What hemorrhagic manifestations are most commonly associated with leptospirosis?

Hemorrhagic Manifestations in Leptospirosis

The most common hemorrhagic manifestations in leptospirosis include subconjunctival hemorrhage, petechiae, ecchymoses, epistaxis, gingival bleeding, hematemesis, melena, hematuria, and pulmonary hemorrhage, with bleeding occurring in approximately 50% of severe cases. 1, 2

Mechanism of Bleeding

• Hemorrhage in leptospirosis results from capillary fragility and endothelial damage rather than coagulopathy, which explains why clotting studies (PT/PTT) are often normal despite active bleeding 1
• The bleeding diathesis is mediated by direct vascular injury from leptospires and immune-mediated disruption of endothelial integrity through cytokine release and complement activation 3
• Thrombocytopenia commonly accompanies the hemorrhagic manifestations and contributes to the bleeding tendency 1, 4

Specific Hemorrhagic Manifestations by Frequency

Most Common (>10% of cases)

• Subconjunctival hemorrhage occurs in approximately 19% of hospitalized patients and is a highly characteristic finding that should raise immediate suspicion for leptospirosis 5
• Conjunctival suffusion (non-hemorrhagic conjunctival redness) is present in 59-86% of cases and often precedes frank hemorrhage 6, 5, 4
• Petechiae and ecchymoses develop on skin and mucous membranes as part of the generalized bleeding diathesis 1

Gastrointestinal Bleeding

• Hematemesis (vomiting blood) and melena (black tarry stools) occur as manifestations of upper gastrointestinal hemorrhage 1
• Gingival bleeding and epistaxis represent mucosal hemorrhage from capillary fragility 1

Genitourinary Bleeding

• Hematuria is detected on urinalysis in the majority of severe cases and reflects both hemorrhage and direct renal tubular damage 1, 7
• Metrorrhagia (abnormal uterine bleeding) can occur in female patients 1

Life-Threatening Hemorrhage

• Pulmonary hemorrhage is the most lethal hemorrhagic complication, occurring in approximately 8% of confirmed cases, with mortality approaching 50% when present 4, 3
• Massive pulmonary hemorrhage typically manifests as hemoptysis, dyspnea, chest pain, and rapidly progressive respiratory failure, with death often occurring within 72 hours of onset 3
• This complication represents leptospirosis-associated pulmonary hemorrhagic syndrome (LPHS), characterized by diffuse alveolar hemorrhage and is the leading cause of death in severe leptospirosis 4, 3

Clinical Context and Recognition

• Hemorrhagic manifestations typically appear during the immune phase of the biphasic illness pattern, occurring 1-3 days after the initial bacteremic phase 1, 6
• The combination of jaundice (70% of severe cases), hemorrhagic signs (50%), acute renal failure (67-82%), and conjunctival findings should immediately trigger consideration of severe leptospirosis (Weil's disease) 2, 4
• Bleeding from needle puncture sites indicates severe capillary fragility and systemic hemorrhagic tendency 1

Critical Pitfall to Avoid

• Do not wait for abnormal coagulation studies to diagnose hemorrhagic leptospirosis—PT, PTT, and fibrinogen are typically normal despite active bleeding because the mechanism is capillary fragility rather than consumptive coagulopathy 1
• Pulmonary hemorrhage can develop rapidly and unpredictably; any patient with leptospirosis who develops cough, dyspnea, or chest pain requires immediate assessment for LPHS with chest imaging and oxygen saturation monitoring 4, 3