Hemorragia alveolar pulmonar como presentación poco frecuente de infección por Leptospira spp: una enfermedad ocupacional del personal militar en zonas tropicales / Pulmonary alveolar hemorrhage as an unusual presentation of Leptospira spp: an occupational-disease of military personnel in tropical zones

Resumen La leptospirosis es una de las zoonosis endémicas más importantes en el mundo con un aumento de la incidencia en los últimos años. En el personal militar podría ser catalogada como una enfermedad ocupacional dado sus actividades específicas en áreas rurales. Su presentación clínica es variable siendo en la mayoría de los casos una enfermedad febril autolimitada. De acuerdo con diversos factores dependientes del patógeno y del hospedero pueden presentarse manifestaciones severas de la enfermedad dentro de la cual destaca el compromiso pulmonar con una alta tasa de mortalidad. Existe evidencia del uso de esteroide sistémico como parte del tratamiento de esta complicación. Presentamos el caso de un paciente joven, militar, que debuta con síndrome de hemorragia alveolar difusa secundario a leptospirosis y presenta una excelente respuesta al tratamiento con altas dosis de metilprednisolona, con una discusión del proceso diagnóstico y aspectos fisiopatológicos de esta condición.

Leptospirosis is one of the most important endemic zoonoses in the world with an increase in incidence in recent years. In military personnel it could be classified as an occupational disease given their specific activities in rural areas. Its clinical presentation is variable being in most cases a self-limited febrile disease. According to various factors dependent on the pathogen and the host, severe manifestations of the disease may occur within which the pulmonary involvement with a high mortality rate stands out. There is evidence of systemic steroid use as part of the treatment of this complication. We present a case of a young, military patient who debuts with diffuse alveolar hemorrhage syndrome secondary to leptospirosis and presents an excellent response to treatment with high doses of methylprednisolone, with a discussion of the diagnostic process and pathophysiological aspects of this condition.

Leptospirose: Características da enfermidade em humanos e principais técnicas de diagnóstico laboratorial / Leptospirosis: Characteristics of the human disease and main laboratory diagnostic techniques

A leptospirose é a zoonose de maior distribuição geográfica, com estimativa de cerca de 60.000 mortes por ano. A doença é causada por bactérias do gênero Leptospira, que possui mais de 300 diferentes sorovares e 64 espécies já identificadas, sendo o ambiente a principal fonte de contaminação. A doença em humanos apresenta manifestações clínicas variadas e caráter bifásico, devendo ser confirmada por meio do diagnóstico laboratorial. O objetivo deste trabalho foi reunir conceitos atualizados sobre a leptospirose humana e as principais técnicas de diagnóstico laboratorial empregadas. A MAT é considerada o padrão-ouro para o diagnóstico da leptospirose, mas devido à baixa sensibilidade na fase inicial da doença é necessário o emprego de técnicas mais sensíveis neste período. Baseado em diversos estudos, as metodologias de PCR, ELISA-IgM e teste rápido apresentaram sensibilidade satisfatória nos primeiros dias após o início dos sintomas. Na segunda semana, a MAT apresentou 100% de sensibilidade, mantendo sua alta especificidade em ambas as fases. No geral, os testes sorológicos de ELISA-IgM e teste rápido apresentaram resultados satisfatórios como métodos de diagnóstico precoce, principalmente tratando-se de locais com pouca infraestrutura, diferente dos laboratórios de referência onde é possível empregar as técnicas de PCR e MAT.

Leptospirosis is the most widespread zoonosis, which has a balance of almost 60,000 deaths per year. Bacteria of Leptospira genus, which has more than 300 different serovars and 64 species already identified, cause the disease, being the environment the main source of contamination. The human disease presents a large set of clinical manifestations, showing biphasic presentation, the reason why leptospirosis must be confirmed by laboratory diagnosis. This study aimed to group recent concepts concerning human leptospirosis and the main diagnosis techniques employed at the laboratory. MAT is considered the gold standard for leptospirosis diagnosis, but has low sensitivity on the onset of disease, leading to the use of techniques with higher sensitivity on this period. Based on several studies, PCR, ELISA-IgM and rapid test presented satisfactory sensitivity on the onset of symptoms. In the second week, MAT showed 100% of sensitivity, maintaining its high specificity in both phases. In general, the ELISA-IgM and rapid serological tests showed satisfactory results as methods for early diagnosis, especially in the case of places with poor infrastructure, different from the reference laboratories where it is possible to use the PCR and MAT techniques.

Neuroleptospirosis con pericarditis y colestasis intrahepática (Síndrome de Weil) / Neuroleptospirosis with Pericarditis and Intrahepatic Cholestasis (Weil syndrome)

Introducción: El síndrome de Weil es una forma grave de la infección bacteriana causada por la bacteria Leptospira, conocida como leptospirosis. Este se caracteriza por la disfunción de múltiples órganos, entre ellos, hígado, riñón, músculos, serosas o el sistema neurológico, en este caso denominado neuroleptospirosis, genera una mortalidad muy elevada cuando no se brinda diagnóstico y tratamiento adecuado. Objetivo: Describir las manifestaciones clínicas, paraclínicos complementarios y tratamiento de un paciente con síndrome de Weil, una condición poco frecuente. Caso clínico: Paciente de 23 años quien consulta en el contexto de síndrome febril agudo asociado con neuritis óptica, dolor torácico y paraclínicos que evidenciaron afectación hepática y cardíaca. Se confirma el diagnóstico de síndrome de Weil dado por neuroleptospirosis, pericarditis y colestasis intrahepática. Conclusiones: mediante un caso clínico de síndrome de Weil, se describe la afectación multisistémica de complicaciones asociadas con leptospirosis, con manifestaciones poco habituales como neuroleptospirosis, pericarditis y colestasis intrahepática(AU)

Introduction: Weil syndrome is a serious form of the bacterial infection caused by the Leptospira bacterium; this is known as leptospirosis. This is characterized by multiple organ dysfunction; for example, the liver, kidney, muscles, of serous type, or the neurological system, in this case called neuroleptospirosis, which produces a very high mortality when adequate diagnosis and treatment are not provided. Objective: To describe the clinical manifestations, complementary paraclinic practice and treatment of a patient with Weil syndrome, as a rare condition. Clinical case: 23-year-old patient who presents with acute febrile syndrome associated with optic neuritis, chest pain, and paraclinical symptoms obviously consistent liver and cardiac involvement. The diagnosis of Weil syndrome is confirmed, specifically defined by neuroleptospirosis, pericarditis, and intrahepatic cholestasis. Conclusions: Through a clinical case of Weil syndrome, the multisystem involvement of complications associated with leptospirosis is described, along with its unusual manifestations, such as neuroleptospirosis, pericarditis, and intrahepatic cholestasis(AU)

Afectación pancreática en infección por leptospirosis / Pancreatic involvement in leptospirosis infection

La leptospirosis en fase ictérica o enfermedad de Weil es una vasculitis zoonótica endémica de la Costa ecuatoriana. Sin embargo, la pancreatitis aguda como parte de esta entidad es una complicación rara vez documentada. En este reporte de caso se presenta a un adulto varón de 63 años con signos de falla multiorgánica y amilasa con rápido ascenso inicial. La leptospirosis no fue tomada como primera opción diagnóstica. El paciente fue tratado debido a un cuadro de SDRA como un shock séptico de foco pulmonar, con falla renal aguda que requirió hemodiálisis, permaneciendo en UCI con antibioticoterapia empírica. El objetivo de este caso es remarcar que la leptospirosis debe siempre estar considerada en el diagnóstico diferencial de ictericia y pancreatitis, sobre todo en nuestro medio.

The icteric presentation of Leptospirosis, also known as Weil's disease, is a zoonotic vasculitis endemic to Ecuador's coastal region. However, reports of pancreatic affection due to this entity are rarely documented. We chose to present the case of a 63 years old male with signs of catastrophic organic failure, associated with a rapid increase in serum amylase concentrations. Due to this presentation, Leptospirosis was not held as the primary culprit of the disease, and was treated at the ICU as septic shock of pulmonary origin with ARDS associated with acute kidney injury that required hemodialysis. Thus this case aims to highlight the importance of Leptospirosis as an important differential diagnosis in any patient hailing from a tropical region with jaundice and pancreatitis.

Hemorragia digestiva e insuficiencia hepática aguda por leptospirosis: una entidad que no debemos olvidar / Gastrointestinal bleeding and acute hepatic failure by leptospirosis: an entity that should not be forgotten

La leptospirosis es una enfermedad causada por la espiroqueta Leptospira. Se trata de una zoonosis de distribución mundial, con predominio en los trópicos. En España no es frecuente pero sí se observan casos en zonas más húmedas o con presencia de ríos, lagos o estanques, como son Cataluña, Andalucía o la Comunidad Valenciana, donde se relaciona con los arrozales. Los transmisores son múltiples animales como vacas o ratas, contagiándose el ser humano mediante contacto directo con estos animales o su orina, o bien de forma indirecta al consumir o estar en contacto con agua contaminada por la orina de éstos. Las manifestaciones clínicas son muy variables, siendo asintomática o poco sintomática en la mayoría de los pacientes. Aunque no ocurre siempre, la leptospirosis cursa con una primera fase con fiebre, mialgias, afectación renal o hemorragia de distintos órganos, seguida de una segunda fase con presencia de ictericia por afectación hepática. La enfermedad de Weil es una forma de leptospirosis grave caracterizada por afectación hepática con ictericia e insuficiencia renal aguda, asociada a una considerable mortalidad. El diagnóstico se basa en técnicas serológicas y detección de DNA mediante PCR. El tratamiento consta de medidas de soporte y antibioticoterapia. Presentamos un paciente con enfermedad de Weil y hemorragia digestiva por leptospirosis, con una evolución clínica fulminante, y hacemos hincapié en la necesidad de tener presente esta entidad, especialmente en ambientes epidemiológicos favorables como el de este paciente, con el fin de lograr un diagnóstico precoz.

Leptospirosis disease is caused by the spirochete Leptospira. It is a worldwide distribution zoonosis, with predominance in the tropics. In Spain, it is not frequent but some cases have been noticed especially in humid areas surrounded by rivers, lakes or ponds, such as Catalonia, Andalucia or the Valencian Community. It is transmitted by a variety of animals such as cows or rats, that are infected either by direct contact with these animals or their urine, or indirectly by consuming or being in contact with water contaminated by their urine. The clinical manifestations are very variable, being asymptomatic or not very symptomatic in most of the patients. Unusually, leptospirosis presents with a first phase with fever, myalgias, liver injury or different organs hemorrhage, followed by a second phase with the presence of jaundice due to hepatic failure. Weil's disease is a kind of severe leptospirosis characterized by hepatic failure with jaundice and acute renal failure, associated with high mortality rates. The diagnosis is based on serological techniques and DNA detection by PCR. The treatment consists of life support measures and antibiotic therapy. A patient with Weil's disease and leptospirosis digestive bleeding is presented, with a fulminant clinical course. In order to achieve an early diagnosis, the need to keep this entity in mind must be emphasized, especially in favorable epidemiological environments as the one of this patient.

Tissue apoptosis in mice infected with Leptospira interrogans serovar Icterohaemorrhagiae

Background: This investigation aimed to evaluate the occurrence of some apoptotic features induced by Leptospira interrogans serovar Icterohaemorrhagiae infection in young BALB/c mice during 2, 4, 7, 10, 14 and 21 days post-infection (dpi). Methods: The animals were euthanized and lung, liver and kidneys were harvested to histopathology analysis and immunohistochemistry to caspase-3 antigen detection was performed. Results: Chromatin condensation in kidney and liver tissues, but not in lung tissue, was observed. Caspase-3 reactive cells, mainly characterized as renal epithelial cells, were detected in the days 14 and 21 at high levels when compared to days 2,4 and 7 (p = 0.025; p <0.05). Lung sections revealed caspase-3 labeled alveolar cells in 10 and 14 days post-infection was higher than observed at 7 days (p = 0.0497; p < 0.05). Liver sections demonstrated reactive cells at a highest level at 14 and 21 days post-infection when comparison to 2,4, 7 and 10 days (p = 0.0069; p<0.05). Conclusions: Our results suggest that infection of L interrogans induce in kidney, liver and lung an activation of apoptosis mediated by caspase-3 dependent pathway in later phases of infectious process.

Reporte de un caso leptospirosis / A case report leptospirosis

La leptospirosis humana es una zoonosis con amplia distribución mundial. Es una enfermedad febril aguda, causada por bacterias del género Leptospira, que infectan a varios animales domésticos y silvestres, los que frecuentemente se transforman en portadores asintomáticos. El hombre se puede infectar al contacto con agua contaminada con la orina de estos animales. En Costa Rica se considera una enfermedad endémica por lo que su conocimiento es de gran importancia. El propósito de este trabajo es presentar un caso de un masculino fallecido a consecuencia de leptospirosis, y comparar las manifestaciones clínicas y los hallazgos de la autopsia con lo mencionado en la literatura sobre leptospirosis.

Human leptospirosis is a zoonosis with worldwide distribution. It is an acute febrile disease caused by bacteria of the genus Leptospira that infect various domestic and wild animals, which often become asymptomatic carriers. The man can be infected by the contact with water or urine contaminated. In Costa Rica leptospirosis is considered an endemic disease so your knowledge is very important. The purpose of this articule is present a case of a male who died from leptospirosis, and compare the clinical and autopsy findings with the literature about leptospirosis.

Factors associated with thrombocytopenia in severe leptospirosis (Weil's disease)

OBJECTIVE: This study was conducted to investigate factors associated with thrombocytopenia in a large cohort of patients with leptospirosis in an endemic area. METHODS: This retrospective study included 374 consecutive patients with leptospirosis who were admitted to tertiary hospitals in Fortaleza, Brazil. All patients had a diagnosis of severe leptospirosis (Weil's disease). Acute kidney injury was defined according to the RIFLE criteria. Thrombocytopenia was defined as a platelet count <100,000/mm3. RESULTS: A total of 374 patients were included, with a mean age of 36.1±15.5 years, and 83.4% were male. Thrombocytopenia was present at the time of hospital admission in 200 cases (53.5%), and it developed during the hospital stay in 150 cases (40.3%). The patients with thrombocytopenia had higher frequencies of dehydration (53% vs. 35.3%, p = 0.001), epistaxis (5.7% vs. 0.8%, p = 0.033), hematemesis (13% vs. 4.6%, p = 0.006), myalgia (91.5% vs. 84.5%, p = 0.038), hematuria (54.8% vs. 37.6%, p = 0.011), metabolic acidosis (18% vs. 9.2%, p = 0.016) and hypoalbuminemia (17.8% vs. 7.5%, p = 0.005). The independent risk factors associated with thrombocytopenia during the hospital stay were lengthy disease (OR: 1.2, p = 0.001) and acute kidney injury (OR: 6.6, p = 0.004). Mortality was not associated with thrombocytopenia at admission (12.5% vs. 12.6%, p = 1.000) or during the hospital stay (12.6% vs. 11.3%, p = 0.748). CONCLUSIONS: Thrombocytopenia is a frequent complication in leptospirosis, and this condition was present in more than half of patients at the time of hospital admission. Lengthy disease and acute kidney injury are risk factors for thrombocytopenia. There was no significant association between thrombocytopenia and mortality. .

Characterization of a virulent Leptospira interrogans strain isolated from an abandoned swimming pool

Pathogenic Leptospira spp. are the etiological agents of leptospirosis, an important disease of both humans and animals. In urban settings, L. interrogans serovars are the predominant cause of disease in humans. The purpose of this study was to characterize a novel Leptospira isolate recovered from an abandoned swimming pool. Molecular characterization through sequencing of the rpoB gene revealed 100% identity with L. interrogans and variable-number tandem-repeat (VNTR) analysis resulted in a banding pattern identical to L. interrogans serogroup Icterohaemorrhagiae, serovar Copenhageni or Icterohaemorrhagiae. The virulence of the strain was determined in a hamster model of lethal leptospirosis. The lethal dose 50% (LD50) was calculated to be two leptospires in female hamsters and a histopathological examination of infected animals found typical lesions associated with severe leptospirosis, including renal epithelium degeneration, hepatic karyomegaly, liver-plate disarray and lymphocyte infiltration. This highly virulent strain is now available for use in further studies, especially evaluation of vaccine candidates.

[Leptospirosis or Weil disease a febrile illness with jaundice]

Leptospirosis is a bacterial zoonotic disease caused by spirochaetes of the genus Leptospira that affects humans and a wide range of animals. The disease was first described by Adolf Weil in 1886, reported as an "acute infectious disease with fever and jaundice". Outbreaks of leptospirosis are usually caused by human exposure to water or soil contaminated with the urine of infected animals through broken skin especially mucosal surfaces. Direct contact with infected animals may also be significant [slaughterhouse workers, veterinary surgeons] or in certain occupations, e.g. workers in rice fields or those who swim in infected surface water or adventure sports in tropical regions. Patients may appear as asymptomatic, mildly ill or toxic. High fever, chills, myalgias particularly prominent in the paraspinal and calf muscles and intense headache are among the first flulike symptoms that may appear. Later in severe disease, jaundice, meningitis and renal failure can develop. Cardiovascular problems are also possible. Diagnoses procedures include testing serologically with a panel of different strains. It is also possible to culture the microorganism from blood, serum and fresh urine. Hygienic methods such as avoidance of direct and indirect human contact with animal urine are recommended as preventive measures. The main preventive measure for leptospirosis is to create awareness about the disease and its prevention. Treatment for leptospirosis is based on antibiotic therapy allied with supportive care. There are no clinical examples of drug resistance developing. This review article also presents survey and the disease burden in Giulan

Acalculous cholecystitis: a rare presentation of leptospirosis progressing to Weil's disease

Leptospirosis is a zoonotic infection with higher incidence in tropics. Leptospirosis, is known for its variable manifestations, and is a clinical challenge for physicians in the tropics. Experienced clinicians, at times can mistake leptospirosis for non-medical conditions. A few reports of leptospirosis presenting as acalculous cholecystitis was found in review of literature. We intent to highlight acalculous cholecystitis as a rare but clinically significant presentation of leptospirosis.

Síndrome de Weil y embarazo / Weil's disease at pregnancy

Se informa el caso de una paciente de 37 años de edad, con 34,4 semana de gestación, ingresada con el diagnóstico de síndrome febril agudo. Dados los antecedentes epidemiológicos, se halló, luego de una pesquisa adecuada, positividad para infección por Leptospira. Evolutivamente presentó íctero intenso y fallo renal agudo que necesitó de diálisis, lo cual mejoró la función renal y finalmente se recuperó la actividad hepática. Se concluyó que el cuadro era una forma de presentación del Síndrome de Weil durante el embarazo. El parto eutócico se presentó a las 34 sem con un recién nacido femenino de 2200 g con buena evolución.

Case of a patient aged 37 with 34, 4 weeks of gestation, admitted con a diagnosis of acute febrile syndrome. According to epidemiologic backgrounds, after a appropriate investigation, we found a positivity to infection from Leptospira. From the evolutionary point of view, she had intensive icterus and acute renal failure needing dialysis, which improved the renal function with recovery of hepatic activity. We conclude that picture was a presentation way of Weil's syndrome during pregnancy. Spontaneous labor occurred at 34 weeks with a female fetus weighing 2200 gr and a good evolution.

Leptospirosis grave asociada con hemorragia pulmonar: presentación de 3 pacientes pediátricos UCIP: Hospital Universitario "José Luis Miranda" / Leptospirosis grave asociada con hemorragia pulmonar: presentación de 3 pacientes pediátricos UCIP: Hospital Universitario

Se presentan tres pacientes pediátricos con una forma clínica grave de leptospirosis no ictérica complicada con alveolitis hemorrágica que evolucionaron al sindrome de distres respiratorio agudo (SDRA). Estos pacientes no presentaron un distres respiratorio genuino ya que además de la neumonitis hemorrágica estuvo presente una disfunción miocárdica en el curso del shock séptico, documentada por ecocardiogramas realizados en las primeras horas del ingreso en UCIP, donde se observó dilatación de ambos ventrículos, disminución de la contractilidad en los segmentos apicales y pared libre del VI y FEVI baja. Uno de los tres pacientes falleció a causa de disfunción múltiple de órganos.

Características clínicas y epidemiológicas de la leptospirosis en el departamento del Quindío, 2005-2006 / Clinical and epidemiological characteristics of leptospirosis in the Quindío department (2005-2006)

Objetivo. Describir el comportamiento clínico, epidemiológico y serológico de los pacientes con leptospirosis humana en el departamento del Quindío en un periodo de 2 años (2005-2006). Diseño. Estudio prospectivo de serie de casos. Resultados. Se diagnosticaron 38 casos de leptospirosis humana en el 2005 y 31 casos en el 2006, en el departamento del Quindío. En ellos se encontró una letalidad de 13% en el 2005 y de 3,2% en el 2006. Las manifestaciones clínicas más frecuentes fueron fiebre, mialgia, ictericia y cefalea. La prueba MAT estandarizada fue el método diagnóstico confirmatorio. La variedad serológica icterohemorrágica se encontró con mayor frecuencia y estuvo presente en la mayoría de los casos de mortalidad. Los hallazgos paraclínicos más frecuentes fueron alteraciones de la función hepática (78%) PK elevada (60%). Conclusiones. Contrario a lo que se cree, la leptospirosis sintomática en el departamento del Quindío no se encontró en la población rural sino en la población urbana. Al realizar la búsqueda, el diagnóstico y el tratamiento adecuado, se disminuyeron las complicaciones y la mortalidad, como se puede observar al comparar los años 2005 y 2006.

Objective. To describe the symptoms, clinical laboratory results and outcome of patients with human leptospirosis in department of Quindío, during two years (2005-2006) Methods. Case series Results. 38 cases were confirmed in 2005 and 31 in 2006. Mortality occurred in 12% in 2005 and in 3% of the cases in 2006. The most important symptoms were fever, myalgies and headache. The MAT serological assay was the confirmatory test in all cases.The icterohemorragic serovar was the most frequent and it was found in the majority of the mortal cases. In 75% there was hepatic dysfunction as revealed by laboratory tests and in 70% of patients there was a rise in levels of creatin kynases enzymes. Conclusions. Contrary to common belief, clinical leptospirosis in Quindío was not found in rural but in urban population. Between the two years in Quindío there were improvements in diagnosis and clinical treatment, leading to an important reduction in mortality.

Leptospirosis: clinical presentation and correlation with serovars.

A total of 2400 patients with pyrexia of unknown origin and or suspected leptospirosis were included in this study. Dark field microscopy detected Leptospira in 690 cases, Leptospira serological Investigations proved positive in 570 out of these 690 patients. Among them 212 had the classical icteric and the other 358 had anicteric type of presentation. Notably eptospira interrogans serovar ictero haemorrhagiae infection was encountered in 212 patients. In 30 patients, who had multi organ dysfunction which included renal failure, hepatic dysfunction or meningitis was due to Leptospira interrogans Serovar cannicola. Coexsistense of leptospirosis and hepatitis B virus infection were noted in 15 patients. Antibody to Leptospira interrogans was demonstrated by Micro agglutination test (MAT) in addition to dark field microscopy positivity in these cases. Similarly HIV antibody was demonstrated in 30 of the 330 anicteric patients. 554 out of 570 cases responded to intra venous penicillin (216), and oral Doxycycline (182) and Augmentin (156), and the remaining 16 patients succumbed to death.