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Clinical Profile of Patients of Leptospirosis and Its Outcome

1,2,3Dr. Hedgewar Rugnalaya Hospital, Aurangabad, Maharashtra, India. DOI: https://doi.org/10.24321/2349.7181.201916 Background: Leptospirosis is an emerging spirochetal zoonosis worldwide. It is underreported and under diagnosed in India. The clinical manifestations of Leptospirosis range from an asymptomatic illness, self-limiting systemic infection to severe and potentially fatal disease. Approximately 1 million severe cases occur per year . Aims and Objectives: To study the clinical profile of acute onset fever (less than 7 days) that are IgM positive for leptospira and to study their in hospital outcome. Methods: This observational study was conducted in Dr. Hedgewar Hospital, Aurangabad, Maharashtra. The IgM positive leptospirosis patients admitted during January 2014 to December 2018 were included in the study. The information on demographic and clinical profile of these patients was recorded and analyzed based on modified Faine’s criteria. Their in hospital outcome was assessed. Result: The study included 62 leptospirosis IgM positive patients. The mean age was 38.14±15.84 years. All patients presented with fever. Acute Respiratory Distress Syndrome (ARDS) was the most common complication seen in 48.38%. Case Fatality Rate (CFR) was found to be 16.12% (10 out of 62 ) patients .


Introduction
Leptospirosis is a zoonosis caused by spirochetes of the genus Leptospira and is prevalent worldwide . 1 The species has almost 20 serogroups and 200 serovars. Current information on global human leptospirosis demonstrates Case Fatality Rate (CFR) of nearly 10 % . 1 Weil's disease is a severe leptospira infection. Most cases occur in men and peak incidence is during the rainy season. 1 The major burden of the disease is in developing countries. 2 The incidence of leptospirosis is estimated to be 10 or more per 100,000 people in the tropics. 1  rodents, dogs, cattle and pigs. The infection is acquired by humans through direct or indirect contact with water or soil contaminated by the urine of infected animals . 2 The high risk groups constitute agricultural laborers, sewage workers, animal handlers and veterinarian. 3 The isolation rate of the causative organism from clinical specimens is low due to indiscriminate use of antibiotics and also difficult and expensive isolation techniques, currently, serological techniques remain the cornerstone of diagnosis. 4

Aims and Objectives
To study the clinical profile of patients of seropositive leptospira and its outcome.

Materials and Methods
This was a single institutional observational study conducted at Dr. Hedgewar Hospital, Aurangabad. The study was approved by ethical committee Dr. Babasaheb Ambedkar Medical Research Society. Purpose of the study was carefully explained to the patients and consent was taken.
The detailed history and presenting symptoms were noted. Thorough clinical examination was done. The laboratory and radiological tests were carried out. The patients were treated with Injection Doxycycline and other supportive care like fluid resuscitation, blood component transfusions, vasopressors, dialysis and respiratory support was provided as and when needed. The data was analysed and presented. Patients with leptospirosis were diagnosed by using m odified Faine's criteria 5 (score >25) . The enzyme immunoassay for IgM with value more than 20U/ml was considered as positive for leptospirosis.

Result and Observations
A total of 62 patients were evaluated with a mean age of 38.14 +/-15.84 years (30M/32F). Of these 49 (79%) had come from rural areas and 13 (21%) were staying in urban Areas. 10 (16%) patients died in the hospital, of these 7 patients were from rural area and 3 patients were from urban area.
19.35 % (12 patients) were also found to be Dengue IgM positive, however their positive status could not be reconfirmed by molecular tests. The incidence of Leptospirosis was observed more in rainy season.   rate, which could explain the high frequency of hypokalemia in leptospirosis. In our study, we had 26.08% patients with hyperkalemia and 30.43% patients with hypokalemia. It may be due to delay in presentation, anuria at the time of admission and or different epidemiological serovar. Daher et al. concluded age >40 years, hyponatremia, elevated serum creatinine, low arterial pH, high levels of AST, crackles and direct bilirubin levels would be useful markers for patients with oliguric AKI in leptospirosis. This is comparable with our results. 10 The other severe form of leptospirosis is hemorrhagic pneumopathy. It is predictor of acute respiratory failure which is one of the main causes of mortality . In our study ARDS was observed in 48.4% patients. Patil V et al., 6 demonstrated the incidence of ARDS in 30.43% patients. In a study done by Sharma et al. 8 ARDS was observed in 30% of thrombocytopenic patients. The mortality shown by various researchers: Tantitanawat et al. 13 18.50%, Vijayachari et al. 9 10% to 15%. our study showed a mortality of 16.12%.
Vasculitis is an important cause of bleeding in leptospirosis. Contributory factors are thrombocytopenia, capillary endothelial damage, coagulation defects from hepatic dysfunction, consumptive coagulopathy and DIC . 11 Bleeding in vital organs is one of the leading causes of death in leptospirosis. 12 Our study showed the incidence of coagulopathy in 8% patients. DIC was observed in 8.69% patients by Patil V et al.
In the study done by Dupont et al. 11 Multivariate logistic regression demonstrated that five factors were independently associated with mortality: dyspnoea, oliguria, leukocytosis more than 12,900/mm3, repolarization abnormalities on electrocardiograms and alveolar infiltrates on chest radiographs ( Figure 1). We had 12.9% patients with neuroleptospirosis. Mathew et al. 4 in his pathological study of brain in five cases revealed encephalitis. He showed that deep altered sensorium and raised CSF protein were two poor prognostic indicators. We had one patient with Acute Demyelinating Encephalomyelitis (ADEM) who succumbed within 48 h of admission. In study done by Patil V et al. 6 30.43% patients had neuroleptospirosis. Panicker et al. 13 showed paraparesis as initial presentation in 42.5% patients. 7.5% patients had a lower motor neuron paraparesis. Myelopathy was seen in 17.5% patients, myeloradiculopathy in 17.5%, and Guillain-Barré syndrome-like presentation in 7.5%.

In Summary
Total 62 IGM positive leptospirosis patients with mean age of 38.14 (±15.84) years. 79% patients were from rural background. 52% patients were females. 61.2% patients presented in rainy season. Common presentations in our study were fever ( 100 %), body ache ( 87.09%), nausea & In our study the incidence of hepatitis was 50.6% and AKI was 14.5%. In the study done by Virendra Patil et al the incidence of hepatitis was 69.56% and AKI was 52.17%. 6 Hyperbilirubinemia is the most frequently noted laboratory abnormality 9 Andrade et al. 10 showed non oliguric acute kidney injury and hypokalemia. The tubular function alterations precede a decrease in the glomerular filtration

Conclusion
• High proportion of cases indirectly reflects the endemic nature of the disease. • The clinical presentation of leptospirosis is highly protean and may vary from subclinical to mild illness to life-threatening complications and death. • Unavailability of microscopic evidence of leptospirosis remained the lacunae of our study. • There is a need for such studies in areas of heavy rainfall and water stagnation where the incidence may be much more