edema
Neurologic: Conscious, coherent, oriented to three spheres,
follows commands
 GCS 15 (E4V5M6)
 The rest of the neurologic examinations were
unremarkable
SUBJECTIVE OBJECTIVE
 18 years old
 Male
 History of wading in flood
 Fever for 3 days
 Headache
 Decreased urine output
for 2 days
 Vomiting and Loose
Stools
 Abdominal Pain
 Calf Pain
 Hypotension (BP 50/30)
 Tachycardia (CR: 115bpm)
 Signs of Dehydration (dry
lips)
 Icteric Sclera
 Conjunctival suffusion
 Multiple scars on lower
extremities
 Tenderness on
Gastrocnemius
To consider LEPTOSPIROSIS
 HD/PICU DAY 1:
 3:40 pm
 Patient was admitted at Pediatric ICU under GREEN
service
 Secure consent
 Diagnostics: CBC, typings, BUN , Crea, S. Electrolytes,
AST, ALT, PT APTT, blood cs, U/A, dengue test,
leptospira test, CXR PAL
 Therapeutics
Line 1: PNSS 1L TRA 52gtts/ min x 6hrs then refer for
RA
Line 2:PNSS 1L TRA 22gtts/,in x 24 hrs (M%)
 Penicillin 2million units Q4 (-)ANST
 Please insert IFC
 Refer to nephro
 Monitor vs q1
 Monitor I and O q shift
 Hook to norepinephrine 31cc + D5w 69cc with
rate of 5
 For possible HD explained to mother
 Hook to o2 via face mask via 10 LPM
 Give dopamine drip at 10 cc / hr
5:40pm
 BP: 110/50
 (-) urine output
10:30pm
please give metolazone 5mg now, then furosemide 4mg
IVP after 1 hr of giving metolazone
HD/PICU DAY 2 : Nephrology Notes
BP: 100/50 (+) Neck vein distention (-) desaturation
give furosimide 80mg now
for hep B and C
PICU notes
Line 1 please regurate to PNSS 22gtts/min as maintenace
Line 2 shift to heplock
 12pm :
 (+) Tachypnea
 For “E” intubation, conditioned well explained to
patient
 For repeat CXR APL
 HD/PICU DAY 2 :
 labored breathing, + distention neck vein , GCS
15 , + crackles
 IVF: PNSS 1 L TRA 22 gtts/min
 O2 via face mask at 10 LPM
 for “E” intubation (refused)
 Meds: Pen G
 Norepinephrine drip @ 5cc/hr
 Dopamine drip @ 10cc/hr
 For hemodialysis once IJ cath is secured
 For IJ cath insertion
 TCVS notes
 S/P femoral cath insertion
 May proceed to HD
1:45PM
HD order: duration 2hrs
blood flow 25ml per min
dialysate flow 400 per hr
Ultrafiltrate 500 per hr
Follow up hepatitis profile
2:33 Pm
+ desaturation
cr=20s
rr=30s fair pulses warm extremeties
CPR STARTED with 5 cycles
3:10: pronounced clinically dead
Septic Shock
Acute Kidney Injury probably secondary to
Leptospirosis
Pulmonary Hemorrhage
Weil’s Disease
Leptospirosis case presentation
 Human leptospiral infections can occur when
mucus membranes and skin are contaminated
by the urine of infected animals, or upon
ingestion of contaminated food and water.
 Rat is the principal source of human infection.
 Leptospirosis is endemic in the Philippines and
the number of cases peak during the rainy
months of June to August. Outbreaks have
been associated with wading in flood waters.
 most important
zoonotic disease in the
world
 Leptospira sp. - obligate
aerobic, motile tightly
coiled spirochetes
 23 pathogenic
species
 8 non-pathogenic
species
LEPTOSPIROSIS
 Reservoir: rodents
 Transmission:
 direct contact (blood, tissues, organs or
urine of infected animals)
 indirect contact (injured mucosa or
skin is exposed to contaminated water
or soil)
LEPTOSPIROSIS
 Common in tropical and subtropical
countries
 The median incidence
 20.6 among males < 19 years of age
 6.8 in females (10 – 19 years of age)
 Increasing incidence in the Philippines
 2,495 cases in 2017 (49.1% higher)
 234 cases from Jan to Jun 2018 (16% higher)
LEPTOSPIROSIS
Leptospires enter human through moist and
abraded skin or mucous membranes
Circulate in the bloodstream
Primary lesion is damage to the
endothelial lining of small blood vessels with
ischemic damage to the liver, kidneys, meninges
and muscles.
Leptospirosis case presentation
 Incubation period 2 to 20 days (mean: 15
days)
 Varied manifestations
 Severity of Illness:
 Asymptomatic or subclinical self-limited
febrile systemic illness (90%)
 Life-threatening illness - jaundice, renal
failure myocarditis, hemorrhage, and
refractory shock (10%)
CLINICAL MANIFESTATIONS
Handbook of Pediatric Infectious Diseases. Philippine Pediatric Society. 2014 Edition.
 ANICTERIC LEPTOSPIROSIS
 initial or the SEPTICEMIC PHASE
 Abrupt with fever, chills, severe headache, malaise,
nausea, vomiting, severe muscular pain and tenderness.
 Conjuctival suffusion with photophobia and orbital pain
w/o chemosis and purulent exudate.
 Hepatosplenomegaly, generalized lymphadenopathy.
 Truncal red maculopapular rash
 Second or immune phase follows a brief asymptomatic
interlude with recurrence of fever (bi phasic)
 Aseptic meningitis
 Icteric / Weil’s Syndrome
 Severe form affecting < 10 % of children
 Hemorrhage and Cardiovascular collapse
 RUQ pain, hepatomegaly, inc. liver enzymes,
hyperbilirubinemia
 Azotemia Oliguria ANURIA
 Clinical features associated with increased risk
for mortality :
 altered mental status,
 respiratory insufficiency (rales, infiltrates),
 hemoptysis,
 oliguric hyperkalemic acute renal failure,
 and cardiac involvement (myocarditis,
complete or incomplete heart block, atrial
fibrillation).
Leptospirosis case presentation
Leptospirosis case presentation
Leptospirosis case presentation
Leptospirosis case presentation
Leptospirosis case presentation
Leptospirosis case presentation
Leptospirosis case presentation
Leptospirosis case presentation
 If children are exposed for more than 7 days,
the dose should be repeated after 1 week.
 Prophylaxis is not 100% effective. Prevention of
exposure is most prudent. Monitor all those
exposed for the occurrence of symptoms of
leptospirosis. The early signs of infection occur
between 4 and 10 days after exposure
 All patients with a presumptive diagnosis of
Leptospirosis will be triaged under the
 Department of Pediatric Nephrology (Patients
< 18 yo) with the following criteria:
 1. Serum Creatinine : > 3 mg/ dl
 2. Presence of any ONE of the Criteria for Pulse
Therapy (See Appendix II)
Leptospirosis case presentation
Leptospirosis case presentation
Leptospirosis case presentation
 Indications for acute renal replacement
therapy or dialysis
 Uremic Symptoms
 Serum creatinine > 3mg/dL
 Serum K > 5 meqs/L in an oliguric patient
 ARDS, Pulmonary hemorrhage
 pH <7.2
 Fluid overload
 Oliguria
RENAL REPLACEMENT THERAPY
 Hemodialysis is preferred over peritoneal dialysis
 Hemodialysis - faster way of removal of toxins
 Hemodialysis versus Peritoneal Dialysis
 mortality (0 vs 10 %)
 renal recovery time (8.3 days vs. 16.2 days)
 reduction of serum bilirubin, urea, and creatinine
RENAL REPLACEMENT THERAPY
Wiwanitkit V. (2006). Comparison between blood exchange and classical therapy for
acute renal failure in Weil’s disease: appraisal on Thai reports. Nephrology
(Carlton);11(5):481.
Leptospirosis case presentation
Leptospirosis case presentation
Leptospirosis case presentation
Leptospirosis case presentation
 Incidence: 20 - 70%
 Consider if with: cough, hemoptysis,
dyspnea
 Pulmonary symptoms usually appear
between the 4th and 6th day of illness
 Pulmonary hemorrhage and Acute
Respiratory Distress Syndrome are
most common
Gouveia, E.L, Metcalfe, J., de Carvalho, A.L.F., Aires, T.S.F., Villasboas-Bisneto, J.C., Queirroz, A., Santos, A.C., Salgado, K., Reis, M.G., and
Ko, A.I. Leptospirosis-associated Severe Pulmonary Hemorrhagic Syndrome, Salvador, Brazil. Emerging Infectious
Diseases • www.cdc.gov/eid • Vol. 14, No. 3, March 2008
 Patients with pulmonary complications
had:
 longer duration of fever
 delayed antibiotic treatment
 platelet count <100,000
 serum creatinine >177umol/L
 bilirubin 32.4 umol/L
Leptospirosis case presentation
Leptospirosis case presentation
 1. Parents should instruct children not to wade
or swim in flood waters.
 2. If exposure to flood waters is unavoidable,
protective gear such as boots, goggles, overalls,
and rubber gloves should be used.
 3. All food and drinking water should be
protected against contamination. Fresh
vegetables and fruit should be washed in
previously boiled or clean water and then
 cooked or peeled.
 .
 4. Boil drinking water for at least 10-15 minutes.
Physical filtration through ceramic orcharcoal
filters is not adequate for leptospirosis.
 5. Food should be protected against rodent attack
or contamination.
 6. If children are exposed to flood waters, antibiotic
prophylaxis may decrease occurrence of clinical
disease and mortality. Prophylactic antibiotics
should be given under the supervision of a
physician, who can give advice regarding effects,
 precautions and contraindications for these
medications.
Leptospirosis case presentation
Leptospirosis case presentation

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Leptospirosis case presentation

  • 1. Mukesh sah, MD,JI Virgen Milagrosa University Foundation
  • 3.  C.R.  18 yrs old  Sitio Sagur Pugaro Suit Dagupan city  Single  Oct. 7, 1999  Roman Catholic  Admitted at R1MC for the first time  Informant : Mother  Realiability : 90 %
  • 4. Chief complaint: “3 DAY HISTORY OF FEVER”
  • 6. 3 days DAY 1 ILLNES • + undocumented fever, + myalgia, Headache • + Abdominal pain, +Dec appetite and activity • Took Paracetamol 2X, no consultation done 2 days DAY 2 ILLNES •+ persistence of above S/SX •↓ urine output with yellow orange in color •+ calf pain 1 WEEK HISTORY OF WADING TO FLOOD
  • 7. 1 day •+ persistence of above S/SX •LBM and vomiting •Last urine output: 12noon < 1ml Few hrs •+ anuria •+DOB •Sought consult to R1MC
  • 8. Review of Systems: • General: (+) body weakness (-) weight loss (+) decrease appetite (-) chills (-) fatigue • Skin: (+) Jaundice (-) pallor (-) pruritus (-) cyanosis (-) rashes (-) hematoma • Head & neck:(-) nodules (-) stiffness (-) swelling (-) pain (-) trauma (+) headache (+) dizziness (-) lightheadedness (-) pain • Eyes: (-) asymmetry (-) infection (+) icteric sclera (-) itchiness (-) diplopia (-)use of glass/lenses (-) lacrimation (-) blurred vision • Ears: (-) hearing problem (-) itching • Mouth & throat: (-) hoarseness (-) sore throat (-) dysphagia • Respiratory: (-) cough (-) colds (-) dyspnea (-) cyanosis (-) hemoptysis
  • 9.  Cardiac: (-) palpitation (-) chest pain (-) orthopnea (-) paroxysmal nocturnal dyspnea (-) easy fatigability (-) edema  GIT: (-) pain (-) anorexia (-) vomiting (-) melena (-) constipation (-) excessive belching (-) bloated (-) loss of appetite (-) abdominal pain(-) diarrhea  Renal: (-) dysuria (-) hematuria (-) nocturia (-) incontinence (-) polyuria (+) anuria (-) urgency (-) frequency (-) gross hematuria (-) tea- colored urine  Genitalia: (-) pain (-) swelling (-) discharge (-) infection  Musculoskeletal: (-) stiffness (-) numbness (+) joint pain (+) muscle pain (calf) (-) change in strength (-) backache  Hematological: (-) pallor (-) hematoma (-) bleeding (-) anemia (-) easy bruising  Endocrine: (-) weight loss (-) edema (-) polyuria (-) polyphagia (-) polydipsia (-) heat intolerance (-) cold intoleranc (-) excessive sweating
  • 10.  Past medical history: EPI Completion No pertinent childhood illnesses No previous surgical interventions  Family history: No history of herediofamilial diseases No history of TB, asthma, DM and cardiac disease.
  • 11.  Personal and Social History: Patient is staying with his father and 2 siblings in a Well- lit, well ventilated bungalow wooden house with own pour- flush toilet. Garbage collected 2-3 times a week Drinking water is tap water No history of travel
  • 12. H- The patient lives with his father with his 2 siblings (his parents are separated) E- He stop schooling at Grade 10 A- He accompanies his father during fishing and usually play basketball during free time. D- No history of illegal drugs. Usually drinks SAN MIG light with his friends and a smoker as well. S- No sexual experience S- No suicidal Ideation
  • 13.  Awake, conscious, coherent, ambulatory, GCS 15, in cardiorespiratory distress with the following vital signs:  BP: 50/30  PR: 98bpm  CR: 85bpm  Temp: 37C
  • 14.  SKIN:  Brown in complexion, no pallor, mild jaundice, no lesions, normal skin turgor, multiple scars on bilateral lower extremities  HEENT:  No areas of balding, no swelling, tenderness  EYES: pale palpebral conjunctivae, icteric sclera, conjunctival suffusion, no cataract, no asymmetry  EARS: at level of lateral canthus of the eyes, symmetrical, non-tender, with no erythema, no discharges, no scaling  NOSE: Nasal mucosa is pink, patent nares, non- deviated septum and no Nasal discharge, non- tendersinuses.
  • 15. MOUTH: pinkish lips, Buccal mucosae is pink, no ulcer, Dry lips  CHEST AND LUNGS:Symmetrical chest wall expansion,No intercostal or subcostal retraction,no tenderness, normal resonant breathing sound,  Heart: Adynamic precordium, Apex beat at 5th ICS left MCL, , (-) thrills, (-) loud and palpable P2; normally split S2; (-) S3, (-) S4.normal rate. (-) murmur, tachycardic.
  • 16. Abdomen. Inspection:, no scars, no spider angioma Auscultation: hypoactive bowel sounds at 6 per minute. Percussion: Tympanic, liver span 8 cm in right midclavicular line, non palpable liver edge. Palpation: (-) tenderness Musculoskeletal: (+) tenderness Gastrocnemius, No bone nor joint deformity, no joint swelling Extremities: full pulses, warm extremities, CRT 2 seconds, no cyanosis, no edema Neurologic: Conscious, coherent, oriented to three spheres, follows commands  GCS 15 (E4V5M6)  The rest of the neurologic examinations were unremarkable
  • 17. SUBJECTIVE OBJECTIVE  18 years old  Male  History of wading in flood  Fever for 3 days  Headache  Decreased urine output for 2 days  Vomiting and Loose Stools  Abdominal Pain  Calf Pain  Hypotension (BP 50/30)  Tachycardia (CR: 115bpm)  Signs of Dehydration (dry lips)  Icteric Sclera  Conjunctival suffusion  Multiple scars on lower extremities  Tenderness on Gastrocnemius
  • 19.  HD/PICU DAY 1:  3:40 pm  Patient was admitted at Pediatric ICU under GREEN service  Secure consent  Diagnostics: CBC, typings, BUN , Crea, S. Electrolytes, AST, ALT, PT APTT, blood cs, U/A, dengue test, leptospira test, CXR PAL  Therapeutics Line 1: PNSS 1L TRA 52gtts/ min x 6hrs then refer for RA Line 2:PNSS 1L TRA 22gtts/,in x 24 hrs (M%)
  • 20.  Penicillin 2million units Q4 (-)ANST  Please insert IFC  Refer to nephro  Monitor vs q1  Monitor I and O q shift  Hook to norepinephrine 31cc + D5w 69cc with rate of 5  For possible HD explained to mother  Hook to o2 via face mask via 10 LPM  Give dopamine drip at 10 cc / hr
  • 21. 5:40pm  BP: 110/50  (-) urine output 10:30pm please give metolazone 5mg now, then furosemide 4mg IVP after 1 hr of giving metolazone HD/PICU DAY 2 : Nephrology Notes BP: 100/50 (+) Neck vein distention (-) desaturation give furosimide 80mg now for hep B and C PICU notes Line 1 please regurate to PNSS 22gtts/min as maintenace Line 2 shift to heplock
  • 22.  12pm :  (+) Tachypnea  For “E” intubation, conditioned well explained to patient  For repeat CXR APL
  • 23.  HD/PICU DAY 2 :  labored breathing, + distention neck vein , GCS 15 , + crackles  IVF: PNSS 1 L TRA 22 gtts/min  O2 via face mask at 10 LPM  for “E” intubation (refused)  Meds: Pen G  Norepinephrine drip @ 5cc/hr  Dopamine drip @ 10cc/hr  For hemodialysis once IJ cath is secured  For IJ cath insertion
  • 24.  TCVS notes  S/P femoral cath insertion  May proceed to HD 1:45PM HD order: duration 2hrs blood flow 25ml per min dialysate flow 400 per hr Ultrafiltrate 500 per hr Follow up hepatitis profile 2:33 Pm + desaturation cr=20s rr=30s fair pulses warm extremeties CPR STARTED with 5 cycles 3:10: pronounced clinically dead
  • 25. Septic Shock Acute Kidney Injury probably secondary to Leptospirosis
  • 28.  Human leptospiral infections can occur when mucus membranes and skin are contaminated by the urine of infected animals, or upon ingestion of contaminated food and water.  Rat is the principal source of human infection.  Leptospirosis is endemic in the Philippines and the number of cases peak during the rainy months of June to August. Outbreaks have been associated with wading in flood waters.
  • 29.  most important zoonotic disease in the world  Leptospira sp. - obligate aerobic, motile tightly coiled spirochetes  23 pathogenic species  8 non-pathogenic species LEPTOSPIROSIS
  • 30.  Reservoir: rodents  Transmission:  direct contact (blood, tissues, organs or urine of infected animals)  indirect contact (injured mucosa or skin is exposed to contaminated water or soil) LEPTOSPIROSIS
  • 31.  Common in tropical and subtropical countries  The median incidence  20.6 among males < 19 years of age  6.8 in females (10 – 19 years of age)  Increasing incidence in the Philippines  2,495 cases in 2017 (49.1% higher)  234 cases from Jan to Jun 2018 (16% higher) LEPTOSPIROSIS
  • 32. Leptospires enter human through moist and abraded skin or mucous membranes Circulate in the bloodstream Primary lesion is damage to the endothelial lining of small blood vessels with ischemic damage to the liver, kidneys, meninges and muscles.
  • 34.  Incubation period 2 to 20 days (mean: 15 days)  Varied manifestations  Severity of Illness:  Asymptomatic or subclinical self-limited febrile systemic illness (90%)  Life-threatening illness - jaundice, renal failure myocarditis, hemorrhage, and refractory shock (10%) CLINICAL MANIFESTATIONS Handbook of Pediatric Infectious Diseases. Philippine Pediatric Society. 2014 Edition.
  • 35.  ANICTERIC LEPTOSPIROSIS  initial or the SEPTICEMIC PHASE  Abrupt with fever, chills, severe headache, malaise, nausea, vomiting, severe muscular pain and tenderness.  Conjuctival suffusion with photophobia and orbital pain w/o chemosis and purulent exudate.  Hepatosplenomegaly, generalized lymphadenopathy.  Truncal red maculopapular rash  Second or immune phase follows a brief asymptomatic interlude with recurrence of fever (bi phasic)  Aseptic meningitis
  • 36.  Icteric / Weil’s Syndrome  Severe form affecting < 10 % of children  Hemorrhage and Cardiovascular collapse  RUQ pain, hepatomegaly, inc. liver enzymes, hyperbilirubinemia  Azotemia Oliguria ANURIA
  • 37.  Clinical features associated with increased risk for mortality :  altered mental status,  respiratory insufficiency (rales, infiltrates),  hemoptysis,  oliguric hyperkalemic acute renal failure,  and cardiac involvement (myocarditis, complete or incomplete heart block, atrial fibrillation).
  • 46.  If children are exposed for more than 7 days, the dose should be repeated after 1 week.  Prophylaxis is not 100% effective. Prevention of exposure is most prudent. Monitor all those exposed for the occurrence of symptoms of leptospirosis. The early signs of infection occur between 4 and 10 days after exposure
  • 47.  All patients with a presumptive diagnosis of Leptospirosis will be triaged under the  Department of Pediatric Nephrology (Patients < 18 yo) with the following criteria:  1. Serum Creatinine : > 3 mg/ dl  2. Presence of any ONE of the Criteria for Pulse Therapy (See Appendix II)
  • 51.  Indications for acute renal replacement therapy or dialysis  Uremic Symptoms  Serum creatinine > 3mg/dL  Serum K > 5 meqs/L in an oliguric patient  ARDS, Pulmonary hemorrhage  pH <7.2  Fluid overload  Oliguria RENAL REPLACEMENT THERAPY
  • 52.  Hemodialysis is preferred over peritoneal dialysis  Hemodialysis - faster way of removal of toxins  Hemodialysis versus Peritoneal Dialysis  mortality (0 vs 10 %)  renal recovery time (8.3 days vs. 16.2 days)  reduction of serum bilirubin, urea, and creatinine RENAL REPLACEMENT THERAPY Wiwanitkit V. (2006). Comparison between blood exchange and classical therapy for acute renal failure in Weil’s disease: appraisal on Thai reports. Nephrology (Carlton);11(5):481.
  • 57.  Incidence: 20 - 70%  Consider if with: cough, hemoptysis, dyspnea  Pulmonary symptoms usually appear between the 4th and 6th day of illness  Pulmonary hemorrhage and Acute Respiratory Distress Syndrome are most common Gouveia, E.L, Metcalfe, J., de Carvalho, A.L.F., Aires, T.S.F., Villasboas-Bisneto, J.C., Queirroz, A., Santos, A.C., Salgado, K., Reis, M.G., and Ko, A.I. Leptospirosis-associated Severe Pulmonary Hemorrhagic Syndrome, Salvador, Brazil. Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 14, No. 3, March 2008
  • 58.  Patients with pulmonary complications had:  longer duration of fever  delayed antibiotic treatment  platelet count <100,000  serum creatinine >177umol/L  bilirubin 32.4 umol/L
  • 61.  1. Parents should instruct children not to wade or swim in flood waters.  2. If exposure to flood waters is unavoidable, protective gear such as boots, goggles, overalls, and rubber gloves should be used.  3. All food and drinking water should be protected against contamination. Fresh vegetables and fruit should be washed in previously boiled or clean water and then  cooked or peeled.  .
  • 62.  4. Boil drinking water for at least 10-15 minutes. Physical filtration through ceramic orcharcoal filters is not adequate for leptospirosis.  5. Food should be protected against rodent attack or contamination.  6. If children are exposed to flood waters, antibiotic prophylaxis may decrease occurrence of clinical disease and mortality. Prophylactic antibiotics should be given under the supervision of a physician, who can give advice regarding effects,  precautions and contraindications for these medications.

Notas del editor

  1. The most important and most common zoonosis, caused by infection with pathogenic spirochetes of the genus Leptospira
  2. The reservoir are mainly rodents Transmission to man occurs through direct contact with blood, tissues, organs, or urine of infected animals, or through indirect contact, when injured mucosa or skin is exposed to contaminated water. In tropical countries, leptospirosis is an endemic disease, with outbreaks occurring during the rainy season, coinciding with flooded areas.
  3. There is increasing incidence of leptospirosis in the Philippines, In 2017, A total of 2,495 leptospirosis cases were reported nationwide from Jan. 1 to Dec. 2, 2017. This figure was 49.1 percent higher than the 1,673 cases recorded during the same period in 2016. At present, a total of 234 leptospirosis cases were recorded compared to last year's 146 cases, covering January 1 to June 29.
  4. Clinical presentation may be mono- or biphasic. Classically described biphasic leptospirosis has an acute SEPTICEMIC PHASE usually lasting 1 week, during which time Leptospira organisms are present in blood, CSF and all other tissues, and the IMMUNE PHASE which lasts 4 to 30 days during which leptospiuria is evident. The acute phase is characterized by nonspecific symptoms, including fever, chills, headache frequently frontal in distribution, myalgia, nausea, vomiting, abdominal pain, and conjunctival suffusion, occasionally accompanied by rash. Distinct clinical findings include notable conjunctival suffusion without purulent discharge (28%–99% of cases) and myalgia of the calf and lumbar regions (40%–97% of cases).
  5. Incubation period is 2-20 days with mean of 15 days Severity of illness vary from Asymptomatic or subclinical self-limited febrile systemic illness (90%) to Life-threatening illness - jaundice, renal failure myocarditis, hemorrhage, and refractory shock (10%)
  6. The following are the indications for renal replacement therapy In our patient elevated serum creatinine, pulmonary hemorrhage and oliguria are the indications
  7. Hemodialysis is preferred over peritoneal dialysis Hemodialysis - faster way of removal of toxins Hemodialysis versus Peritoneal Dialysis mortality (0 vs 10 %) renal recovery time (8.3 days vs. 16.2 days) reduction of serum bilirubin, urea, and creatinine
  8. 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 Complications occur in 20-70% of patients Usually presents with cough, hemoptysis, dyspnea on the 4th and 6th day of illness Such in our case Pulmonary hemorrhage and Acute Respiratory Distress Syndrome are most common
  9. Significant risk factors for pulmonary complications are delayed antibiotic treatment and thrombocytopenia at the onset of the disease. The pathogenesis is not clearly defined although vascular endothelial involvement has been demonstrated to occur through an immunologic mechanism in which the toxin acts as an antigen. The disruption of the vascular endothelium would lead to an increase in permeability, which would in turn give rise to alveolar bleeding