Weil's disease in a young homeless man living in Lisbon.

Leptospirosis is a zoonotic disease of worldwide distribution caused by infection with Leptospira genus bacteria, a pathogenic spirochaete. We present the case of a 29-year-old man admitted to our hospital with fever and multiorgan failure. He provided poor information about his symptoms. No recent travel or occupational history was reported and his clinical presentation did not suggest any infectious foci. His relatives later disclosed that he had been homeless for 3 weeks in the context of behavioural changes, obtaining foodstuff from waste containers and water from rain puddles. In the setting of this epidemiology, his presentation of fever, jaundice, acute renal injury and thrombocytopaenia suggested leptospirosis. Prompt empirical antimicrobial coverage was started, alongside organ support therapy. The diagnosis was later confirmed through microscopical and molecular methods. The patient made a full recovery. Leptospirosis should be considered early in the diagnostic work-up of any patient with acute febrile illness with multiorgan system involvement, with the identification of risk factors being essential to treat early in development of the disease.

Case report: Weil's disease with multiple organ failure in a child living in dengue endemic area.

BACKGROUND: There were few reports in the literature of Weil's disease with multiple organ failures, especially in children living in dengue endemic areas. CASE PRESENTATION: A 12-year-old child was admitted to Tangerang district hospital with a provisional diagnosis of dengue infection. On the third day of hospitalization, dengue diagnostic tests were negative. As fever still remained and was followed by jaundice, decreasing hemoglobin, increasing bilirubin with abnormal value of liver enzymes; other causes of disease were investigated. Leptospirosis was confirmed by rapid IgM test (SD(®)) for leptospira; and micro-agglutination test which indicated Leptospira serogroup bataviae infection. The patient developed Weil's disease during the course of illness. Renal function was back to normal on the 21st day of hospitalization, while hemoglobin and bilirubin returned to normal three weeks after discharged. CONCLUSIONS: Our report highlights the importance of considering leptospirosis as a differential diagnosis in children with acute febrile illness; even when the signs and symptoms for the more common diagnoses such as dengue or typhoid fever were pathognomonic. A normal leukocyte count with neutrophilia and negative dengue NS1, dengue IgM, and Salmonella typhi IgM on admission should raise suspicion of leptospirosis, and prompt diagnostic assays for leptospirosis should be conducted.

Different patterns in a cohort of patients with severe leptospirosis (Weil syndrome): effects of an educational program in an endemic area.

The aim of this study is to investigate the changes in clinical pattern and therapeutic measures in leptospirosis-associated acute kidney injury; a retrospective study with 318 patients in Brazil. Patients were divided according to the time of admission: 1985-1996 (group I) and 1997-2010 (group II). Patients were younger in group I (36 ± 13 versus 41 ± 16 years, P = 0.005) and the numbers of oliguria increased (21% versus 41% in group II, P = 0.014). Higher frequency of lung manifestations was observed in group II (P < 0.0001). Although increased severity, there was a significant reduction in mortality (20% in group I versus 12% in group II, P = 0.03). Mortality was associated with advanced age, low diastolic blood pressure, oliguria, arrhythmia, and peritoneal dialysis, besides a trend to better mortality with penicillin administration. Leptospirosis is occurring in an older population, with a higher number of oliguria and lung manifestations. However, mortality is decreasing and can be the result of changes in treatment.

Weil's disease with elevated plasma D-dimer.

We report a case of Weil's disease manifesting elevation of plasma D-dimer in the acute phase. Later, in the convalescent phase after treatment, the plasma levels of D-dimer returned to normal. Plasma D-dimer can be used as a marker of fibrin formation and degradation. Based on our observations, we conjecture that fibrin formation and fibrinolysis may occur in the acute phase of Weil's disease.

[Clinical reasoning and decision-making in practice. A man with jaundice, renal function disorder, thrombocytopenia, muscular pain and confusion]. / Klinisch denken en beslissen in de praktijk. Een man met icterus, nierfunctiestoornissen, trombocytopenie, spierpijn en verwardheid.

A 51-year-old man became jaundiced, after experiencing flu-like symptoms for a week. On admission anaemia, thrombocytopenia, and hepatic and renal function disorders were present. One month previously he had had sinusitis. Thrombotic thrombocytopenic purpura (TTP)/haemolitic-uraemic syndrome (HUS) was suspected, but the thrombocyte count rose spontaneously. The leukocytosis indicated an infectious cause of the symptoms and the jaundice appeared to originate from intrahepatic cholestasis. All symptoms could be traced to leptospirosis icterohaemorrhagica (known as 'Weil's disease'). The source was possibly the patient's fishpond. He recovered spontaneously and was also treated with antibiotics. Leptospirosis, a multi-organ disease is seen ever more infrequently as an occupational disease in stock farmers and increasingly frequently in people whose hobbies involved animals.

Desmopressin therapy for massive hemoptysis associated with severe leptospirosis.

Massive hemoptysis in patients with severe leptospirosis is often resistant to conventional therapies and can rapidly become fatal. Desmopressin is a fast-acting blood-saving agent used in various hereditary and acquired clotting disorders. We used desmopressin infusions to treat massive pulmonary hemorrhage in six leptospirosis patients with respiratory failure, shock, and multiple organ dysfunction. Hemoptysis ceased rapidly in every case, and five patients finally recovered. Two additional patients with less severe hemoptysis were also successfully treated.

[Hematological parameters in characterization of anemia in leptospirosis]. / Gematologicheskie parametry v kharakteristike anemii pri leptospiroze.

Blood samples from 46 patients with leptospirosis were analyzed on a Cobas Vega (ABX, France) device over the course of disease. Hemoglobin content, erythrocyte count, mean volume of erythrocytes, mean content and mean concentration of hemoglobin in an erythrocyte, anisocytosis index, reticulocyte count, and content of free hemoglobin (FH) were analyzed. Anemia (normocytic normochromic hyperregeneratory) is a typical manifestation of leptospirosis during the second week of disease. The leading pathogenetic mechanism of anemia associated with leptospirosis is erythrocyte hemolysis, whose intensity during the acute period depends on the severity of intoxication and extracorporeal methods of detoxication. Persistence of anemia during convalescent period is due to involvement of the kidneys (nephrotic nephritis).

[Leptospira interrogans serovar Pomona: detection of antigenic differences among 3 regional isolates from cattle and a reference strain]. / Leptospira interrogans serovar Pomona: detección de diferencias antigenicas entre tres aislamientos regionales de bovinos y una cepa de referencia.

Leptospirosis is a zoonosis caused by Leptospira interrogans. This disease is diagnosed by quantification of specific immunoglobulins in serum by the microagglutination test (MAT). The aims of this research were: a) to compare the protein profiles of 3 clinical isolates of bovine leptospirosis with the reference strain used for the MAT, and b) to identify the immunodomain antigens of the regional isolates through PAGE and immunoblotting techniques of bovine sera from infected, vaccinated and MAT-negative animals. Coomassie-blue stained gels revealed extensive protein similarities between pathogenic and reference strain. Most infected (8/10) and vaccinated animal sera (4/7) showed by immunoblotting a similar reactivity against the proteins from pathogenic leptospires, with a strong band of 25-30 kDa which was not detected in the reference strain. The lack of correlation between MAT and immunoblotting techniques for infected animals could be due either to the infection stage at which the diagnosis was made or to the immunoglobulin isotype involved in the response. Results obtained would confirm the antigenic differences between the 3 isolates and the reference strain.

Leptospira interrogans serovar Pomona: detección de diferencias antigenicas entre tres aislamientos regionales de bovinos y una cepa de referencia / Leptospira interrogans serovar Pomona: detection of antigenic differences among 3 regional isolates from cattle and a reference strain

Leptospirosis is a zoonosis caused by Leptospira interrogans. This disease is diagnosed by quantification of specific immunoglobulins in serum by the microagglutination test (MAT). The aims of this research were: a) to compare the protein profiles of 3 clinical isolates of bovine leptospirosis with the reference strain used for the MAT, and b) to identify the immunodomain antigens of the regional isolates through PAGE and immunoblotting techniques of bovine sera from infected, vaccinated and MAT-negative animals. Coomassie-blue stained gels revealed extensive protein similarities between pathogenic and reference strain. Most infected (8/10) and vaccinated animal sera (4/7) showed by immunoblotting a similar reactivity against the proteins from pathogenic leptospires, with a strong band of 25-30 kDa which was not detected in the reference strain. The lack of correlation between MAT and immunoblotting techniques for infected animals could be due either to the infection stage at which the diagnosis was made or to the immunoglobulin isotype involved in the response. Results obtained would confirm the antigenic differences between the 3 isolates and the reference strain.(AU)

Leptospira interrogans serovar Pomona: detección de diferencias antigenicas entre tres aislamientos regionales de bovinos y una cepa de referencia / Leptospira interrogans serovar Pomona: detection of antigenic differences among 3 regional isolates from cattle and a reference strain

Leptospirosis is a zoonosis caused by Leptospira interrogans. This disease is diagnosed by quantification of specific immunoglobulins in serum by the microagglutination test (MAT). The aims of this research were: a) to compare the protein profiles of 3 clinical isolates of bovine leptospirosis with the reference strain used for the MAT, and b) to identify the immunodomain antigens of the regional isolates through PAGE and immunoblotting techniques of bovine sera from infected, vaccinated and MAT-negative animals. Coomassie-blue stained gels revealed extensive protein similarities between pathogenic and reference strain. Most infected (8/10) and vaccinated animal sera (4/7) showed by immunoblotting a similar reactivity against the proteins from pathogenic leptospires, with a strong band of 25-30 kDa which was not detected in the reference strain. The lack of correlation between MAT and immunoblotting techniques for infected animals could be due either to the infection stage at which the diagnosis was made or to the immunoglobulin isotype involved in the response. Results obtained would confirm the antigenic differences between the 3 isolates and the reference strain.

Serological study of the frequency of leptospiral infections among dairy cows in farms with suboptimal reproductive efficiency in Galicia, Spain.

Between March 1996 and September 1997, 15 farms located in Galicia (NW Spain) and experiencing suboptimal reproductive efficiency were visited and blood samples were obtained from all the lactating cows (n=442). Additionally, 1060 samples were obtained monthly from a cohort of 219 lactating cows belonging to nine of the farms between March 1996 and April 1997. All the samples were tested by microscopic agglutination (MAT) using live antigens representing the following Leptospira interrogans serogroups: Australis, Autumnalis, Ballum, Canicola, Grippotyphosa, Icterohaemorrhagiae, Louisiana, Pomona, Sejroe, Shermani and Tarassovi. Eighty-one of the 442 cows were positive against one or more serogroups (P=18.33%). Serologically, L. bratislava and L. grippotyphosa were detected as the most prevalent serovars (P=7.92 and 7.69%, respectively) and as the serovars against which the probability of seroconversion was highest (P=0.27 and 0.25, for a 12-month period, respectively) among those studied. The proportional hazards regression method was used for evaluating the seasonal trend of seroconversions against these two serovars. The risk of seroconversion against L. grippotyphosa was significantly higher during spring. The risk of seroconversion against L. bratislava did not differ significantly among seasons. Our results suggest that infections by L. bratislava did not follow, among the study animals and during the study period, the pattern typically described for non-adapted serovars, pointing out the possibility that some strains of this serovar could behave as adapted serovars.

Competitive enzyme-linked immunosorbent assay for detection of Leptospira interrogans serovar pomona antibodies in bovine sera.

A competitive enzyme-linked immunosorbent assay (ELISA) using a specific monoclonal antibody (M898) was developed for detection of bovine antibodies to Leptospira interrogans serovar pomona. This assay was evaluated using field sera (n = 190) with serovar pomona microscopic agglutination test (MAT) titers of > or =100 as the positive population (group A); field sera (n = 1,445) which were negative in the MAT (1:100 dilution) for serovar pomona (group B); and sera (from a specific-pathogen-free cattle herd [n = 210]) which were negative in the MAT (1:100 dilution) for serovars canicola, copenhageni, grippotyphosa, hardjo, pomona, and sejroe (group C). At the cutoff point recommended by receiver operating characteristic (ROC) curve analysis of the combined ELISA results of serum groups A, B, and C, the sensitivity and specificity values were 93.7 and 96.3%, respectively. The value for the area under this ROC curve was 0.977, indicating a high level of accuracy for the ELISA. Similar results were obtained from the analysis of the combined results of serum groups A and B and from the analysis of the combined results of serum groups A and C.

[Care of a patient with leptospirosis icterohemorrhagica]. / Cuidar a un paciente con leptospirosis icterohemorrágica.

Leptospirosis is an acute generalized infectious disease caused by a spirochete of the genus Leptospira. Humans become infected by direct contact with the animal reservoir or indirectly through standing water or contaminated wet areas; once the leptospira has entered the body through the mucosa or eroded skin, it is spread by blood circulation. It can cause hepatic, renal and muscular disorders, as well as meningeal inflammation. We report the case of a patient admitted to the ICU for an infectious process produced by leptospira. Complications are described and identified as nursing problems and/or diagnoses. Following the NANDA nomenclature, the diagnoses were: Tissue-perfusion disturbance. Deterioration of gas exchange. Deterioration of verbal communication. Nutritional disorder. These categories enabled specific nursing interventions to be planned for the patient's care. The patient died of multiple organ failure in spite of conventional care and treatment.

Leptospirosis in Kuala Lumpur and the comparative evaluation of two rapid commercial diagnostic kits against the MAT test for the detection of antibodies to leptospira interrogans.

The aim of the study was to look into the epidemiology of serodiagnosed cases of leptospirosis at the University Hospital and compare two commercial ELISA Assays to the Microscopic Agglutination Test (MAT). Demographic data for all serodiagnosed cases for the years 1991-1997 were collected. From this data, 104 sera (n = 104) were selected as samples for comparative evaluation of the commercial ELISAs (INDX Dip-S-Ticks and PanBio ELISA) to the MAT test. Thirty two (n = 32) negative control sera were selected from serodiagnosed cases of other differential diagnosis of leptospira infection. The MAT test is a standard test that detects agglutination antibodies to leptospira biflexa, while the INDX Dip-S-Ticks is an ELISA dot test assaying for total anti-leptospira antibodies. The PanBio ELISA is a colorometric assay in test well strips to detect anti-leptospira IgM. The sensitivity, specificity, and efficiency of tests were calculated at a MAT cut-off value of 1:320. Demographic data showed that leptospirosis peaks during March-May and Aug-Nov coinciding with the inter-monsoon period with more men being infected than women and more adults than children. The sensitivity, specificity, and efficiency of test for the INDX Dip-S-Ticks were 83.3%, 93.8% and 87.5% while the values for the PanBio ELISA were 54.2%, 96.9% and 71.3%. The suboptimal PanBio result could be related to the blocking effect of high IgG titres or could be related to the diagnostic MAT cut-off values used in this study. The data hence reflects a pattern of transmission that is related to "wet" occupational risk factors. The commercial assays evaluated, are easier to perform but interpretation of results should be based on level of endemicity. The INDX Dip-S-Ticks allows this flexibility and is a practical alternative to the MAT test.

Leptospirosis: una revisión / Leptospirosis: a review

Es una zoonosis de distribución mundial, ocasionada por una espiroqueta. La principal fuente de infección para el hombre lo constituyen los roedores. Penetra al hombre a través de piel y mucosas, y luego de un período de incubación de 7 a 12 días ocurre una fase septicemica y una inmune. Sus manifestaciones clínicas incluyen insuficiencia renal aguda, trastornos hematológicos, hepáticos, respiratorios y del sistema nervioso. En la presente revisión se dicuten aspectos epidemiológicos, etropatogénicos clínicos de diagnóstico y tratamiento de esta patología

Risk factors associated with the seroprevalence of leptospirosis among students at the veterinary school of Zaragoza University.

The prevalence and risk factors associated with leptospirosis were studied in veterinary students in Zaragoza. Sera were collected at the beginning and end of the academic year 1994 to 1995 and were tested by ELISA against a pool of Leptospira interrogans serovars bratislava, canicola, grippotyphosa, hardjo, icterohaemorrhagiae and pomona antigens. At the beginning of the study the prevalence was 8.14 per cent and at the end it was 11.4 per cent. The incidence of the disease during the study was 0.0394. Risk factors associated with leptospirosis included: taking the course specialising in food inspection and technology, on-farm work, contact with pets in general, and particularly carnivores, and contact with animal traders. The symptoms associated with the disease were myalgia and fever, and the treatment of the symptoms provided some protection.

[The clinical aspects of acute liver failure in leptospirosis]. / Klinicheskie aspekty ostroi pechenochnoi nedostatochnosti pri leptospiroze.

Acute hepatic insufficiency is the main link in the pathological process in leptospirosis determining the degree of severity of the condition and level of bodily compensatory potentialities. Pathogenetically, hepatic insufficiency runs its course through the following three stages: compensated, sub-compensated, and decompensated characterized by different levels of functional (excretory-biliary, protein-synthetizing, hemostatic, detoxicating) inadequacy.

[Hemostatic disorders in a severe course of icterohemorrhagic leptospirosis (a clinico-morphological study)]. / Narusheniia gemostaza pri tiazhelom techenii ikterogemorragicheskogo leptospiroza (kliniko-morfologicheskoe issledovanie).

Morphologic studies were made on the brain tissue and internal organs of those deceased (n = 75) who had died of leptospirosis icterohemorrhagica during different periods of the condition, with the results obtained being compared to clinical and laboratory findings. It has been shown that realization of the pathogenic potential of the disease-producing germ is exercised both through direct generalized injury to the endothelium of microvessels, parenchymal cells (predominantly those of the liver and kidneys) by toxic substances of Leptospira and (to a larger degree) through disorders of hemostasis presented as thrombosis of vessels of the microcirculatory bed with subsequent development of hemorrhagic manifestations and alterative changes of hypoxic genesis in vital organs. Early haemocoagulatory disorders are characterized by marked and stable hypocoagulation, with direction of the processes of fibrin formation and fibrinolysis being different, which fact is consistent with diversity of structural formations originating from fibrin in the microcirculatory bed of the deceased. Prophylaxis of grave pathologic changes in the organism leading to lethal outcome consists in correction of hemostatic disorders during early phases of the disease course, which is to be pathogenetically substantiated and situational one because of the problem posed by verification of stages of that syndrome of disseminated intravascular coagulation in patients with grave course of leptospirosis icterohemorrhagica.