LEPTOSPIROSIS-CASE REVIEW

• 9 yr old  child develops fever,myalgia, calf pain  of 4 days duration. he was playing in water logged foot ball ground few days ago. he has high colored urine ,but no skin or mucosal bleed. no member in famiyl is suffering from hepatitis, he stays in nonendemic area for dengue. he has not travelled in the recent past

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• what are the possibilities?
• can it be leptospirosis/dengue/typhoid?
• if it is leptospirosis then what is the management?

with a history of exposure to infected animals or an environment contaminated with animal urine with one or more of the following

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 Calf muscle tenderness

 Conjunctival suffusion

 Anuria or oliguria and/or proteinuria

 Jaundice

 Hemorrhagic manifestations (intestines, lung)

 Meningeal irritation

 Nausea, Vomiting, Abdominal pain, Diarrhoea.

Probable: Suspected case with positive presumptive laboratory diagnosis.

Confirmed: Suspect/Probable case with conrmatory laboratory test.

 

what is the criteria fro diagnosis?

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Presumptive diagnosis

 A positive result in IgM based immune- assays, slide agglutination test or latex agglutination test or immunochromatographic test.

 A Microscopic Agglutination Test (MAT)titre of 100/200/400 or above in single sample based on endemicity.

 Demonstration of leptospires directly or by staining methods Confirmatory diagnosis  Isolation of leptospires from clinical specimen

 Four fold or greater rise in the MAT titer between acute and convalescent phase serum specimens run in parallel.

 Positive by any two different type of rapid test.

 Sero-conversion.

 PCR tes

 

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• STEP -I : How to clinically suspect Leptospirosis ?

Refer to case definition

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• STEP-2 : How to treat clinically suspected Leptospirosis ?

             Adults: Doxycycline 100 mg twice a day for seven days. Pregnant & lactating

             mothers should be given capsule ampicillin 500 mg every 6 hourly.

          Children< 8 years: Amoxycillin/ Ampicillin 30-50 mg/kg/day in divided doses for 7

            days.

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• STEP-3: Laboratory screening of all suspected leptospirosis cases by rapid            immunodiagnostic test :

         Certain rapid tests are available for diagnosis of leptospirosis. They do not require xpertise                  or  any expensive instruments. However, they require conrmation by ELISA.

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• STEP-4: Treatment at CHC for mild disease and rapid immunodiagnostic positive cases

                 Adults: Doxycycline 100 mg twice a day for seven days. Pregnant & lactating

                  mothers should be given capsule ampicillin 500 mg every 6 hourly.

                 Children<8 years: Amoxycillin/ Ampicillin 30-50 mg/kg/day in divided doses for 7 days.

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• STEP-5: How to treat patients with negative ELISA and negative rapid immunodiagnostic test and clinically stable cases ?

              Adults: Doxycycline 100 mg twice a day for seven days. Pregnant & lactating  mothers           should          be given capsule ampicillin 500 mg every 6 hourly.

           Children< 8 years: Amoxycillin/ Ampicillin 30-50 mg/kg/day in divided doses for 7 days.

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• STEP-6: When to shift patients to higher centre?

         All suspected leptospirosis cases whether positive or negative with rapid    immunodiagnostic  test       having feature of organ dysfunction as follows should be IMMEDIATELY shifted to higher centre.

Renal :�

 Decreased urine output (< 400 ml per day)

 High blood urea (> 60 mg. % )

 High S. Creatinine (> 2.5 mg% )

 Clinical features of uremia,breathlessness,convulsion,delirium,and / or

altered level of consciousness

Hepatic :

 Jaundice

 High S. Bilirubin(>3.0m.g. %)

Pulmonary :

 Breathlessness

 Haemoptysis

 Increased respiratory rate

 X- ray chest showing opacities

Blood :�

 Bleeding tendency

 Low platelet count

Neurological :

 Altered level of consciousness

While shifting patients to the higher centres, relevant clinical profile  along with the treatment given should be furnished

 Treatment at medical college/tertiary level health care facility

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Treatment should be started as early as possible. Any case of fever in leptospiraendemic areas during monsoon and post-monsoon season should be administered antibiotics as follows-

Adults: Doxycycline 100 mg twice a day for seven days

Inj. Crystalline penicillin 20 lacs IU IV every 6 hourly after sensitivity test. (For the individuals who are sensitive to penicillin group of drugs following alternative regimes maybe used)

Ceftriaxone 1 gm IV x 6 hourly for 7 days

OR

Cefotaxime 1 gm IV x 6 hourly for 7 days

OR

Erythromycin 500 mg IV x 6 hourly for 7 days

Pregnant & lactating mothers should be given capsule ampicillin 500 mg every 6 hourly.

Children< 8 years: Amoxycillin/ Ampicillin 30-50 mg/kg/day should be given in divided doses for 7 days

Inj. Crystalline penicillin should be given 2–4 lacs IU/kg/ day for 7 days. (For individuals who are sensitive to penicillin group of drugs following alternative regimes may be used)

Ceftriaxone 50-75 IV mg/kg/day for 7 days

OR

Cefotaxime50-100 IV mg/kg/day for 7 days

OR

Erythromycin 30-50mg/kg/day in divided dose for 7 days

In disease progression multiple organs such as kidney, liver, lungs , CVS and CNS may be involved. The management of organ involvement does not differ then that of  non-leptospirosis causes.

reference: national guidelines on leptospirosis 2015