What is spinal involvement in leptospirosis?

Spinal Involvement in Leptospirosis

Spinal involvement in leptospirosis is uncommon but can manifest as meningitis, myelitis, or epidural abscess requiring prompt diagnosis and treatment to prevent neurological complications and mortality.

Clinical Manifestations of Spinal Involvement

• Leptospirosis can present with neurological manifestations during its immunologic phase, most commonly as aseptic meningitis 1
• The disease follows a biphasic pattern with an initial septicemic phase (4-7 days) followed by an immunologic phase when neurological complications typically develop 2
• Neurological manifestations can include meningitis, myelitis, or spinal cord involvement 3
• Symptoms of spinal involvement may include:
  • Headache (persistent or worsening) 4
  • Altered mental status 4
  • Neck stiffness 1
  • Focal neurologic deficits 4
  • Back pain and tenderness 3
  • Radiculopathy or myelopathy 3

Diagnostic Approach

• Lumbar puncture with CSF analysis is recommended for patients with leptospirosis who develop:

  • Unusual, worsening, or persistent headache 3
  • Altered mental status 3
  • Unexplained nausea or vomiting 3
  • New focal neurologic deficits 3

• CSF findings in leptospiral meningitis typically include:

  • Elevated protein (commonly >150 mg/dL) 3
  • Normal or depressed glucose 3
  • Pleocytosis with predominant lymphocytes 1

• Imaging studies for suspected spinal involvement:

  • MRI with gadolinium enhancement is the preferred imaging modality 3
  • CT may be used when MRI is unavailable 3
  • Imaging can detect epidural abscess, meningeal enhancement, or myelitis 3

Treatment Considerations

• Early antibiotic therapy is crucial and should be initiated as soon as leptospirosis is suspected 2

• For mild to moderate disease: doxycycline or penicillin 2

• For severe disease with neurological involvement: high-dose intravenous penicillin or third-generation cephalosporins 2

• Surgical consultation should be obtained for:

  • Spinal instability 3
  • Spinal cord or nerve root compression 3
  • Significant sequestered paraspinal abscess 3

• Surgical intervention may be required for:

  • Decompression of neural elements 3
  • Debridement of infected tissue 3
  • Stabilization of the spine if structural integrity is compromised 3

Monitoring and Follow-up

• Regular neurological assessment is essential during treatment 3
• Follow-up imaging (MRI) is recommended to assess treatment response 3
• Periodic surgical consultation during the course of medical treatment 3

Prognosis and Complications

• Untreated leptospiral meningitis can be fatal 3
• Early diagnosis and treatment significantly improve outcomes 4
• Potential complications include:
  • Hydrocephalus 3
  • Permanent neurological deficits 3
  • Spinal instability requiring long-term management 3

Clinical Pitfalls and Caveats

• Leptospirosis is often misdiagnosed as other febrile illnesses like influenza, dengue, or viral hepatitis 5, 6
• Neurological manifestations may be overlooked in the context of multisystem involvement 7
• Laboratory confirmation may take time, so treatment should not be delayed if clinical suspicion is high 1, 6
• In endemic areas, consider leptospirosis in patients with fever and neurological symptoms, especially after exposure to contaminated water or animals 4, 2