Everything you’ve always wanted to know about leptospirosis

This is the case of a 23-year-old male from Bulacan who, three days before being admitted to the emergency room had a 40-degree fever, chills, headache, neck stiffness, productive cough, nausea, and muscle pain.

At the time of his initial visit, he denied photophobia (sensitivity to light), rash, abdominal pain, and diarrhea. On physical examination, he was found to be tachycardic (with increased heartbeat) and febrile (38.5C). He received two liters of normal saline. He was reassessed and found to be hemodynamically stable, then sent home with prescriptions for fever and nausea/vomiting. The patient reported that his fever was controlled with acetaminophen, but his nausea persisted.

Two days after his first ER visit, the patient developed symptoms of photophobia, non-bloody, watery stools, non-bloody, greenish or bright yellow vomitus up to seven times per day, bloody sputum, and dark tea-colored urine.

On the night prior to his second ER visit, the patient also noticed yellowing of his eyes and face and the onset of abdominal pain. The patient admitted swimming in floodwater two weeks before his second ER visit but denied skin abrasions and water ingestion. At the ER, he was started on triple intravenous antibiotics while awaiting blood/sputum/urine/stool cultures, gram stains, and serological test results. The patient developed respiratory distress while at the ER.

He was weaned to supplemental oxygen via nasal cannula and had no further respiratory distress or evidence of recurrent pulmonary hemorrhage. The patient was transferred to the ward but demonstrated jaundice, decreased abdominal stiffness/tenderness to palpation predominantly in the right upper abdomen and epigastric region. Laboratory values of liver enzymes, serum creatinine (a blood test that measures the level of creatinine in the blood, which is a waste product of muscle metabolism), and creatine kinase (enzyme from muscles) all decreased. The patient was started on a clear liquid diet and continued to demonstrate nausea and pain below the rib cage without vomiting. Serological tests (blood tests that look for the presence of antibodies in a blood sample) returned significant only for leptospira immunoglobulin M (IgM). The patient’s antibiotics were narrowed to intravenous doxycycline. The patient was discharged after demonstrating clinical improvement on completion of seven days of intravenous doxycycline, educated about his illness, and counseled on methods for decreasing risk.

Leptospirosis is a disease caused by the bacterium leptospira that can be found in contaminated water or soil. Many kinds of wild and domestic animals carry the bacteria, including: livestock (cows, pigs, horses, sheep, goats, etc,), dogs, cats, rodents, marine mammals (sea lions, seals, etc.), zoo animals, wild pigs. The bacteria can survive in contaminated water or soil for weeks to months.

Infection is through contact with water or soil containing urine or body fluids from infected animals, especially after hurricanes, flooding, or heavy rainfall.

Causes

• Directly touching body fluids from an infected animal.

• Eating food or drinking water contaminated by the urine of an infected animal.

• Contact with infected soil or even contaminated body of water like lakes, lagoons, creeks, floodwater.

It can also spread from activities like water recreation, such as swimming; kayaking; canoeing or rafting in rivers, swamps or creeks; hiking or hunting; gardening; yard work; and outdoor cleaning and maintenance; jobs like working at a veterinary clinic, dairy farming, or butchering.

It's rare for people to spread leptospirosis to other people. However, if you are experiencing homelessness or living in a shelter or other facilities that have a lot of people living closely together, you may also have a higher risk of getting leptospirosis.

Just like people, animalscan become infected through contact with contaminated urine or other body fluids in water or soil. Signs and symptoms in infected animals can vary widely, and some animals don't show symptoms at all. Infected animals may continue to urinate the bacteria into the environment for several months or years.

About one million cases of leptospirosis occur globally each year with nearly 60,000 deaths. Usually, patients experience fever, headache, chills, body or muscle aches, vomiting or nausea, yellowed skin and eyes (jaundice), red eyes, stomach pain, diarrhea, and rash, Many of these symptoms can be mistaken for other diseases. Some people may even have no symptoms at all. It generally takes two to 30 days to get sick after having contact with the bacteria that cause leptospirosis. The disease may occur in two phases:

• In the first phase, people may have fever, chills, headache, muscle aches, vomiting, or diarrhea. The person may feel better for a while but become ill again.

• Some people may suffer a more severe second phase with kidney or liver failure, or inflammation of the membrane around the brain and spinal cord (meningitis).

The illness can last from a few days to several weeks. Without treatment, getting better may take several months and can lead to kidney damage, meningitis (inflammation of the membrane around the brain and spinal cord), liver failure, breathing difficulty, and even death.

Prevention

• Don't swim or wade in water that might be contaminated with animal urine, especially after hurricanes, floods, or heavy rainfall.

• Avoid contact with animals that may be infected.

• Cover your cuts or scratches with waterproof bandages.

• Wear waterproof protective clothing, shoes or boots near floodwater or other water or soil that may be contaminated with animal urine.

Before taking part in water recreation activities like swimming, boating, fishing, and adventure racing:

• Research the location you'll be in the water for possible leptospirosis infections for that area. Check your local health department. If you're traveling internationally, check CDC Travelers' Health.

• Cover scrapes and wounds with waterproof bandaging and wear shoes if leptospirosis or other diseases are known in the area.

Prevention at work

People at risk include veterinarians, veterinary staff, those raising farm animals, dairy workers, those in animal control, butchers or slaughterhouse workers, sewage and sanitation workers, military and first responders. If you may be exposed as a result of your job, take steps to protect yourself at work: Wash hands frequently, use personal protective equipment (gloves, footwear, eye protection), clean and disinfect surfaces and equipment, vaccinate animals against leptospirosis, and isolate sick animals, exercise control around your work area.

Low-risk exposure

At low-risk are those individuals with a single history of wading in flood or contaminated water without wounds, cuts or open lesions of the skin. Rx: Doxycycline single dose within 24 to 72 hours from exposure>

Moderate-risk exposure

At moderate risk are those with a single history of wading in flood or contaminated water and the presence of wounds cuts, or open lesions of the skin, or accidental ingestion of contaminated water. Rx: Doxycycline 200mg once daily for three to five days to be started immediately within 24 to 75 hours from exposure.

High-risk exposure

At high risk are those individuals (those residing in flooded areas, rescuers and relief workers) continuous exposure to floodwater or contaminated water with or without wounds, cuts or open lesions. At high risk, too, are those swimming in floodwater, especially in urban areas infested with domestic/sewer rats and those who ingested contaminated water. Rx: Doxycycline 200mg once weekly until the end of exposure.

Individuals should continue to monitor themselves for fever and other flu-like symptoms and wear personal protection since antibiotic prophylaxis is not 100-percent effective. The decision to give prophylaxis depends on the risk exposure assessment. If you think you may have leptospirosis, see a healthcare provider right away so that they can run tests and start you on effective medicine to treat it.