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Leptospirosis - Long Case Write-Up
DEFINITION
Leptospirosis is a zoonotic bacterial infection caused by pathogenic spirochetes of the genus Leptospira (most commonly L. interrogans). It is the most widespread zoonosis worldwide, endemic in tropical and subtropical regions. The disease ranges from a mild self-limited febrile illness to the severe Weil's disease - characterized by the classic triad of jaundice, acute renal insufficiency, and hemorrhage.
- Goldman-Cecil Medicine, 27th ed., Ch. 298
CASE PRESENTATION (Template)
Presenting Complaint:
A [age] year-old [occupation: farmer / sewage worker / military personnel / flood victim / veterinarian] male/female presents with:
- High-grade fever with chills (sudden onset)
- Severe headache (bitemporal/frontal, throbbing)
- Myalgia - particularly severe in the calves and thighs
- Nausea, vomiting, abdominal pain
- Conjunctival suffusion (without discharge)
- Jaundice (if Weil's disease phase)
- Oliguria / reduced urine output
HISTORY OF PRESENTING ILLNESS
Exposure History (CRITICAL - ask about the 30 days prior to symptoms):
- Contact with flood water, rivers, paddy fields, soil, or mud
- Occupational exposure: farming, sewage work, mining, slaughterhouse, veterinary work
- Recreational exposure: swimming/wading in potentially contaminated water, adventure sports
- Contact with animals (rodents, dogs, cattle, pigs, horses)
- Skin abrasions or open wounds present at time of exposure
Timeline - Biphasic Illness:
| Phase | Timing | Features |
|---|---|---|
| Phase 1: Leptospiremic/Bacteremic Phase | Days 1-7 (up to 10 days) | Sudden fever, rigors, severe headache, myalgias (calves), conjunctival suffusion, nausea, vomiting, rash |
| Brief Improvement | Day 4-9 | Apparent defervescence lasting 1-3 days |
| Phase 2: Immune/Leptospiruric Phase | Days 7-14+ | Recurrence of fever, organ involvement (jaundice, AKI, meningitis, hemorrhage, uveitis) |
Note: Many patients do not show classic biphasic pattern and may present with an undifferentiated febrile illness.
Severity Assessment:
- Mild/Anicteric (~90%): flu-like, self-limited
- Severe/Icteric - Weil's Disease (~10%): jaundice + AKI + hemorrhage + multiorgan failure
PAST MEDICAL HISTORY
- Previous episodes of jaundice or fever
- Diabetes mellitus, CKD, liver disease (worsen prognosis)
- Immunosuppression status
- Vaccinations (leptospirosis vaccine available in some countries)
SOCIAL & OCCUPATIONAL HISTORY
- Occupation (high-risk: farmer, sewer worker, military, vet)
- Recent flooding / travel to endemic areas (India, Malaysia, Brazil, SE Asia)
- Animal contact (especially rats, dogs)
- Living conditions: sanitation, rodent infestation
CLINICAL FEATURES
General Examination
- Ill-looking patient
- Fever (high-grade, 38-40°C)
- Tachycardia
- Jaundice (if Weil's disease)
- Pallor (hemolysis)
- Dehydration
Classic Physical Signs
| Sign | Description |
|---|---|
| Conjunctival suffusion | Bilateral conjunctival redness WITHOUT discharge or pain - highly characteristic |
| Calf muscle tenderness | Severe myalgia in calf/thigh - nearly pathognomonic |
| Jaundice | Deep obstructive-looking jaundice (hyperbilirubinemia >30 mg/dL) with RELATIVELY MILD transaminase elevation (distinguishes from viral hepatitis) |
| Hepatosplenomegaly | Tender hepatomegaly; splenomegaly less common |
| Petechiae/purpura | Bleeding tendency - petechiae, ecchymoses |
| Rash | Maculopapular, erythematous (transient, trunk) - 10-20% |
Systems Review
Renal:
- Oliguria or paradoxically non-oliguric AKI (characteristically non-oliguric early)
- Proximal tubular dysfunction: hypokalemia (urinary K+ wasting), glycosuria, bicarbonaturia
- Urinalysis: hematuria, proteinuria, pyuria, granular casts
- AKI mechanism: acute tubulointerstitial nephritis (direct spirochetal tubular injury)
Hepatic:
- Jaundice: deep, due to hepatocellular damage (bile leakage from sinusoidal disruption)
- Elevated bilirubin (predominantly conjugated), mildly elevated transaminases
- Key point: disproportionately high bilirubin relative to transaminases - contrast with viral hepatitis
Pulmonary (Severe/Fatal):
- Pulmonary hemorrhage / diffuse alveolar hemorrhage (DAH)
- ARDS
- Hemoptysis - major cause of death
- Can occur even in the absence of jaundice
Cardiovascular:
- Myocarditis with arrhythmias (especially Weil's disease)
- ECG: conduction defects, ST-T changes
Neurological:
- Aseptic meningitis: headache, meningismus, photophobia, CSF shows lymphocytic pleocytosis
- Meningoencephalitis (rare)
- Uveitis (late manifestation - weeks to months after acute illness)
Hematologic:
- Thrombocytopenia (common, platelet <100,000)
- Anemia (hemolytic or blood loss)
- Coagulopathy / DIC in severe cases
INVESTIGATIONS
Routine/Non-specific
| Test | Expected Finding |
|---|---|
| CBC | Leukocytosis (neutrophilia), thrombocytopenia, anemia |
| ESR/CRP | Elevated |
| LFTs | Elevated conjugated bilirubin (markedly), mildly raised ALT/AST (ratio of bilirubin:transaminase elevated - distinguishing feature) |
| Creatinine/Urea | Elevated (AKI) |
| Electrolytes | Hypokalemia (tubular potassium wasting - characteristic) |
| ABG | Metabolic acidosis |
| Coagulation | Prolonged PT/PTT, decreased fibrinogen (DIC in severe cases) |
| Urinalysis | Hematuria, proteinuria, pyuria, granular casts |
| CPK | Elevated (rhabdomyolysis) |
| CXR | Bilateral infiltrates (pulmonary hemorrhage/ARDS) |
| ECG | Arrhythmias, ST-T changes |
Specific Diagnostic Tests
1. PCR (Polymerase Chain Reaction) - PREFERRED early test
- Blood PCR: high sensitivity in first 5-7 days (leptospiremic phase)
- Urine PCR: useful after day 7 (leptospiruric phase)
- Rapid, specific, does not require live organisms
2. Serology
- MAT (Microscopic Agglutination Test) - GOLD STANDARD
- Requires live Leptospira cultures in laboratory
- Fourfold rise in paired samples (10-14 days apart) = definitive diagnosis
- Single high titer ≥1:800 = probable diagnosis
- Negative in first week (antibodies not yet formed)
- ELISA IgM: faster, more widely available; useful from day 5-7 onwards
- Sensitivity improves in the immune phase
- Rapid Lateral Flow Assays: field use in endemic areas (lower sensitivity/specificity)
3. Culture
- Blood culture: positive in leptospiremic phase (days 1-7) - SLOW (weeks to grow)
- Urine culture: positive after day 7
- EMJH medium; organism is fastidious - rarely used clinically
4. Dark-field Microscopy
- Direct visualization of leptospires in blood/urine
- Low sensitivity and specificity - NOT recommended for routine diagnosis
Diagnostic Algorithm Summary:
Early illness (Days 1-7): PCR blood > Culture blood > Serology (likely negative)
Late illness (Days 7-14+): Serology (MAT/ELISA) > PCR urine > Culture urine
Paired sera: Acute (day 1) + Convalescent (day 14+) → fourfold MAT rise = confirmed
DIFFERENTIAL DIAGNOSIS
| Diagnosis | Differentiating Features |
|---|---|
| Dengue fever | Rash, thrombocytopenia, negative MAT/PCR for leptospira; NS1 antigen positive |
| Malaria | Blood smear positive, parasitemia; specific geographic exposure |
| Viral hepatitis (A/E/B) | Very high transaminases (>1000 IU/L), hepatitis serology positive |
| Scrub typhus | Eschar, lymphadenopathy, Weil-Felix positive, responds to doxycycline |
| Typhoid fever | Widal positive, relative bradycardia, rose spots, blood culture positive |
| Hantavirus | Rodent exposure, pulmonary syndrome, thrombocytopenia |
| Septicemia | Blood cultures positive for organism |
| Acute Cholecystitis | RUQ pain, Murphy's sign, ultrasound findings |
Key diagnostic clue: Calf tenderness + Conjunctival suffusion + Jaundice with disproportionately mild transaminase elevation + Hypokalemia in a patient with flood/water exposure = Leptospirosis until proven otherwise.
MANAGEMENT
General Principles
- Hospital admission for moderate-severe disease
- ICU for: severe AKI, pulmonary hemorrhage, ARDS, shock, arrhythmias
- Empirical antibiotics should be started immediately based on clinical suspicion - do not wait for confirmation
- Jarisch-Herxheimer reaction possible 1-48 hours after starting antibiotics (sudden fever, rigors, hypotension) - manage supportively
Antibiotic Therapy
| Severity | Regimen | Duration |
|---|---|---|
| Mild disease | Doxycycline 100 mg PO twice daily (preferred - also covers rickettsial infections) | 7 days |
| Mild alternatives | Amoxicillin 500 mg TDS or Azithromycin 500 mg once daily | 7 days |
| Moderate-Severe (Weil's disease) | IV Benzylpenicillin 1.5 MU 6-hourly OR | 7 days |
| IV Ampicillin 1g 6-hourly OR | 7 days | |
| IV Ceftriaxone 1g once daily (preferred in penicillin allergy, also covers meningitis) | 7 days |
Note: Doxycycline 200 mg/week for chemoprophylaxis in high-risk exposure settings.
Supportive Management
Fluid and Electrolytes:
- IV fluid resuscitation (normal saline) for dehydration and non-oliguric AKI
- Aggressive potassium replacement (hypokalemia from tubular wasting)
- Monitor input/output carefully
Renal Support:
- Non-oliguric AKI: aggressive IV fluids + electrolyte replacement
- Oliguric/anuric AKI or fluid overload: early hemodialysis (intermittent HD) or peritoneal dialysis - early initiation is lifesaving
- Monitor creatinine, electrolytes, urine output daily
Pulmonary Hemorrhage:
- High-flow oxygen, mechanical ventilation if needed
- IV methylprednisolone (controversial but used in severe pulmonary hemorrhage)
- PEEP ventilation for ARDS
Hepatic:
- Vitamin K for coagulopathy
- Fresh Frozen Plasma (FFP) for active bleeding with coagulopathy
- Monitor INR
Hematologic:
- Platelet transfusion if <20,000 or active bleeding
- FFP for coagulopathy/DIC
Cardiovascular:
- Cardiac monitoring for arrhythmias
- Manage shock: IV fluids, vasopressors if needed
COMPLICATIONS
| System | Complication |
|---|---|
| Renal | AKI (oliguria carries poor prognosis), CKD (rare) |
| Pulmonary | Pulmonary hemorrhage (leading cause of death in modern series), ARDS |
| Hepatic | Liver failure (rare), jaundice |
| Cardiac | Arrhythmias, myocarditis, cardiac arrest |
| Neurological | Aseptic meningitis, meningoencephalitis, uveitis (months later) |
| Hematologic | DIC, thrombocytopenia |
| Ocular | Uveitis (weeks-months after acute illness - late sequela) |
Prognostic indicators of poor outcome:
- Oliguria (vs. non-oliguria)
- Pulmonary involvement / hemoptysis
- Cardiac arrhythmias
- Severe jaundice (bilirubin >30 mg/dL)
- Thrombocytopenia
- Multiorgan failure
PREVENTION
Individual:
- Avoid contact with potentially contaminated water/soil
- Protective clothing/footwear for occupational exposure
- Doxycycline 200 mg weekly chemoprophylaxis for high-risk military/adventure exposure
Public Health:
- Rodent control programs
- Improved urban drainage and flood control
- Animal vaccination (dogs, livestock)
Vaccine:
- Human vaccines available in some countries (Cuba, France, China - limited availability)
- Recommended for high-risk occupational groups
PROGNOSIS
- Overall mortality: 5-15% in severe Weil's disease; higher in pulmonary hemorrhage (up to 50%+ if ARDS develops)
- Most patients with non-oliguric AKI recover renal function completely
- Uveitis may develop 2-4 weeks to months after acute illness
KEY POINTS FOR EXAM
- Organism: Leptospira interrogans - spirochete (question mark shaped), 0.1 x 6-20 microns
- Transmission: Rodent urine via broken skin/mucosa - NOT person-to-person
- Classic triad of Weil's disease: Jaundice + AKI + Hemorrhage
- Pathognomonic clue: Calf tenderness + Conjunctival suffusion (without discharge)
- Key lab finding: High bilirubin with MILDLY raised transaminases + Hypokalemia (tubular wasting)
- AKI type: Non-oliguric early (proximal tubular dysfunction) - aggressive fluids; Oliguric = dialysis
- Diagnosis: PCR (early) + MAT serology (gold standard, paired sera, 4x rise)
- Treatment: Doxycycline (mild) / IV Penicillin or Ceftriaxone (severe)
- Jarisch-Herxheimer: Occurs 1-48h after starting antibiotics - manage supportively
- Late complication: Uveitis (weeks-months later)
Sources: Goldman-Cecil Medicine, 27th Ed. (Ch. 298); Comprehensive Clinical Nephrology, 7th Ed. (Ch. 71); Brenner & Rector's The Kidney, 10th Ed. (Ch. 44). Recent review: Predictors of severe leptospirosis (Eur J Med Res, 2025).
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