1. Leptospirosis update
Dr.T.V.Rao MD
Dr.T.V.Rao MD

2. Scientific Beginning
It was first described by Adolf Weil in 1886 when he reported an "acute infectious disease with enlargement of spleen, jaundice and nephritis". Leptospira was first observed in 1907 from a post mortem renal tissue slice.
Dr.T.V.Rao MD

3. Leptospirosis - Zoonosis
Leptospirosis is an acute arthropod-zoonotic infection of worldwide significance caused by spirochete Leptospira interregna's which has 23 serogroups and >200 serovars. Various factors influencing the animal activity, suitability of the environment for the survival of the organism and behavioural and occupational habits of human beings can be the determinants of incidence and prevalence of the disease.
Dr.T.V.Rao MD

4. What is leptospirosis?
Leptospirosis, also known as canicola fever, haemorrhagic jaundice, infectious jaundice, mud fever, spirochetal jaundice, swamp fever, swineherd's disease, caver's flu or sewerman's flu, is a bacterial infection resulting from exposure to the Leptospira interrogans bacterium.
Dr.T.V.Rao MD

5. Leptospirosis also called as Weil’s Disease after its inventor.
Dr.T.V.Rao MD

6. Weil’s disease signifies Leptospirosis
There is an acute form of human infection known as Weil's disease, where the patient suffers from jaundice, though this term is often (incorrectly) used to describe any case of infection..
Dr.T.V.Rao MD

7. Leptospirosis 2011
Dr.T.V.Rao MD

8. Synonyms Mud / Swamp fever Japanese 7 day fever Rice Field Fever
Spirochete Jaundice
Canicola Fever
Leptospiral Jaundice
Autumn Fever
Swineherd’s Disease
Dr.T.V.Rao MD

9. The Causative Bacterium
Order Spirochaetales – Treponema, Borrelia, Leptospira
Family – Leptospiraceae, susceptible to heat, cl, acid
Genus – Leptospira, 26 serogroups, 250 serovars
interrogans, biflex, ictero hemorrhagica, hebdomidis
Corkscrew shaped, delicate, flexible spirochete, Gram -ve
6 to 20  long & 0.1  thick, coiled, flagellate, actively motile
Dr.T.V.Rao MD

10. Reservoirs
Wild and domestic animals rodents, livestock (cattle, horses, sheep, goats, swine), canines, and wild mammals are the reservoir for leptospirosis. Many animals have prolonged leptospiruria without suffering from the disease themselves.
Dr.T.V.Rao MD

11. Classification: Phylum: Spirochaetes Class: Spirochaetes
Order: Spirochaetales
Species: Leptospira
Family: Leptospiraceae
Dr.T.V.Rao MD

12. What causes Leptospirosis
Leptospirosis is a bacterial disease that affects humans and animals. Leptospira bacteria are found worldwide and there are many different types or serovars capable of causing disease. Disease caused by Leptospira bacteria is most common in temperate or tropical climates and appears to be rare in North America.
Dr.T.V.Rao MD

13. Morphology
The Leptospira appear tightly coiled thin flexible Spirochetes 5 – 15 microns long.
Fine spiral of 0.1 – 0.2 microns
One end appears bent forms a hook.
Actively motile
Seen best with dark field Microscopy.
Dr.T.V.Rao MD

14. Greater Understanding with Electron Microscopy
Electron Microscopy show thin axial filament and a delicate membrane
In dark field it may appear as chain of miniature cocci.
Dr.T.V.Rao MD

15. Resistance and Disinfection
Leptospira species can be inactivated by 1% Sodium hypochlorite
70%ethanol,
glutaraldehyde,
formaldehyde,
detergents and acid.
This organism is sensitive to moist heat (121 ° C for a minimum of 15 min))and is also killed by pasteurization.
Dr.T.V.Rao MD

16. Leptospirosis – A Major Zoonotic Infection
Weil's disease is comparatively rare, though 'mild' cases of leptospirosis happen everywhere there are carriers, and it is believed that leptospirosis is one of the most common zoonotic infections in the world. Millions of people are infected each year, but information and treatment can be limited, especially in the developed world where cases are considered 'rare' by the medical community.
Dr.T.V.Rao MD

17. Dr.T.V.Rao MD

18. Animals spread Leptospirosis
Rats, Mice, Wild Rodents, Dogs, Swine, Cattle are principle source of infection
The above animals excrete Leptospira both in active infection and Asymptomatic stage
The Leptospira survive and remain viable for several weeks in stagnant water.
Dr.T.V.Rao MD

19. Modes of Transmission Through skin abrasions, intact mucus membrane
1. Direct contact with urine or tissue of infected animal
Through skin abrasions, intact mucus membrane
2. Indirect contact
Broken skin with infected soil, water or vegetation
Ingestion of contaminated food & water
3. Droplet infection
Inhalation of droplets of infected urine
Dr.T.V.Rao MD

20. Human infection is accidental No human to human transmission
Animal Source
Urine
Tissue
Feces
Environment
Contam
Survive
Human
Infection
Human infection is accidental
No human to human transmission
Dr.T.V.Rao MD

21. Dr.T.V.Rao MD

22. Pathogenic Strains x Non pathogenic Leptospirosis
There are several species of Leptospira only few are pathogenic to Humans, rest to some Animals and Many in Nature as saprophytes
Leptospira Interrogans is Pathogenic there are 200 serovars.
Leptospira biflexa Non Pathogenic there are 60 serovars
Further classifications are made on shared antigens
Dr.T.V.Rao MD

23. Genomic based classification
DNA – DNA hybridization studies proved more specific
The traditional serologic classification has limitations at Molecular level, but useful at Epidemiological studies.
Dr.T.V.Rao MD

24. Comparative Morphology of Spirochetes
Dr.T.V.Rao MD

25. Culturing of Leptospira
Leptospira grows best under aerobic conditions at 280 to 300c best demonstrated in Semisolid agar media
Optimal Media
Fletchers Media
Stuarts Media
Optimal growth after 1 – 2 weeks
Dr.T.V.Rao MD

26. Growth requirements
Leptospira derive energy from oxidation of long chain fatty acids, and cannot use or carbohydrates or amino acids as major energy source.
Dr.T.V.Rao MD

27. Antigenic structure
All isolates of L.inttterogans from different parts of the world are serologically related and exhibit cross reactions in serologic tests.
Overlapping of Antigens do occur in different species.
Outer envelop contains large amount of Lipopolysaccharides ( LPS )
Antigenic structure varies from one strain to other
This variation forms the basis of serologic classification
Dr.T.V.Rao MD

28. Genome of Leptospira
L. interrogans serogroups Icterhaemorrhagiae consists of a 4.33 mega base large chromosome and a 359 kilo base small chromosome, totalling 4,768 predicted genes. A series of genes have been discovered that could potentially be related to adhesion. This genome differs from the two other pathogenic spirochete (Treponema palladium and Borrelia burgdorferi), though some similar genes are visible (CHGC, 2004).
Dr.T.V.Rao MD

29. PATHOGENESIS leptospira skin,mucosa
Initial stage leptospiremia toxic symptoms
(1~3days) three symptoms:
fever,myalgia,fatigue;
three signs:
conjunctival suffussion;
muscle tenderness;
enlargement of lymphonodes;
Dr.T.V.Rao MD

30. Pathogenesis Leptospira are present in the water bodies
Enter through breaks in the skin ( cuts and abrasions ) and mucous membranes
Enters through Mouth – Nose – Conjunctive
Rarely enters though ingestion.
Incubation period 1 – 2 weeks
When multiples blood stream produces fever.
May establish organ involvement in Kidney and Liver,
May produce hemorrhage and necrosis in the tissues and initiates dysfunction of these organs
Dr.T.V.Rao MD

31. Sequence of Leptospira Infection
Dr.T.V.Rao MD

32. Clinical Illnesses Types Anicteric (common 95% recover)
Icteric ( Weil’s Syndrome) (rare, fatal)
Hepato-renal syndrome
Hemorrhagic syndrome with ARF
Atypical pneumonia syndrome
Aseptic meningo-encephalitis
Myocarditis, Chronic uveitis

33. Clinical Presentation
90% of Cases
Anicteric
Common, mild
< 2% Mortality
10% of Cases
Icteric
Rare, Severe
15% Mortality
Dr.T.V.Rao MD

34. May present with Jaundice Hemorrhage Nitrogen retention
The Illness is Biphasic with initial temperature when the second phase comes with raise of IgM titers raise
Aseptic meningitis – initial headache, stiffness of neck, pleocytosis of Cerebro spinal fluid
Dr.T.V.Rao MD

35. Pathogenesis of Severe Disease
Vasculitis
Damage to small
blood vessels
Leptospira
Massive migration of fluid from
Intravascular to interstitial compartment
Direct cytotoxic injury
Immunological injury
Renal dysfunction, vascular
Injury to internal organs
Dr.T.V.Rao MD

36. Presenting with Jaundice is significant and Important, Serious Manifestation
Dr.T.V.Rao MD

37. May present with Major Complications
Nephritis
Hepatitis.
Manifestations in eye
Muscular lesions
Many infections are mild and subclinical
Dr.T.V.Rao MD

38. Weil’s Syndrome
Weil's syndrome is a severe form of leptospirosis that causes a continuous fever, stupor, and a reduction in the blood's ability to clot, which leads to bleeding within tissues. Blood tests reveal anaemia. By the third to sixth day, signs of kidney damage and liver injury appear. Kidney abnormalities may cause blood in the urine and painful urination. Liver injury tends to be mild and usually heals completely.
Dr.T.V.Rao MD

39. May present as Atypical Pneumonia
Dr.T.V.Rao MD

40. Hepatitis - Leptospirosis
Hepatitis is the frequent complication
Elevation of serum creatine phospholipase enzyme raise differentiates from Viral hepatitis where the enzyme is not raised
Dr.T.V.Rao MD

41. Nephritis - Leptospirosis
Kidney involvement in animals produce chronic disease of the kidney and the infected animal starts shedding large number of Leptospira and main source of environmental contamination of bacteria and results I human infections
Human urine also contain Spirochetes in the second and third week of infection
Dr.T.V.Rao MD

42. Complications Azotemia Oliguria Hemorrhage Purpura Hemolysis
Gastrointestinal bleeding
Hypoprothrombinemia and Thrombocytopenia
Dr.T.V.Rao MD

43. Differential Diagnosis
Fever
Viral fever, Malaria, Typhus
Jaundice
Malaria, Viral hepatitis, Sepsis
Renal Failure
Malaria, Hanta virus, Sepsis
Meningitis
Bacterial / Viral causes
Hemorrhagic Fever
Dengue, Hanta virus, Typhus
Differential Diagnosis

44. Early and Prompt Diagnosis is Highly Essential
The development of simpler, rapid assays for diagnosis has been based largely on the recognition that early initiation of antibiotic therapy is important in acute disease but also on the need for assays which can be used more widely.
Dr.T.V.Rao MD

45. Laboratory Tests TC / DC / ESR / Hb / Platelet count
Serum Bilirubin / SGOT/ SGPT
Blood Urea, Creatinine & Electrolytes
Chest X-Ray; ECG
Tests for diagnosis of Leptospirosis
Culture for Leptospira: Positive
MAT; Sero conversion or 4 fold rise/ high titer
ELISA / MSAT : positive
MAT: Microscopic agglutination test
(M)SAT: Microscopic slide agglutination Test

46. Leptospiremic phase < 7days
Approach to Diagnosis
Clinical Features
Leptospiremic phase < 7days
Blood Culture
PCR
Immune phase > 7d
ELISA
MSAT
Repeat
MAT
Dr.T.V.Rao MD

47. Laboratory Diagnosis Specimens 2 CSF, Tissues Microscopic examination
1 Blood to be collected in a heparin tube
2 CSF, Tissues
Microscopic examination
3 Urine to be collected with great care to avoid contamination
4 Serum for agglutination tests
Dr.T.V.Rao MD

48. Leptospira under the Microscope
Dark Field Microscopy FL
Long, Thin, Highly Coiled
Dr.T.V.Rao MD

49. Culturing Leptospira
Blood and Urine be cultured in Fletcher’s semisolid agar or other media chemically defined protein-free media for the growth of leptospires have been proposed.
Dr.T.V.Rao MD

50. Time Relationship of Tests
1 week
1 month
2 months
1 year
5 years
MAT
ELISA or SAT
Dr.T.V.Rao MD

51. WHO Guide - Faine’s Criteria2
Headache
Fever
Temp > 39 F 4
Conjn. suffusion
Meningism
Muscle pain 1
Jaundice
Alb,  creatinine 5
Rain fall 4
Contaminate H20 1
Animal contact 15
ELISA IgM + ve
SAT positive
MAT high titer 25
MAT rising titer
Definite
Culture positive
Score of 25 or more – Presumptive Diagnosis
Score of 20 to 25 – Possible case of leptospirosis
Dr.T.V.Rao MD

52. Serology based Testing
Variety of serological tests other than MAT have been developed for the diagnosis of leptospirosis. Among them are the complement fixation test , several enzyme-linked Immuno-Sorbant assay formats , the macroscopic slide agglutination test , the microcapsule agglutination test , the indirect Haemagglutination assay , the dipstick assay , and other methods . Each assay has its own advantages, drawbacks, and limitations
Dr.T.V.Rao MD

53. Serology Agglutinating antibodies raise to very high titers
1 : 10,000 or higher
occurs 5 – 10 weeks after onset of infection
Dr.T.V.Rao MD

54. What is MAT Testing
Each serum sample was tested against 21 or as specified different serovars by MAT by the standard procedure . Agglutination was examined by dark-field microscopy at a magnification of ×100. The reported titer was calculated as the reciprocal of the highest dilution of serum that agglutinated at least 50% of the cells for each serovar used.
Dr.T.V.Rao MD

55. What is MAT Confirmed Test
A MAT-confirmed case was defined as a fourfold increase in antibody titer or a single titer ≥1:200, according to the case definition of the Centres for Disease Control and Prevention
Dr.T.V.Rao MD

56. Serology - ELISA Several Immunoassays are available as commercial kits
Detection of IgM and razing titers of IgG will guide in association with clinical history will help in Diagnosis
Dr.T.V.Rao MD

57. Newer and Rapid Methods in Diagnosis
Several rapid tests are evolved for the
diagnosis of leptospirosis. They are easy to perform and read, although needs to be scientifically evaluated with respect to sensitivity and specificity.
Dri-Dot test gave considerable sensitivity (67.7%)along with good specificity (78%)by Ig M ELISA.
Dr.T.V.Rao MD

58. Treatment
Antibiotic of choice is Benzyl Penicillin given by injection in doses of 5 mega units in a day, for 5 days.
If the patients are genuinely hypertensive to Penicillin opted with Erythromycin 250mgs four times a day for a period of 5 days.
Dr.T.V.Rao MD

59. Preferred treatment Penicillin 6 million units daily I.V (10-14 days)
Amoxicillin, Erythromycin, & Doxycycline
Patients with MOF(Multi organ failure) to be observed and treated in intensive care unit
Dr.T.V.Rao MD

60. Treatment - Other alternatives
The leptospirosis can be effectively treated with
Doxycycline
Ampicillin
Amoxicillin
Severe patients need administration Intravenous Penicillin or Amoxicillin
Dr.T.V.Rao MD

61. Epidemiology Rainfall; Contaminated environment
Poor Sanitation; Inadequate drainage facilities
Presence of rodents, cattle & stray dogs
Walking/ working bare foot poses high risk
Difficult to pinpoint the source of infection
Any person can get infected, if exposed to contaminated and environment
Dr.T.V.Rao MD

62. Epidemiology Leptospirosis causes several animal infections
Most wide spread zoonotic infection in Nature
Human infections are accidental associated with contamination of water, other materials contaminated with excreta and animal flesh.
Animal carriers often excrete upto 100million leptospirosis per ml of urine
Dr.T.V.Rao MD

63. Epidemiology - Occupation
Certain occupational groups such as agriculture workers in rice and cane fields, miners and sever cleaners are potential victims
Dr.T.V.Rao MD

64. Leptospirosis – India’s Concern
The first of its kind in India was reported in the 1920s from Andaman and Nicobar Islands.
In 1993, a serosurvey of conservancy workers in Madras (using MAT) revealed a prevalence rate of 32.9%.
In 1994, an increase in the number of individuals with uveitis was noted at Aravind Eye hospital, Madurai, India after an epidemic of leptospirosis in South India; the epidemic followed severe flooding of the Tamil Nadu District in the autumn of 1993
In 1995, a seroprevalence rate of 12% leptospirosis was found among febrile and jaundice patients in Pondicherry
Dr.T.V.Rao MD

65. How Man gets Infected Water the great source Drinking Swimming
Bathing, as the urine of Rodents chronically infected contaminate water sources
Children get infected when in contact with infected Dogs
Dr.T.V.Rao MD

66. Control of Leptospirosis
Rodent control is most important.
Human’s should avoid contact with water contaminated with animal contact.
Dr.T.V.Rao MD

67. Chemoprophylaxis
Doxycycline 200 mg orally once a week is simple effective measure. When heavy exposure is anticipated
Dr.T.V.Rao MD

68. Vaccination in humans
Vaccination for humans is justified where they cannot be separated from animal sources or where the animals cannot be immunized successfully
Necessity of human vaccinated will arise where people live and work in proximity to rodents in wet, tropical conditions, in wet rice planting and harvesting, in military operations, or working in sewers.
Yet no universally accepted vaccine is available for humans
Dr.T.V.Rao MD

69. Vaccination of Animals
Vaccinating animals have a dual purpose
1 Protecting animals
2 Protecting humans who may contract leptospirosis from them
It is probably true as that immunization of animals will prevent leptospirosis in people in contact with them.
It proved true in 1980 when extensive vaccination of dairy cows in New Zealand lead to marked decreased incidence in Humans.
Animals immunized experimentally with polysaccharide derived from Leptospira LPS linked to diphtheria Toxoid were protected against challenges
Several other vaccines in use to suit local needs.
Dr.T.V.Rao MD

70. New Vaccine trails - Leptospira
Dr.T.V.Rao MD

71. Walking in Flood Waters can Infect
With the rats comes the threat of illnesses such as Weil's Disease, which is transmitted to humans via contaminated water and is carried by up to 30 per cent of the rodent population.
Dr.T.V.Rao MD

72. Prevention Prevention is difficult due to wild animal infection
Good sanitation, Immunization of live stock
Personal hygiene, PPE, Water treatment
No useful human vaccines – multiple serovars
Doxycycline 200 mg weekly for at risk groups
Dr.T.V.Rao MD

73. Created for Health Awareness on Leptospirosis
Dr.T.V.Rao MD