People will acquire Leptospirosis from contact via water or moist soil, contaminated with the urine of infected animals or the bodily fluids of infected animals.There is an increased incidence in Hawaii (worse on wetter-windward side). Leptospires enter the body from abrasions or contact with mucous membranes.Leptospirosis in travelers is under-recognized and increasing.

Worse in floods and river rafting.

Symptoms

Symptoms of Leptospirosis with out jaundice: Incubation period can be 7-14 (Sometimes 2-21 days).

Usually no symptoms and 90-95% are self-limited but 5-10% are severely sick.
Symptoms of affected people follow 2 phases:

Phase 1: Leptospiremic phase (3-7 days)
-Sudden onset, severe frontal headache, muscle aches (calf and thighs), high fever, abdominal pain, nausea, vomiting, diarrhea, rashes (maculopapular, urticarial, hemorrhagic), enlarged liver, spleen and lymph nodes, conjunctival suffusion - very red eye. (A suffusion is an increased prominence of the vessels of the eye and not the same as a conjunctivitis).

Phase 2: Immune phase (0-30 days)
-coincides with antibodies, and low grade fever
-Meningitis and uveitis (which can occur later)

Severe Leptospirosis (Weil's Disease)
- involves jaundice, kidney failure, bleeding and cardiovascular collapse - possible biphasic phase, mild phase
- no usual " mortality in severe disease is 4-40% but may increase in the elderly
- worse prognosis with dyspnea, decreased urine output, elevated wbc and abnormal EKG or chest x-rays
- pulmonary hemorrhage has increased mortality with epidemics in China, Brazil, and Nicaragua. These cases don't have jaundice and represent a different variant of Leptospirosis

Diagnosis
- confirmed with serology taken from 2 samples of blood, taken 10-14 days apart
- a positive test is a 4-fold increase in antibodies in that time period
- compared with a 4-fold increase, 10-14 days apart
- lgM anti-bodies can appear after 4 days and peak at week 3-4
- white blood count can be normal but with elevated neutrophils, lower platelets
- CSF antibodies appear by day 10
- ESR elevated
- culture should be attempted with special media (check with lab) culture blood and CSF in 1st phase
- urine in 2nd phase
- specimens should be mid-stream and alkalinized after collection
- dialysis fluid - good culture
- culture may take 6wks to become positive

Other Tests
- CSF fluid is usually normal in second phase, elevated protein, normal glucose and pleocytosis with PMN cells, 1st and later lymphocytes
- Liver function tests - high bilirubin, alkaline phosphates, and transaminase - Elevated amylase (but not pancreatitis
- Urinalysis - has proteinuria

Differential Diagnosis
- Malaria, Rickettsia, Typhoid, Hemorrhagic disease

Diagnostic Red Flags
- history of mud, water, or animal contact
- history of skin, cuts, or abrasions
- conjunctival suffusion (This can be confused with conjunctivitis)
- severe myalgia (calf and back) " acute severe headache
- fever and new onset arterial fibrillation - Hepatitis and elevated wb
- fever and elevated creatine kinase
- fever and elevated amylase
- elevated with bilirubin levels and mild transaminase

Treatment
- start treatment as soon as suspicious
- antibiotics given within 4 days of symptoms, reduce multi-organ complications
- late antibiotics also helpful
- Penicillin, Doxycycline, Erythromycin, for 7-10 days, Ceftriaxone is a good choice as it may cover other infections
- Quinolones are also good (some resistance to chloramphenicol, vancomycin, and aminoglycoside
- must have strict attention to fluids and electrolytes to prevent kidney failure
- connect coagulation abnormalities
- dialysis may be necessary

Bottom Line
- high index of suspicion
- early treatment
- good supportive treatment

Prevention
- identify high risk travelers such as adventure travelers or those water rafting
- avoid contaminated water and soil
- wear protective clothing
- cover cuts and abrasions
- treat drinking water (iodination works well, maybe better than filters)
- shower after possible exposure
- avoid submersion

Vaccine
- Exists and is used for high risk groups in some countries
-Paris uses it for sewage workers, but this is only specific to specific types of Leptospirosis, not useful at all for travelers

Chemoprophylaxis
- 200mg of Doxycycline once weekly is effective for short- term, high-risk activity -start 1wk before and continue 1wk after, Zithromax works well for children

Dengue Fever - overlaps with Leptospirosis but Dengue pain is more boney pain. Leptospirosis is more of a severe muscular pain.


Leptospirosis links:

CDC http://www.cdc.gov/ncidod/dbmd/diseaseinfo/leptospirosis_g.htm

Health Promotion and Education http://www.astdhpphe.org/infect/Lepto.html