Leptospirosis is a grossly underdiagnosed disease in
our country due to lack of awareness, protean manifestations and
inadequate diagnostic facilities in many areas(1). Early diagnosis and
appropriate treatment can prevent fatal outcome. We report four cases
here, three of which we came across during the epidemic that Mumbai
witnessed in the year 2000 and one recently in September 2002.
Case Report
Case 1
An eight-year-old boy was admitted with history of
fever with chills since five days, puffiness of face and arthralgia
since one day. A presumptive diagnosis of urinary tract infection was
made. A day later he developed sudden onset breathlessness, hemoptysis
and hematemesis (250 to 300 mL). He also had subconjunctival hemorrhage.
Suspecting pulmonary edema, frusemide was given and dobutamine infusion
was started. Blood was collected for leptospirosis detection [by dark
ground illumination (DGI) and ELISA] and doxycycline was administered.
He rapidly deteriorated with falling oxygen saturation, altered
sensorium and generalized tonic-clonic seizures. He expired six hours
later. Chest X-ray was not possible. Complete blood count showed:
Hb 8.7 g/dL, total white cell count of 5750/cumm, N 70%, L 30%,
platelets were adequate. Urine examination revealed 10-15 pus cells/hpf,
few casts and bacteria. Serum creatinine was 2.4 mg/dL. Dark ground
illumination (DGI) revealed leptospira in blood (report received after
death of the patient). Leptospiral IgM antibodies were detected by EIA
(dipstick ELISA).
Case 2
Six year old girl was admitted with fever since
fifteen days and approximately 50 mL hematemesis for two days. The
patient had cold extremities, feeble pulses and tachy-cardia. Patient
received intravenous fluids, antibiotics (cefotaxime) and blood
trans-fusion. Doxycycline was also administered and dark ground
illumination and ELISA tests for leptospirosis were ordered. CBC showed
total white cell count 9300/cumm, N 40%, L 53%, bands 17%, Hb 10.7 g/dL
and low platelets on smear examination. DGI and ELISA for leptospira
were positive, therefore crystalline penicillin was added. Patient
improved clinically and was discharged.
Case 3
Seven-month-old male child was being treated for
gastroenteritis with dehydration. Three days later he was found to be
tachypneic, edematous and had ascites. Amikacin was started. On clinical
suspicion of leptospirosis, blood was sent for DGI and ELISA tests,
which came positive. Penicillin and doxycycline were administered. Other
investigations revealed: CBC showed Hb of 10 g/dL total white cell count
of 23,500/cumm, N 31%, L 67%, E 2%, Urine had 1-2 pus cells/hpf, serum
creatinine was 0.7 mg/dL, blood urea 24 mg/dL and blood sugar 60 mg/dL.
Patient improved and was discharged.
Case 4
A ten-year-old boy was admitted for fever, vomiting
since 10 days, passing blood in stools and approximately 100-150 mL
hematemesis since two days and myalgia. On examination, he was febrile,
pale, dehydrated and had a palpable spleen. Investigations revealed Hb
12.2 g/dL, total white cell count 1140/cumm with a differential of N 67%
(bands 11%), L 28% and B 5%. Smear showed trophozoites and gametocytes
of Plasmodium falciparum. Serum creatinine was 1 mg /dL; Liver
function tests, chest X-ray and urine examination were normal.
Leptospira test by DGI was positive. Chloramphenicol was started,
chloroquine and doxycycline were added in view of the positive reports
of Plasmodium falciparum and leptospirosis. The patient improved
and was later discharged.
Discussion
Leptospirosis is a zooanthroponosis caused by a
pathogenic spirochete of genus Leptospira, the species Leptospira
interrogans(2,3). It is characterized by a broad spectrum of
clinical manifestations varying from inapparent infection to fulminant
fatal disease. In the mild form it may present as an influenza like
illness with headache and myalgia. Severe form characterized by
jaundice, renal dysfunction and hemorrhagic diathesis is referred to as
Weil’s syndrome(2). The first case of leptospirosis from India was
reported in 1929 by Taylor and Goyal from Andaman and Nicobar
Islands(3). It is known to occur in sporadic as well as epidemic form in
mainland India. There has been a significant increase in the reported
cases of leptospirosis from India since 1980s. Epidemics have been
increasingly reported from Orissa, Maharashtra, Karnataka, Tamil Nadu
and Kerala(4,5). The primary lesion caused by leptospires is damage to
the endothelial lining of small blood vessels with resultant ischemic
damage to liver, kidneys, meninges and muscles. A low index of suspicion
of this disease coupled with the diversity and non-specificity of the
presentation accounts for the significant number of cases that go
unrecognized(6).
Leptospirosis should be considered in the
differential diagnosis of any acute febrile illness(7). As there is an
overlap of the clinical features of leptospirosis with other infections
like influenza, dengue hemorrhagic fever, enteric fever and viral
hepatitis A, a high index of suspicion is required to diagnose
leptospirosis in a child, especially in endemic areas.
Definitive diagnosis is based on demonstration of the
infecting organism from clinical specimens of blood (first seven days),
cerebrospinal fluid (day four to ten) and from urine (after tenth day)
by phase contract or dark field microscopy. However, the skill required
and the high frequency of artifacts limit their use(7). Serologic tests
like microscopic slide-agglutination test (MAT), indirect
hemagglutination test, dipstick ELISA and dot ELISA for IgM antibodies,
in the presence of clinical symptoms compatible with leptospires
establish the diagnosis(7).
Although this is a multisystem disease with varying
presentation, in our cases, prolonged fever, gastroenteritis, bleeding
tendency, renal symptoms and signs were conspicuous. The patients did
not come from the same locality. The first patient (case 1) who expired,
the respiratory distress appeared to be due to acute respiratory
distress syndrome (ARDS) with severe hemorrhagic disease. This first
case alerted us to keep leptospirosis in mind and suspect it in the
other two cases which presented a month later. In the fourth case, there
was co-existence of two infections (malaria and leptospirosis).
These case reports emphasize the importance of a high
index of suspicion about this disease in view of the recent emergence
and difficult diagnosis, to institute prompt treatment and reduce fatal
outcome.
Contributors: BV prepared the script and reviewed
the literature. SRD co-drafted and reviewed the final script.
Funding: None.
Competing interests: None stated.
