Leptospirosis in children

 Leptospirosis, an infectious disease that affects humans and animals, is considered the most
common zoonosis in the world.
 It is caused by pathogenic spiral bacteria that belong to the genus Leptospira.
 There are 22 species identified within the genus Leptospira, and these are further divided into
over 300 serovars.
 Leptospirosis has a worldwide distribution, but most human cases occur in tropical and
subtropical countries.
 Leptospires infect many species of animals, including rats, mice, and moles; livestock such as
cattle, goats, sheep, horses, andpigs; wild mammals like raccoons or opossums; and domestic
dogs.
 Infected animals excrete spirochetes in their urine for prolonged periods.
 The rat is the principle source of infection.
 Humans acquire infection after getting exposure to water or soil contaminated with rat urine.
 Agricultural workers, veterinarians, meat handlers, rodent control workers and laboratory
personnel are at risk of getting infected because of occupational exposure.
 Infection is common in the monsoons and during flooding.
 Groups at high risk for leptospirosis include persons exposed occupationally or recreationally to
contaminated soil, water, or infected animals.
 High-risk occupations include agricultural workers, veterinarians, abattoir workers, meat
inspectors, rodent control workers, laboratory workers, sewer workers, and military personnel.

 Exposure to contaminated floodwaters is also a documented source of infection.

 Transmission via animal bites and directly from person to person has been rarely reported.

Pathogenesis

 Leptospires enter human hosts through mucousmembranes (primarily eyes, nose, and mouth),
transdermally through abraded skin, or by ingestion of contaminated water and spread to all
organs hematogenously.
 The organisms damage the endothelial lining of small blood vessels, with leakage and
extravasation of blood cells, hemorrhage and ischemic damage to various organs including liver,
kidneys, meninges and muscles.

ClinicalManifestations

 Human infection ranges from asymptomatic infection to a severe multiorgan involvement which
is often fatal.
 The incubation period is usually 1-2 weeks.
  Leptospirosis can occur as anicteric disease which is more common with less severe
manifestation or as rare icteric form which is more severe.

A. Anicteric Leptospirosis
 This occurs as a biphasic illness with septicemic phase followed by an immune phase.
 Septicemic phase is associated with the multiplication of Leptospira in the bloodstream,
cerebrospinal fluid and other tissues.
 Immune phase is characterized by the development of antibodies to Leptospira and
disappearance of the organisms.

Septicemic phase

 The onset is abrupt with high grade fever with rigors and chills, lethargy, severe myalgia,
headache, nausea, vomiting.
 There may be conjunctival suffusion with photophobia and orbital pain, generalized
lymphadenopathy and hepatosplenomegaly.
 Transient maculopapular rash may be seen in <10% cases.
 Hypotension with bradycardia and circulatory collapse is rare.
 Some patients develop acute respiratory distress syndrome with respiratory failure.
 Most patients are asymptomatic within one week.

Immune Phase or Leptospiruric phase

 In some patients, after a brief asymptomatic phase, the second phase, called the immune or
leptospiruric phase, becomes manifest where Leptospira localize to tissues to cause specific
signs and symptoms.

The important clinical features are in the immune phase are:

 Fever which is less pronounced than in early phase.

 Aseptic meningitis with abnormal CSF pleocytosis is seen occasionally among children.
 Hepatitis is characterized by enlargement of the liver, elevation of bilirubin with a modest
increase in liver enzymes.
 Renal involvement is characterized by abnormal findings in the urine analysis (hematuria,
proteinuria and casts), azotemia with oliguria or anuria.
 Encephalitis, cranial nerve palsies, paralysis and papilledema are rare.
 Central nervous system abnormalities usually normalize within 1 week; mortality is rare.
 A self limited unilateral or bilateral uveitis can occur during this phase, rarely resulting in
permanent visual impairment.
 Renal failure is the principal cause of death of fatal case.
 B. Icteric Leptospirosis (Weil’s syndrome)

 Weil syndrome is a severe form of leptospirosis seen more commonly inadults (>30 yr) than in
children.
 The initial manifestations are similar to anicteric leptospirosis .
 The immune phase, is characterized by jaundice, acute renal dysfunction, thrombocytopenia,
and, in fulminant cases, pulmonary hemorrhage and cardiovascular collapse.
 Hepatic involvement leads to right upper quadrant pain, hepatomegaly, direct and indirect
hyperbilirubinemia, and modestly elevated serum levels of hepatic enzymes. Liver function
usually returns to normal after recovery.
 Patients have abnormal findingson urinalysis (hematuria, proteinuria, and casts), and azotemia
is common, often associated with oliguria or anuria. Acute kidney failure occurs in 16–40% of
cases.
 Abnormal electrocardiograms are present in 90% of cases, but congestive heart failure is
uncommon.
 Transient thrombocytopenia occurs in >50% of cases.
 Rarely, hemorrhagic manifestations occur, including epistaxis, hemoptysis, and pulmonary,
gastrointestinal, and adrenal hemorrhage.
 Patients with pulmonary hemorrhage syndrome may have >50% mortality rate, although the
overall mortality rate for severe disease is lower, about 5–15%.

Diagnosis

 Leptospirosis should be considered in the differential diagnosis of acute flulike febrile illnesses
with a history of direct contact with animals or with soil or water contaminated with animal
urine.
 Leptospirosis should be differentiated from other febrile illnesses commonly seen in the
monsoon season like malaria, dengue, enteric fever, acute viral hepatitis and hantavirus
infections.
 Complete blood count shows anemia, leukocytosis with polymorph predominance and
thrombocytopenia.
 The CRP is elevated and
 Liver enzymes are mildly elevated with SGOT more than SGPT.
 The CPK is high.
 In patients with Weil disease there is elevated serum creatinine, deranged coagulation
parameters and direct hyperbilirubinemia with raised transaminases.
 Specific diagnosis is established by serologic testing, microscopic demonstration of the organism
or culture.
1) Culture - Leptospira can be cultured from blood or CSF during the first 10 days of illness and
from the urine for several weeks beginning at second week.
2) Dark field microscopy (DFM) is used to detect Leptospira in blood within the first 10 days of
illness and from the urine from the second week onwards.
3) Detection of Antibodies to Leptospirosis
 Antibodies to leptospirosis start appearing 5 days after the onset of fever. Therefore
timing of tests is important.
 Serologic tests form the mainstay in the diagnosis of leptospirosis.
a. Macroscopic slide agglutination test (MSAT):
 It is a genus specific test and uses killed Leptospira as antigen.
b. Igm ELISA and Igm specific dot ELISA tests:
 These tests detect genus specific IgM antibodies which tend to become positive early in
the disease around fourth day of illness.

The above mentioned tests are sensitive about 80– 90%, but not specific. They do not
differentiate between pathogenic and saprophytic Leptospira and the infecting serovar
cannot be identified.

c. Microscopic agglutination test (MAT):

 It is a serovar specific test and is the gold standard of serological tests to detect
leptospirosis due to its high specificity.
 The MAT is usually positive 10–12 days after onset and reaches a peak by the third
week.
 It involves the use of a battery of live leptospiral cultures to be used as antigen. It is
done in specialized laboratories.
 Initial high titer of 1:100 or rising titers (fourfold increase) obtained 2 weeks apart are
diagnostic.

TREATMENT

In mild illness, leptospirosis usually responds to oral amoxicillin,azithromycin, cefixime and

doxycycline.
Antibiotic administration especially before the 7 th day of illness reduces the length of the
hospitalization and leptospiruria.
For a severe case of leptospirosis, parenteral penicillin G (6-8 million U /m2 /24 hr q 4 hr IV) for
7 days is the drug of choice. Ceftriaxone and IV tetracycline are also acceptable alternatives.
 [ NELSON-Treatment with penicillin G, cefotaxime, ceftriaxone, or doxycycline (in children ≥8 yr of
age)should be instituted early when the diagnosis is suspected.

Parenteral penicillinG (6-8millionU/m2/day divided every 4 hr IV for 7 days) is recommended, with

doxycycline 2 mg/kg/day divided in 2 doses with maximum of 100 mg twicedaily as an alternative
for patients allergic to penicillin.

Cefotaxime,ceftriaxone, and azithromycin have been evaluated in clinical trials and have
demonstrated equivalent effectiveness with doxycycline.

These antibiotics can be used as alternatives in patients for whom doxycycline is contraindicated.]

Supportive care

 Maintenance of fluid electrolyte balance

 Treatment of cardiovascular collapse
 Dialysis for renal failure
 Use of ionotropes in hypotension refractory to fluid therapy.

PREVENION

 Rodent control and avoidance of contact with contaminated water and soil will prevent
infection.
 Parents should instruct child not to wade through flood waters, or play in stagnant water.
 Immunization of livestock and family pets(cats and dogs) has been recommended as a means of
eliminating some of the animal resorvoirs.