CASE REPORT ON

LEPTOSPIROSIS
MIGUEL, JOSE SOFRONIO
MARTIN, JOVINE
MIGUEL, KENNETH
MORAL, JOE FELIX
RAJASUNDAR, RAGU
RAMACHANDRAN, INDUJA
RAJAN, RAHUL
MENDOZA, KIMBERLY
RAJENDRAN, JAYA

Department of Emergency Medicine

Department of Health - East Avenue Medical Center
 CASE PROFILE
 A.S.
 36, Female, Married, Housewife
 Brgy. Commonwealth, Quezon City
 November 11, 2019
 3:46 PM

DEPARTMENT OF EMERGENCY MEDICINE

 TRIAGE
 CHIEF COMPLAINT : Fever
 GENERAL SURVEY : Ambulant, awake, not in
respiratory distress
VITAL SIGNS : BP : 90/60 mmHg
HR : 90 bpm
RR : 18 cpm
Temp : 37.8 °C
Pain Scale : 7/10 (muscle pain)
 TRIAGE CLASSIFICATION : Urgent
DEPARTMENT OF EMERGENCY MEDICINE
 PRIMARY SURVEY
SURVEY FINDINGS INTERVENTION
A AIRWAY Patency of airway; -
B BREATHING RR; O2 sat; breathing pattern; auscultation -

C CIRCULATION BP; HR; CRT; peripheral and central pulses -

D DISABILITY GCS / neurological examination; CBG -

E EXPOSURE Temperature, injuries -

DEPARTMENT OF EMERGENCY MEDICINE

 HISTORY OF PRESENT ILLNESS
Present illness started 4 days prior to admission, patient complains
(5/10) of muscle pain with associated undocumented intermittent fever,
chills, and polyuria (yellow urine). No abdominal pain, vomiting, diarrhea,
painful urination, and rashes noted. Patient self medicate with Alaxan
500mg tablet and Bioflu tablet every 4-5 hours, which provided temporary
relief for the muscle pain and fever, respectively.
During the Interim, symptoms persisted and the patient continued self-
medications.

DEPARTMENT OF EMERGENCY MEDICINE

 HISTORY OF PRESENT ILLNESS
6 hours PTA, consult was done at a local health center and laboratory
tests were done (CBC and UA). Patient was diagnosed as a case of UTI, was
prescribed with unrecalled antibiotics, then, subsequently, sent home.
Few hours PTA, persistence of fever and muscle pain (7/10) now
accompanied by 5 episode of vomiting (non-projectile, non-bilous,
previously ingested food), nausea, and 3 episodes of loose watery stools,
prompted consult at our institution.

DEPARTMENT OF EMERGENCY MEDICINE

PAST MEDICAL HISTORY
 No known allergies to food or drugs
 No medical and surgical history
 No psychiatric history

OBGYN history
 G1P1 (1001)  3 day cycle, moderate flow (1-2 pads)
 LMP : October 28, 2019  Not in birth control

SOCIAL HISTORY
 Married for 12 years, with 1 son (10 years old)
 Been staying at current residence for 11 years, no known leptospirosis
case in the neighborhood, not flood prone area; patient had no history of
waddling in flood
 High School graduate; housewife, part-time manicurist

D E PNonsmoker,
A R T M E N T Non-
O F Ealcoholic
M E R G E Nbeverage
C Y M E Ddrinker,
I C I N E Denies illicit drug use
FAMILY HISTORY
 (+) Hypertension – Paternal side

DEPARTMENT OF EMERGENCY MEDICINE

 REVIEW OF SYSTEMS
 (+) dizziness

 (+) headache

 (+) chills

 (+) poor appetite

 (+) Difficulty of breathing

 (-) abdominal pain

 (-) jaundice
DEPARTMENT OF EMERGENCY MEDICINE
 PHYSICAL EXAMINATION
SKIN : Dry, no rashes , warm to touch, normal skin turgor.

HEENT:

HEAD: Normocephalic , symmetrical, atraumatic , no tenderness and masses or lesions.

EYES: Symmetrical, Anicteric sclerae, (+) conjunctival suffusion , pupils are equally reactive to
light, normal consensual reaction

EARS: No ear swelling, lesions, tenderness, or discharge

NOSE: Symmetrical, no obstruction or congestion, lesions, exudates or inflammations, no

sinus
tenderness

MOUTH AND THROAT: No mouth sores, no bleeding gums , tongue is pinkish white and no
deviations, tonsil inflammations and uvula is in the midline
DEPARTMENT OF EMERGENCY MEDICINE
 PHYSICAL EXAMINATION
NECK: No tenderness, no palpable lymph nodes, trachea is in the midline.

CHEST AND LUNGS: symmetrical chest expansion, clear breath sounds , no

retractions

CARDIOVASCULAR: Adynamic precordium, PMI at 5th ICS (MCL), NRRR, No

murmur

ABDOMEN: no scars, discoloration and striae , flabby, bowel sounds:

9/min(normoactive), non tender ,soft

EXTREMITIES: no deformities, (+) calf tenderness, no joint swelling, no edema ,

FEP , CRT <2 secs.

DEPARTMENT OF EMERGENCY MEDICINE

 PHYSICAL EXAMINATION
Motor
NEUROLOGICAL EXAMINATION 5 5
 Oriented, follows commands 5 5
 GCS 15 (E4V5M6) Sensory

I Not tested VII No asymmetry 100% 100%

↓ ↓
II/III 2-3mm EBRTL VIII Intact gross hearing 100% 100%
III IX
Able to swallow
IV Full EOMS X  Nuchal rigidity not tested
VI XI Good shrug  No nystagmus, ataxia
V V1-3 intact XII Tongue midline
DEPARTMENT OF EMERGENCY MEDICINE
 SALIENT FEATURES
This is a case of PERTINENT POSITIVE PERTINENT NEGATIVE
patient SA , 36
 Fever  No history of
y/o,female with
 Muscle pain
Chief complaint of
 Chills waddling in flood
fever
 Polyuria  No rashes
 Nausea and vomiting  No abdominal pain
 (+) Conjunctival suffusion
 (+) Calf tenderness  No jaundice
Initial impression
 DIAGNOSIS
RULED IN RULED OUT
 DIAGNOSIS
RULED IN RULED OUT
 COURSE AT THE EDTC
ORDERS
BP: 90/60 IVF: PLRS 1L to run for 6 hours
CR: 90 Paracetamol 1gm IV
RR: 18 Penicillin G 1.5M IV
TEMP: 37.8 Diet: DAT
02 sat: Diagnostics:
-CBC, BUN, Crea, Serum electrolytes, Dengue test, Lepto test
(+) conjunctival - Chest Xray, 12L ECG
suffusion - ABG
(+) calf pain

DEPARTMENT OF EMERGENCY MEDICINE

 COURSE AT THE EDTC
COMPLETE BLOOD COUNT COMPLETE BLOOD COUNT
WBC 5.8 MCV 90.8
Hgb 117.0 MCH 29.9
Hct 0.36 MCHC 330.0
RBC 3.9 RDW 11.9
Differential count:
Neutrophil 0.88 Blood type: B
Lymphocyte 0.09 Rh Positive
Monocyte 0.03
Eosinophil 0.00
Basophil 0.00
Platelet 166

DEPARTMENT OF EMERGENCY MEDICINE

 COURSE AT THE EDTC
ARTERIAL BLOOD GAS PT/ APTT
pH 7.613 PT 11.8
pCO2 14.4 INR 0.94
pO2 128 APTT 26.8
SaO2 100%
ctCO2 15
HCO3 14.2

DEPARTMENT OF EMERGENCY MEDICINE

 COURSE AT THE EDTC
BLOOD CHEMISTRY
CREATININE 159.40 DENGUE BLOT
BUN 7.00 NS1Ag Negative
SODIUM 134.80 IgG Negative
POTASSIUM 3.22 IgM Nega
SGOT 129.00
SGPT 149.00
TOTAL BILIRUBIN 57.40
DIRECT BILIRUBIN 48.60
TOTAL PROTEIN 70.00
ALKALINE PHOSPHATASE 140.00

DEPARTMENT OF EMERGENCY MEDICINE

 COURSE AT THE EDTC
TIME ORDERS
Time (30 mins) Put progress notes here
Put VITAL SIGNS and
pertinent physical
examinations, signs,
and symptoms here.

DEPARTMENT OF EMERGENCY MEDICINE

 COURSE AT THE EDTC
TIME ORDERS
Time (45 mins) Put progress notes here.
Put VITAL SIGNS and
pertinent physical Indicate disposition
examinations, signs,
and symptoms here.

DEPARTMENT OF EMERGENCY MEDICINE

Final Diagnosis
 COURSE IN THE WARD
DAY 1
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN

(+) Fever BP: 110/70 Leptospirosis Dx:

Leptospirosis test
(+) Myalagia CR: 89 Moderate Blood chemistry
(+) Vomitting RR: 21 CBC
Dengue Test
(+) Epigastric pain T: 37.8 C UA
(+) Diarrhea O2 sat : 96 FA
Total Bilirubin
(-) Oliguria SGPT
SGOT
CXR

TX;
PNSS 1L + 20megs KCl
Pen G 1.5 MU Iv q6
Methylprednisolone 1g Iv OD
Paracetamol 300mg Iv q4
Omeprazole 40mg Iv OD

Monitor urine Output

DAY 2
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN

(+) Fever BP: 100/60 Leptospirosis Dx:

Moderate Repeat
(+) Myalagia CR: 98
Blood chemistry
(+) Vomitting RR: 18 CBC
(+) Epigastric pain T: 36.5 C
(+) Diarrhea O2 sat : 97%
(-) Oliguria
TX;
PNSS 1L
Pen G 1.5 MU Iv q6
Methylprednisolone 1g Iv OD
Paracetamol 300mg Iv q4
Omeprazole 40mg Iv OD

Monitor Urine output

 DAY 3
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN

(-) Fever BP: 110/60 Leptospirosis Dx:

(+) Vomitting CR: 86 Moderate Repeat
(+) Epigastric pain RR: 17 Blood chemistry
(-) Dyspnea T: 36.5 C CBC
(-) Chest Pain O2 sat : 97% UA

TX;
PNSS 1L + 40megs KCl
Metochlopromide 10mg Iv q8
Pen G 1.5 MU Iv q6
Methylprednisolone 1g Iv OD
Paracetamol 300mg Iv q4
Omeprazole 40mg Iv OD

Monitor Urine output

 DAY 4
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN

(-) Fever BP: 110/60 Leptospirosis Dx:

(-) Vomitting CR: 86 Moderate Repeat
(-) Epigastric pain RR: 19 Blood chemistry
(-) Dyspnea T: 36.5 C CBC
(-) Chest Pain O2 sat : 96% UA

TX;
PNSS 1L + 40megs KCl
Calcium Gluconate on 250cc D5W
Pen G 1.5 MU Iv q6
Methylprednisolone 1g Iv OD
Paracetamol 300mg Iv q4
Omeprazole 40mg Iv OD

Monitor Urine output

Discharge Diagnosis (indicate date of discharge)
DISCUSSION
 LEPTOSPIROSIS
 It is one of the most common zoonoses with human infection
caused by the etiologic agent Leptospira interrogans
 It occurs commonly through superficial cuts and open
wounds after exposure to a contaminated environment (e.g.
flood), direct contact with infected animals or following
rodent bites.
 Leptospirosis is endemic in the Philippines and the number of
cases peak during the rainy months of June to August.
Outbreaks have been associated with wading in flood waters.
DEPARTMENT OF EMERGENCY MEDICINE
What clinical manifestations should alert a health practitioner to suspect
leptospirosis among patients presenting with acute fever?

 The incubation period of leptospirosis may range from 2 to 28

days
 The mildest presentation of leptospirosis is fever, headache,
and myalgia, accompanied by other nonspecific findings such
as nausea and vomiting, diarrhea, nonproductive cough, and
maculopapular rash. Conjunctival suffusion (red eyes without
exudate) and severe calf pain may be characteristic.

DEPARTMENT OF EMERGENCY MEDICINE

 SUSPECTED CASE OF LEPTOSPIROSIS
 Any individual presenting with acute febrile illness of at least 2 days AND
either residing in a flooded area or has high-risk exposure (defined as
wading in floods and contaminated water, contact with animal fluids,
swimming in flood water or ingestion of contaminated water with or
without cuts or wounds) PLUS atleast 2 of the following:
 myalgia,
 calf tenderness,
 conjunctival suffusion,
 chills,
 abdominal pain,
 headache,
 jaundice,
 oliguria

DEPARTMENT OF EMERGENCY MEDICINE

DEPARTMENT OF EMERGENCY MEDICINE
 MILD LEPTOSPIROSIS
 Any suspected case of leptospirosis presenting with
 acute febrile illness and various manifestations
 BUT with stable vital signs,
 anicteric sclerae,
 with good urine output,
 and no evidence of meningismus / meningeal irritation, sepsis /
septic shock, difficulty of breathing nor jaundice
 and can take oral medications and can be managed on an OUT-
PATIENT setting
DEPARTMENT OF EMERGENCY MEDICINE
 MODERATE - SEVERE LEPTOSPIROSIS
 Any suspected case of leptospirosis presenting with acute febrile illness associated
with
 unstable vital signs,
 jaundice/icteric sclerae,
 abdominal pain,
 nausea, vomiting and diarrhea,
 oliguria/anuria,
 meningismus / meningeal irritation,
 sepsis / septic shock,
 altered mental states
 or difficulty of breathing and
 Hemoptysis
 BEST managed in a HEALTHCARE / HOSPITAL SETTING

DEPARTMENT OF EMERGENCY MEDICINE

 Severe manifestations of Leptospirosis
 include any combination of jaundice, renal failure,
hemorrhage (most commonly pulmonary), myocarditis, and
hypotension refractory to fluid resuscitation. Other
complications include aseptic meningitis and ocular
involvement including uveitis.
 Weil’s disease is characterized by a triad of fever, jaundice,
and splenomegaly. Current usage of the term “Weil’s disease”
refers to fever, jaundice, and renal failure and is often
considered synonymous with severe leptospirosis.
DEPARTMENT OF EMERGENCY MEDICINE
Clinical features associated with increased risk
for mortality
 altered mental status
 respiratory insufficiency (rales, infiltrates)
 Hemoptysis
 Oliguric hyperkalemic acute renal failure
 Cardiac involvement (myocarditis, complete or incomplete
heart block, atrial fibrillation)

DEPARTMENT OF EMERGENCY MEDICINE

 LABORATORY DIAGNOSIS OF LEPTOSPIROSIS

 A. DIRECT DETECTION METHOD

 1. Culture and isolation - gold standard but time consuming and
labor intensive
 2. Polymerase Chain Reaction (PCR) - has the advantage of early
confirmation of the diagnosis especially during the acute
leptospiremic phase.

DEPARTMENT OF EMERGENCY MEDICINE

 LABORATORY DIAGNOSIS OF LEPTOSPIROSIS

 B. INDIRECT METHOD
 1. Microagglutination Test (MAT) - a four-fold rise of the titer from
acute to convalescent sera is confirmatory of the diagnosis

 2. Specific IgM Rapid Diagnostic Tests like LeptoDipstick®, Leptospira

IgM ELISA (PanBio), MCAT and Dridot® - serologic tests in a single test
format for the quick detection of Leptospira genus-specific IgM
antibodies in human sera.

 3. Nonspecific Rapid Diagnostic Tests like LAATS (Leptospira Antigen-

Antibody Agglutination Test (Leptospira Serology Bio-Rad) detects
Leptospira antibody in human serum through agglutination reaction
which may persist for years.
DEPARTMENT OF EMERGENCY MEDICINE
 The following are non-specific laboratory tests that can support the diagnosis of
leptospirosis and can be used to alert the health practitioner to monitor for the
development of complications:
 1. Complete blood count (CBC) with platelet count may show peripheral leukocytosis
with neutrophilia. Thrombocytopenia is common. Platelet count of < 100,000/cu mm
is a risk factor for bleeding and pulmonary hemorrhage.
 2. Urinalysis shows proteinuria, pyuria, and often hematuria. Hyaline and granular
casts may also be present during the first week of illness. Findings may sometimes be
mistaken for UTI.
 3. Serum creatinine can be initially normal and can elevate during the course of the
illness. An increasing serum creatinine is indicative of impending acute kidney injury.
 4. Serum creatine phosphokinase (CPK-MM) is elevated in patients with severe
myalgia.
 5. Liver function tests – Bilirubin, ALT, AST, and alkaline phosphatase may show slight
elevation. Hyperbilirubinemia may take time to resolve.
 6. Bleeding parameters (Prothrombin time, partial thromboplastin time PTT) may be
prolonged.
DEPARTMENT OF EMERGENCY MEDICINE
 What laboratory findings and ancillary
procedures may indicate SEVERE leptospirosis?
1. Complete blood count (CBC) with platelet count – leucocytosis
(WBC>12,000 cells/cumm) with neutrophilia and thrombocytopenia
(<100,000 cells/cu mm)
2. Serum creatinine > 3 mg/dL (or CrCl < 20 ml/min) and BUN > 23 mg/dL
3. Liver function tests - AST/ALT ratio > 4x, Bilirubin > 190 umol/L
4. Bleeding parameters - prolonged prothrombin time (PT) < 85%
5. Serum potassium > 4 mmol/L
6. Arterial blood gas (ABG) - severe metabolic acidosis(ph< 7.2, HCO3 < 10)
and hypoxemia (PaO2 < 60 mmHg, SaO2 < 90%, PF ratio <250)
7. Chest radiograph demonstrating extensive alveolar infiltrates
8. Electrocardiogram showing signs of heart block, myocarditis,
repolarization abnormalities

DEPARTMENT OF EMERGENCY MEDICINE

 TREATMENT
1. MILD LEPTOSPIROSIS
 Doxycycline
 Amoxicillin
 Azithromycin dihydrate
2. MODERATE - SEVERE
 PEN G
 Parenteral Ampicillin
 3rd generation cephalosporin (cefotaxime, ceftriaxone), and
 Parenteral azithromycin dihydrate.

**Antibiotic therapy should be completed for 7 days, except for azithromycin

dihydrate which could be given for 3 days.

DEPARTMENT OF EMERGENCY MEDICINE

DEPARTMENT OF EMERGENCY MEDICINE
DEPARTMENT OF EMERGENCY MEDICINE
 Pre-exposure prophylaxis
 Doxycycline (hydrochloride and hyclate) 200 mg once weekly,
to begin 1 to 2 days before exposure and continued
throughout the period of exposure

DEPARTMENT OF EMERGENCY MEDICINE

DEPARTMENT OF EMERGENCY MEDICINE
 References

DEPARTMENT OF EMERGENCY MEDICINE

 PRESENTORS’ NAMES
Department of Emergency Medicine
Department of Health - East Avenue Medical Center