Leptospirosis Sung Chul Hwang Dept. of Pulmonary and Critical Care Medicine Ajou University School of Medicine

Introduction Spirochetal disease, finely coiled, motile, 0.1  x 6 – 20  Systemic infection manifested as widespread vasculitis Zoonosis L. interogans 23 serogroups and 187 serovars L. biflexa : non-pathogenic, saprophyte

Historical back ground 1921 : Takaki 창경원 죽은 족제비 – L. icterohemorragiae 분리 1942 : sekiguchi – L. canicola from mouse 1951 : 미군, 동경 401 의무 시험소 - 국내 들쥐 로부터 ictohemorrhagiae 분리 1975 : 경기 강원 충북, “ 출혈성 폐렴양 괴질 ” 1984 년 10 월 : 강원도 원주, 괴질 환자에서 렙 토스피라 균을 분리 동정 1984 년이후 : 매년 9-11 월 환자 및 야생쥐 - leptospira 균이 동정됨

Epidemiology Disease of the wild animals Incidental human infection by direct or indirect contact with the animal 20-40s active males: farmers or soldiers in harvest time 9-10 peak  into November 추수, 탈곡, 벌초, 성묘, 나무하기, 훈련, 등

Reservoires of Infection Rats Dogs Live stocks Rodents including rabbits Wild animals Cats

Sources of Human Infections Contaminated Water or soil from infected urine Direct animal contacts Occupational exposure : farmers, vets, abattoire workers Recreational exposure : campers, swimmers, visiting graveyards

Routes of Infection Contact with water or soil contaminated animals Direct contact with the by urine from infected source, farmer, vets, butchers, recreational activities Rodents carry EH fever, scrub typhus, paratyphus, leptospirosis Factors for high incidence : rain during harvest time, carrier rate in rodents Spirochetes survive longer in wet swampy conditions

국내 주민의 항체 보유율 – : 11.69% – : 5.9 % 1985 in febrile patients : 20% in febrile patients : 11.6%

국내 야생쥐의 균 보유율 1984 : 15.5% 1985 : 14.9% 1986 : 16% 1987 : 30.9% ( 파주, 여주 )

Microbiology and distribution Mainly serogroup ictohemorrhagiae and canicola 전북, 서울, 강원, 충북, 충남 CH-48 : 춘천지방, 혈청형 미상 Serovar : mainly lai

Pathogenesis Entry sites : skin wounds or abrasions in hand and feet and mucous membranes, conjunctiva, nasal, oral Bacteremia involving the entire body including eye, CSF Systemic effect and vasculitis due to endotoxin (hyaluronidase) and burrowing motility Hemorrhagic necrosis esp. in liver, lung, and kidneys  jaundice, ARF, hemorrhages

Clinical types Types Pneumonitis33%57.7% Rash type17% Weil ’ s disease15% Renal failure13%53.8% “ Flue-like ” 15%13.5% Acute Hepatitis 8% Combination86.5%

Phase I (Septicemic) Following incubation period of 7-10 days High spiking fever, headaches, myalgia, arthralgias Lasting 4 – 7 days Proteinuria and increased creatinnine Organism detectable but serologic diagnosis not possible

Phase II (Immune) Much more variable Induction of IgM Antibodies 1- 3 day freedom  recurrence of symptoms Lower fever, CNS signs Maybe cultured from urine but not from blood or CSF

Weil’s Disease Less common but severe form Mild phase I, initially Followed by severe Jaundice, Azotemia, and Hemorrhage from Lungs, GI tract, and other organs (3-6 day) Oliguric renal failure and Liver dysfunction dominate the clinical picture

Clinical Signs of Leptospirosis Pulmonary infiltrates, pneumonitis, hemorrhages Conjunctival injection Jaundice Muscle tenderness Abdominal tenderness CVA tenderness Abnormal auscultation Erythema, petechiae, neck stiffness, adenopathy

Lab. Diagnosis Microbiologic identification : Blood or CSF  first 10 days Urine  second week (Fletcher ’ s, EMJH Medium) Serology: screening  Microscopic Slide Agglutination (MST), titration & serogroup identification  Microscopic Agglutination (MAT), detection of IgM (ELISA)

Chest X-rays 33 – 64 % of patientssjows abnormality Bilateral nodules, rosette densities Diffuse ill-defined infiltrates Massive confluent consolidation Bilateral, Non-lobar, peripheral predominance Rare pleural reaction Complete resolution within 5 to 10 days

Treatment Early anti-microbial therapy is important  shorten the course and prevent carrier state Choice : Penicillin G, Ampicillin May cause “ Jarish-Huxheimer type reaction ” Mild cases oral Doxycycline or Amoxicillin

Prevention Vaccination of domestic animals Rodent control Protective gloves and boots Avoid swimming in contaminated waters Vaccination in endemic region

Differential Diagnosis EH fever Rickettsial disease : Scrub typhus, murine typhus Acute viral hepatitis Sepsis Influenza Aseptic Meningitis

Conjunctival hemorrhage in leptospirosis