Leptospira disease lecture (Leptospirosis)

2021-01-31 12:00 AM

Liver damage in leptospirosis causes jaundice. This is caused by damage to the blood vessels that feed the liver cells, leading to cell necrosis and by mycotoxin causing red blood cell destruction.

Define

Leptospirosis is an acute infectious disease caused by Leptospira spirochetes. Mainly transmitted through the skin, mucous membranes. The clinical features are systemic toxic sepsis syndrome and liver and kidney damage syndrome.

It is a disease of animals that spread to humans, there is a natural disease.

Course history

Before 1886, Leptospira disease was often mistakenly diagnosed with yellow fever, malaria, dengue, hepatitis ...

In 1886, Weil described the Leptospira disease as a separate disease from the above, but it was not until 1914 that Spirochete was successfully cultured. From 1914 to 1940 many diseases were discovered to be caused by Leptospira such as autumn fever, 7-day fever in Japan, swamp fever in Europe…

Epidemiology

Pathogens

Leptospira family, fresh microscopy under the black background microscope shows the spirochetes are long, thin filaments with 15-30 very close together, the ends are usually curved C-shaped. Size: 4-30 micrometers 0, 1-0.2micrometers moves strongly in a vortex and straight up like a spring. Spirochetes are able to penetrate the skin and mucous membranes, especially scratched skin. Catching Gram-negative color, aerobic, grows slowly in the culture media, pH is appropriate 7.2-7.5, temperature 28-300C.

Spirochetes has weak resistance, is killed at 500C / 10 minutes. light and conventional disinfectants easily kill Leptospira. However, Leptospira is cold tolerant, and can survive in water for up to 3 weeks. Persistent living in muddy, stagnant water with basic pH (pH = 7.7), the best water is from field sewers, streams.

Leptospira is known to cause human and animal disease to be divided into about 23 groups, consisting of 240 serotypes, each with its own specific antigens. Between types, there is partial cross-agglutination, making diagnosis difficult. In Vietnam, 15 types have been discovered, of which 5 types are often pathogenic:

  1. ictero-hemorragiae.
  2. australis.
  3. grippotyphosa.
  4. bataviae.
  5. hebdomadis.        

Inoculum

As animals, including cattle such as sheep, goats, pigs, dogs, cats ... There are also many kinds of wild animals such as bears, leopards, mice ...

Accidental illness, not a source of the disease. However, some authors believe that there is human-to-human transmission by spirochetes through the urine of patients.

Infection

Skin, mucous membranes: Due to contact with water, mud and soil, there is a spirochete pollution. This is the main route of transmission.

Gastrointestinal tract: Through food, drinking water (not boiled, cooked) is contaminated. Especially the respiratory tract due to inhalation of contaminated water droplets in the form of aerosols.

The body is aware and immune

All ages and sexes can get sick. However, the disease of occupational nature is common in wading farmers, herders, soldiers practicing in muddy water, etc. Currently, Leptospirosis is classified as a group of occupational diseases covered by insurance.

Immunity: Leaving for stable immunity after illness, but only with the infected serotype. So can still be with another type.

The epidemic usually spreads in areas with epidemic outbreaks, sometimes causing large epidemics. Or it happens in the summer and autumn. In our country there are many outbreaks in Luong Son - Hoa Binh, Ha Bac, Northwest, Central Highlands etc.

Mechanism of pathogenesis and pathology

Mechanism of pathogenesis

After passing through the skin and mucous membranes, Leptospira into the blood causes sepsis, lasting about 5-7 days, corresponding to the onset stage. Then Leptospira localized into organs: liver, kidney, meninges, heart, lungs, adrenal and cause damage to these organs. This phase lasts 7-8 days, corresponding to the full-blown period. Usually from the 8th day of the disease, the spirochetes are passed out in the urine.

Liver damage in leptospirosis causes jaundice. The cause is damage to the blood vessels that nourish liver cells, leading to cell necrosis and by mycotoxins that destroy the red blood cells.

Kidney damage: Mainly renal tubular damage causes minimal-anuria, increased urea and creatinine and is the main cause of death. The cause of damage to the kidney tubules is due to lack of blood oxygen and the direct action of the endotoxin Leptospira.

Hemorrhage: Caused by a toxin damage the vessel wall and partly due to intravascular clotting.

Pathology

Liver: enlarged liver, congested, microscopic hemorrhage, reversed liver rafts. Kupffer cells proliferate. There may be scattered necrosis and hemorrhage. Biliary tract has many small bile.

Kidney: Enlarged, sometimes with small hemorrhage in the renal tubules, cells swell, split, and necrosis causes obstruction. Edema of the renal slot and mononucleosis.

Other organs: Meningitis, heart, spleen, pancreas, lymph nodes, etc. edema, hemorrhage, and lymphocyte infiltrates.

Divide the clinical form

Typical normal form (hemorrhagic jaundice).

Fake flu.

Cerebral type, meningitis.

Meningitis.

Renal body.

Lung form.

Cardiovascular system.

 

Symptoms study according to each clinical form

Typical normal form (hemorrhagic jaundice)

Incubation

5-14 days, may vary from 2-26 days. There is no clinical manifestation.

Onset

Is the stage of sepsis, usually lasts 4-9 days manifest?

Fever is suddenly high at 39-40 0 C, chills, constant or fluctuating fever with rapid pulse, fluctuating BP.

Fatigue, headache, eye pain, nausea, vomiting. In severe cases, there are signs of confusion and delirium.

Skin mucosal congestion clearly dilated vessels, red eyes, many blood rays like ankle, may have bleeding under the conjunctiva. Nasal mucosa congestion or nosebleeds. A maculopapular rash may appear late in the first week of illness.

Muscle pain is usually severe, spontaneous and increases with the palpation, especially calf muscles, thigh muscles, abdominal straight muscles, nape muscles etc. pain makes it difficult for the patient to walk, not dare to breathe deeply, etc.

Toan Phat

Corresponding local spirochete stage causes damage to the viscera.

The syndrome of more severe toxic infections:

The higher the fever, the stronger the oscillation.

Symptoms of nerve poisoning are worse: delirium, struggles.

Rapid pulse blood pressure fluctuates.

Myalgia increases.

Blood tests:

Leukocytes increased, polymorphonuclear leukocytes increased, blood sedimentation rate increased.

Hepatobiliary syndrome: Jaundice, mucosal jaundice appears 5-7 days of the disease. The skin and eyes are yellow on the congested background, so it looks like a lavender or orange. Yellow urine, large, soft, painful liver.

Blood bilirubin increased, both direct and indirect bilirubin increased, but indirect bilirubin increased more.

Yeast transaminases (SGOT, SGPT) increased slightly.

Urine: urobilinogen, bilirubin (+).

Feces: stercobilin (+)

Kidney Syndrome: Small, anuria.

Test: Urea and blood creatinine increase

The urine contains Albumin, red blood cells, white blood cells, cylindrical shape.

Meningeal syndrome: Epidural meningitis.

Hemorrhagic syndrome: Orange discharge, bleeding under the skin or internal organs (bleeding from the digestive tract, adrenal glands, etc.). Red blood cells decrease with heavy bleeding.

Respiratory Syndrome: Cough, bloody, dyspnea, pneumonia.

Get sick

Usually marked with a polymorph Nuria: the temperature gradually decreases. Systemic symptoms decreased; the patient recovered. In some cases, the fever came back, but it was milder.

Symptoms

Kidney: Acute renal failure is a serious complication that can easily cause death: Expression of anuria, blood urea, high blood creatinine, patient is comatose due to high blood urea.

Cardiovascular: Myocarditis, cardiomyopathy.

Hemorrhage: Massive bleeding of organs causes acute anemia; blood clots may be scattered intravascular.

Lung: Acute pulmonary edema.

In addition, there can be: paralysis, iris inflammation, neuritis, blindness.

Diagnose

clinical

Toxic infection syndrome.

Muscle pain spontaneously, increased with palpation

Syndrome of liver, kidney damage, etc.

Specific test

Direct microscopy: Black background microscopy, samples taken from blood (in the first 5 days of illness), cerebrospinal fluid, centrifuged urine etc. found mobile spirochetes.

Cultured in a specific medium (Terkich) or infused to guinea pigs.

Serology diagnosis: Martin - Pettit solubility reaction, performed 7 days apart. The reaction is positive when the titer of the second serum is increased 4 times that of the first serum or when the antibody titer is higher than 1/1000.

Immunofluorescence response gives rapid results.

Specific, sensitive ELISA response.

Note: There is cross-reactivity between serotypes.

Define

Leptospirosis is an acute infectious disease caused by Leptospira spirochetes. Mainly transmitted through the skin, mucous membranes. The clinical features are systemic toxic sepsis syndrome and liver and kidney damage syndrome.

It is a disease of animals that spread to humans, there is a natural disease.

Course history

Before 1886, Leptospira disease was often mistakenly diagnosed with yellow fever, malaria, dengue, hepatitis ...

In 1886, Weil described the Leptospira disease as a separate disease from the above, but it was not until 1914 that Spirochete was successfully cultured. From 1914 to 1940 many diseases were discovered to be caused by Leptospira such as autumn fever, 7-day fever in Japan, swamp fever in Europe…

Epidemiology

Pathogens

Leptospira family, fresh microscopy under the black background microscope shows the spirochetes are long, thin filaments with 15-30 very close together, the ends are usually curved C-shaped. Size: 4-30 micrometers 0, 1-0.2micrometers moves strongly in a vortex and straight up like a spring. Spirochetes are able to penetrate the skin and mucous membranes, especially scratched skin. Catching Gram-negative color, aerobic, grows slowly in the culture media, pH is appropriate 7.2-7.5, temperature 28-300C.

Spirochetes has weak resistance, is killed at 500C / 10 minutes. light and conventional disinfectants easily kill Leptospira. However, Leptospira is cold tolerant, and can survive in water for up to 3 weeks. Persistent living in muddy, stagnant water with basic pH (pH = 7.7), the best water is from field sewers, streams.

Leptospira is known to cause human and animal disease to be divided into about 23 groups, consisting of 240 serotypes, each with its own specific antigens. Between types, there is partial cross-agglutination, making diagnosis difficult. In Vietnam, 15 types have been discovered, of which 5 types are often pathogenic:

  1. ictero-hemorragiae.
  2. australis.
  3. grippotyphosa.
  4. bataviae.
  5. hebdomadis.        

Inoculum

As animals, including cattle such as sheep, goats, pigs, dogs, cats ... There are also many kinds of wild animals such as bears, leopards, mice ...

Accidental illness, not a source of the disease. However, some authors believe that there is human-to-human transmission by spirochetes through the urine of patients.

Infection

Skin, mucous membranes: Due to contact with water, mud and soil, there is a spirochete pollution. This is the main route of transmission.

Gastrointestinal tract: Through food, drinking water (not boiled, cooked) is contaminated. Especially the respiratory tract due to inhalation of contaminated water droplets in the form of aerosols.

The body is aware and immune

All ages and sexes can get sick. However, the disease of occupational nature is common in wading farmers, herders, soldiers practicing in muddy water, etc. Currently, Leptospirosis is classified as a group of occupational diseases covered by insurance.

Immunity: Leaving for stable immunity after illness, but only with the infected serotype. So can still be with another type.

The epidemic usually spreads in areas with epidemic outbreaks, sometimes causing large epidemics. Or it happens in the summer and autumn. In our country, there are many outbreaks in Luong Son - Hoa Binh, Ha Bac, Northwest, Central Highlands etc.

Mechanism of pathogenesis and pathology

Mechanism of pathogenesis

After passing through the skin and mucous membranes, Leptospira into the blood causes sepsis, lasting about 5-7 days, corresponding to the onset stage. Then Leptospira localized into organs: liver, kidney, meninges, heart, lungs, adrenal and cause damage to these organs. This phase lasts 7-8 days, corresponding to the full-blown period. Usually from the 8th day of the disease, the spirochetes are passed out in the urine.

Liver damage in leptospirosis causes jaundice. The cause is damage to the blood vessels that nourish liver cells, leading to cell necrosis and by mycotoxins that destroy the red blood cells.

Kidney damage: Mainly renal tubular damage causes minimal-anuria, increased urea and creatinine and is the main cause of death. The cause of damage to the kidney tubules is due to lack of blood oxygen and the direct action of the endotoxin Leptospira.

Haemorrhage: Caused by toxin damage the vessel wall and partly due to intravascular clotting.

Pathology

Liver: enlarged liver, congested, microscopic haemorrhage, reversed liver rafts. Kupffer cells proliferate. There may be scattered necrosis and haemorrhage. Biliary tract has much small bile.

Kidney: Enlarged, sometimes with small haemorrhage in the renal tubules, cells swell, split, and necrosis causes obstruction. Oedema of the renal slot and mononucleosis.

Other organs: Meningitis, heart, spleen, pancreas, lymph nodes, etc. oedema, haemorrhage, and lymphocyte infiltrate.

Divide the clinical form

Typical normal form (hemorrhagic jaundice).

Fake flu.

Cerebral type, meningitis.

Meningitis.

Renal body.

Lung form.

Cardiovascular system.

 

Symptoms study according to each clinical form

Typical normal form (hemorrhagic jaundice)

Incubation

5-14 days, may vary from 2-26 days. There is no clinical manifestation.

Onset

Is the stage of sepsis, usually lasts 4-9 days manifest?

Fever is suddenly high at 39-40 0 C, chills, constant or fluctuating fever with rapid pulse, fluctuating BP.

Fatigue, headache, eye pain, nausea, vomiting. In severe cases, there are signs of confusion and delirium.

Skin mucosal congestion clearly dilated vessels, red eyes, many blood rays like the ankle, may have bleeding under the conjunctiva. Nasal mucosa congestion or nosebleeds. A maculopapular rash may appear late in the first week of illness.

Muscle pain is usually severe, spontaneous and increases with the palpation, especially calf muscles, thigh muscles, abdominal straight muscles, nape muscles etc. pain makes it difficult for the patient to walk, not dare to breathe deeply, etc.

Get sick completely

Corresponding local spirochete stage causes damage to the viscera.

The syndrome of more severe toxic infections:

The higher the fever, the stronger the oscillation.

Symptoms of nerve poisoning are worse: delirium, struggles.

Rapid pulse blood pressure fluctuates.

Myalgia increases.

Blood tests:

Leukocytes increased, polymorphonuclear leukocytes increased, blood sedimentation rate increased.

Hepatobiliary syndrome: Jaundice, mucosal jaundice appears 5-7 days of the disease. The skin and eyes are yellow on the congested background, so it looks like a lavender or orange. Yellow urine, large, soft, painful liver.

Blood bilirubin increased, both direct and indirect bilirubin increased, but indirect bilirubin increased more.

Yeast transaminases (SGOT, SGPT) increased slightly.

Urine: urobilinogen, bilirubin (+).

Faeces: stercobilin (+)

Kidney Syndrome: Small, anuria.

Test: Urea and blood creatinine increase

The urine contains Albumin, red blood cells, white blood cells, cylindrical shape.

Meningeal syndrome: Epidural meningitis.

Hemorrhagic syndrome: Orange discharge, bleeding under the skin or internal organs (bleeding from the digestive tract, adrenal glands, etc.). Red blood cells decrease with heavy bleeding.

Respiratory Syndrome: Cough, bloody, dyspnea, pneumonia.

Get sick

Usually marked with a polymorph Nuria: the temperature gradually decreases. Systemic symptoms decreased; the patient recovered. In some cases, the fever came back, but it was milder.

Symptoms

Kidney: Acute renal failure is a serious complication that can easily cause death: Expression of anuria, blood urea, high blood creatinine, the patient is comatose due to high blood urea.

Cardiovascular: Myocarditis, cardiomyopathy.

Haemorrhage: Massive bleeding of organs causes acute anaemia; blood clots may be scattered intravascular.

Lung: Acute pulmonary oedema.

In addition, there can be paralysis, iris inflammation, neuritis, blindness.

Diagnose

clinical

Toxic infection syndrome.

Muscle pain spontaneously increased with palpation

Syndrome of the liver, kidney damage, etc.

Specific test

Direct microscopy: Black background microscopy, samples were taken from the blood (in the first 5 days of illness), cerebrospinal fluid, centrifuged urine etc. found mobile spirochetes.

Cultured in a specific medium (Terkich) or infused to guinea pigs.

Serology diagnosis: Martin - Pettit solubility reaction, performed 7 days apart. The reaction is positive when the titer of the second serum is increased 4 times that of the first serum or when the antibody titer is higher than 1/1000.

Immunofluorescence response gives rapid results.

Specific, sensitive ELISA response.

Note: There is cross-reactivity between serotypes.

Epidemiology

Areas with natural pathogens, people in contact with fields, mud, swimming, raising pigs and cattle, etc.

Differential diagnosis

Viral hepatitis

All have fever, jaundice, but in viral hepatitis, there are two distinct stages of jaundice and jaundice. Symptoms of haemorrhage and renal failure are seen only in severe cases without myalgia and meningeal syndrome.

Test for high SGOT, SGPT, normal or decreased blood urea. Leukocytes are calm, the rate of blood settling does not increase.

Dengue haemorrhage

There is a fever, congested mucosal skin, muscle pain, but in dengue, there is no jaundice, muscle pain, but when squeezed, it is less painful. Assay: WBC is normal or decreased, blood is deposited normally, urea is not increased, platelet decreases, Hematocrit increases, HI (+) reaction.

Treatment

The principles of treatment

Prevent kidney failure by rehydrating electrolyte fluids and using diuretics in the presence of renal failure.

Use specific antibiotics.

Treat the cause

In mild cases can use doxycycline 200 mg/day. For patients who require hospitalization, strong intravenous penicillin should be used. Penicillin can cut fever 4-6 hours after taking the drug and reduce the growth of Leptospira. The duration of using antibiotics is 5-7 days. Alternative antibiotics are Ampicillin, amoxicillin, tetracycline, doxycycline, erythromycin, streptomycin and Cephalosporin etc.

Subjects of treatment

Antibiotic

Dosage, usage

Preventive

Doxycycline

200mg / time x 1 time / week - Drink

Minor illness

Doxycycline

Ampicillin

Amoxicillin

100mg / time x 2 times / day - Drink

500-750mg / time x4 times / day - Drink

500mg / time x 4 times / day - Drink

Moderate and severe illness

Penicillin G

 

Ampicillin

0.5-1.5 million UI / time x 4 times / day - Intravenous injection

0.5-1gram / time x 4 times / day - Intravenous injection

Symptomatic treatment

Prevention and treatment of acute renal failure

Kidney damage has prognostic significance, so early treatment is needed to prevent acute kidney failure according to the following principles:

Infusion, additional water electrolytes according to hematocrit and electrolyte, against acidosis.

Diuretic early when the phenomenon of oliguria begins with oriental medicine: corn stubble, lemon juice. Medicines: Lasix, Mannitol etc.

When prolonged anuria, high urea ... need peritoneal dialysis, an artificial kidney (as indicated).

Cardiovascular support.

If there is bleeding

For drugs to stop bleeding, stabilize the vessel wall, blood transfusion (when heavy bleeding).

Nutrition

Sufficient and improve body resistance.

Prevention

General prevention

Effects on all three links of the immune process:

For pathogens: Kill rats, early detect and treat infected or disease-carrying animals. Treat the patient and disinfect the outbreak.

For infectious factors: Protect well water and food sources. Wetlands have to clear sewers. Personnel working in outbreaks should be equipped with protective clothing (gloves, boots) to avoid close skin and limbs.

Specific

Use a live-attenuated vaccine. However, it has not been widely applied and must know the serotype of the disease, and is usually only used for vulnerable subjects such as: Veterinary staff, soldiers entering outbreaks, etc.

 

Areas with natural pathogens, people in contact with fields, mud, swimming, raising pigs and cattle, etc.

Differential diagnosis

Viral hepatitis

All have fever, jaundice, but in viral hepatitis, there are two distinct stages of jaundice and jaundice. Symptoms of hemorrhage and renal failure are seen only in severe cases without myalgia and meningeal syndrome.

Test for high SGOT, SGPT, normal or decreased blood urea. Leukocytes are calm, the rate of blood settling does not increase.

Dengue hemorrhage

There is a fever, congested mucosal skin, muscle pain, but in dengue, there is no jaundice, muscle pain, but when squeezed, it is less painful. Assay: WBC is normal or decreased, blood is deposited normally, urea is not increased, platelet decreases, Hematocrit increases, HI (+) reaction.

Treatment

The principles of treatment

Prevent kidney failure by rehydrating electrolyte fluids and using diuretics in the presence of renal failure.

Use specific antibiotics.

Treat the cause

In mild cases can use doxycycline 200mg / day. For patients who require hospitalization, strong intravenous penicillin should be used. Penicillin can cut fever 4-6 hours after taking the drug and reduce the growth of Leptospira. The duration of using antibiotics is 5-7 days. Alternative antibiotics are: Ampicillin, amoxicillin, tetracycline, doxycycline, erythromycin, streptomycin and Cephalosporin etc.

Subjects of treatment

Antibiotic

Dosage, usage

Preventive

Doxycycline

200mg / time x 1 time / week - Drink

Minor illness

Doxycycline

Ampicillin

Amoxicillin

100mg / time x 2 times / day - Drink

500-750mg / time x4 times / day - Drink

500mg / time x 4 times / day - Drink

Moderate and severe illness

Penicillin G

 

Ampicillin

0.5-1.5 million UI / time x 4 times / day - Intravenous injection

0.5-1gram / time x 4 times / day - Intravenous injection

Symptomatic treatment

Prevention and treatment of acute renal failure

Kidney damage has prognostic significance, so early treatment is needed to prevent acute kidney failure according to the following principles:

Infusion, additional water electrolytes according to hematocrit and electrolyte, against acidosis.

Diuretic early when the phenomenon of oliguria begins with oriental medicine: corn stubble, lemon juice. Medicines: Lasix, Mannitol etc.

When prolonged anuria, high urea ... need peritoneal dialysis, artificial kidney (as indicated).

Cardiovascular support.

If there is bleeding

For drugs to stop bleeding, stabilize the vessel wall, blood transfusion (when heavy bleeding).

Nutrition

Sufficient and improve body resistance.

Prevention

General prevention

Effects on all three links of the immune process:

For pathogens: Kill rats, early detect and treat infected or disease-carrying animals. Treat the patient and disinfect the outbreak.

For infectious factors: Protect well water and food sources. Wetlands have to clear sewers. Personnel working in outbreaks should be equipped with protective clothing (gloves, boots) to avoid close skin and limbs.

Specific

Use a live-attenuated vaccine. However, it has not been widely applied and must know the serotype of the disease, and is usually only used for vulnerable subjects such as Veterinary staff, soldiers entering outbreaks, etc.