What is the treatment for Weil's disease (Leptospirosis)?

Treatment of Weil's Disease (Leptospirosis)

Doxycycline (100 mg orally twice daily for 7 days) is the first-line treatment for Weil's disease (severe leptospirosis) and should be initiated as early as possible to maximize efficacy. 1

Clinical Presentation of Weil's Disease

Weil's disease represents the severe form of leptospirosis characterized by:

• Jaundice and conjugated hyperbilirubinemia
• Acute kidney injury (typically nonoliguric with hypokalemia)
• Hemorrhagic manifestations (including pulmonary hemorrhage)
• Multi-organ failure
• Mortality rate of 5-15% in severe cases 1, 2

Other common clinical features include:

• High fever
• Severe headache
• Muscle pain (particularly thigh cramps)
• Conjunctival suffusion (redness without exudate)
• Chills
• Skin rash 1, 3

Treatment Algorithm

1. Antimicrobial Therapy (Start Immediately)

• First-line treatment:

  • Doxycycline 100 mg orally twice daily for 7 days 1

• Alternative treatments (especially for contraindications to doxycycline):

  • 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:

  • Children under 8 years: Avoid doxycycline (contraindicated)
  • Pregnant patients: Use penicillin G or erythromycin instead of doxycycline 1

2. Supportive Care for Organ Dysfunction

• Renal support:

  • Early and daily hemodialysis for acute kidney injury 2
  • Low daily net fluid intake 2
  • Monitor electrolytes closely (especially potassium due to common hypokalemia) 2

• Respiratory support:

  • Lung-protective ventilation strategies for patients with pulmonary hemorrhage or ARDS 2
  • Monitor for respiratory distress which can develop rapidly (within 72 hours of presentation) 3

• Hepatic support:

  • For severe hyperbilirubinemia not responding to conventional treatment, plasma exchange may be considered as an adjunctive therapy 4

Important Clinical Considerations

1. Early treatment is crucial: Initiate antimicrobial therapy as soon as leptospirosis is suspected, even before laboratory confirmation, as delays can lead to rapid clinical deterioration 3

2. Laboratory diagnosis:

   • Blood cultures within first 5 days of illness
   • Serological testing (fourfold rise in antibody titers)
   • PCR testing of blood or urine 1

3. Monitoring requirements:

   • Daily renal function tests
   • Liver function tests
   • Complete blood count (watch for thrombocytopenia)
   • Respiratory status 1, 3

Common Pitfalls and Caveats

• Diagnostic delay: The clinical presentation may evolve over several days, and antibody testing takes time. Do not delay treatment while awaiting confirmation 3

• Jarisch-Herxheimer reaction: May occur after antibiotic administration, causing temporary worsening of symptoms

• Misdiagnosis: Weil's disease is often misdiagnosed as viral hepatitis, dengue fever, malaria, or other causes of febrile illness with multi-organ involvement 1

• Treatment failure: If no improvement is seen with initial therapy, consider adding a second antibiotic or changing to an alternative regimen

• Relapse: Monitor patients for potential relapse after completing treatment course, which may require retreatment

Early recognition and prompt antimicrobial therapy are the cornerstones of successful management of Weil's disease, with supportive care tailored to the specific organ systems affected.