Leptospirosis is a bacterial disease that affects humans and animals. It is caused by bacteria of the genus Leptospira. In humans, it can cause a wide range of symptoms, some of which may be mistaken for other diseases. Some infected persons, however, may have no symptoms at all.
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 %
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
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
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
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
The most important and most common zoonosis, caused by infection with pathogenic spirochetes of the genus Leptospira
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.
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.
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).
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%)
The following are the indications for renal replacement therapy
In our patient elevated serum creatinine, pulmonary hemorrhage and oliguria are the indications
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
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
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