What are the clinical presentations and treatment options for Leptospirosis?

Leptospirosis Clinical Presentation and Treatment

Leptospirosis should be treated with doxycycline (100 mg orally twice daily for 7 days) for mild to moderate cases, while severe cases require intravenous penicillin G or ceftriaxone, especially when jaundice has developed. 1

Clinical Presentation

Leptospirosis has a wide spectrum of clinical manifestations ranging from asymptomatic infection to severe multi-organ failure. The presentation can be categorized into mild and severe forms:

Common Presentations

• Fever: Present in over 90% of cases 2
• Severe headache
• Myalgia (muscle pain)
• Conjunctival suffusion (redness without exudate)
• Chills
• Exanthema (skin rash) 1

Organ-Specific Manifestations

1. Hepatic involvement:

   • Jaundice (significantly associated with mortality, OR 1.2, p=0.04) 2
   • Hepatomegaly and/or splenomegaly 3

2. Renal involvement:

   • Acute kidney injury (often requiring dialysis in severe cases)
   • Oliguria 4

3. Pulmonary manifestations:

   • Pulmonary hemorrhage
   • Acute respiratory distress syndrome
   • Atypical radiographic lung disease 5, 6

4. Neurological involvement:

   • Meningitis
   • Meningoencephalitis 6

5. Cardiac involvement:

   • Myocarditis
   • Pericarditis (independently predictive of severe disease, p<0.02) 6

Laboratory Findings

• Thrombocytopenia (platelets <140 G/L) in approximately 65% of patients 6
• Normal white blood cell count initially
• Elevated liver enzymes
• Elevated creatinine and blood urea nitrogen in renal involvement

Severe Form (Weil's Disease)

Characterized by:

• Jaundice
• Renal failure
• Hemorrhagic manifestations
• Multi-organ dysfunction
• Mortality rate of 5-15% 1

Diagnostic Approach

1. Clinical suspicion based on:

   • Compatible symptoms
   • Exposure history (contact with contaminated water, soil, or animals)
   • Travel to endemic areas

2. Laboratory confirmation:

   • Blood cultures (within first 5 days of illness) 3
   • Cerebrospinal fluid analysis
   • Serological tests
   • PCR testing
   • Immunofluorescence assays 1

Treatment Options

Mild to Moderate Disease

• First-line: Doxycycline 100 mg orally twice daily for 7 days 1

Severe Disease

• First-line options:
  • Penicillin G: 1.5 million IU IV every 6 hours for 7 days
  • Ceftriaxone: 1-2 g IV daily for 7 days
  • Ampicillin: 1 g IV every 6 hours for 7 days 1

Special Populations

• Pregnant patients: Avoid doxycycline; use penicillin G or erythromycin 1

Important Treatment Considerations

• Treatment should be initiated as soon as leptospirosis is suspected
• Treatment may not be helpful after jaundice has developed 3
• Blood cultures should be transferred at room temperature to reference laboratory 3
• Combination antibiotic therapy may be associated with lower mortality rates 2

Prognostic Factors and Pitfalls

Poor Prognostic Indicators

• Jaundice
• Cardiac involvement
• Need for intensive care
• Requirement for dialysis
• History of alcoholism
• Pre-existing chronic liver disease 2, 6

Common Pitfalls

1. Delayed diagnosis due to:

   • Non-specific symptoms resembling other febrile illnesses
   • Atypical presentations
   • Low clinical suspicion in non-endemic areas 7

2. Underreporting due to:

   • Lack of diagnostic capabilities
   • Mild cases being self-limiting 2

3. Treatment delays after jaundice has developed, which may reduce effectiveness 3

Prevention

• Avoid swimming in potentially contaminated waters
• Use personal protective equipment in high-risk occupations
• Control rodent populations
• Treat water for consumption in endemic areas 1