Leptospirosis

CASE 1

• A 49 year old woman came to the hospital in December with loss of appetite, muscle aches, and fever for 1 week. She was treated for malaria, but her fever persisted. Today, she decided to come to the clinic, because she has developed a splitting headache, stiff neck, and a dry cough. She was admitted to the hospital for further evaluation.

• The patient is a homemaker who also sells fruit, eggs, and other consumables from a roadside store. She has no ill contacts. Ten days before the onset of her symptoms, the patient cleaned out an storeroom in her compound that had become flooded during a particular heavy thunderstorm.

• On physical examination, she appeared mildly jaundiced with a temperature of 38.8. Patchy subconjunctival hemorrhages (without purulence) were noted in both eyes (see below). There was mild enlargement of the liver.

• Blood chemistries revealed a total bilirubin of 3.6; the transaminases were three times normal. The serum creatinine was 80 mmol/L

• A lumbar puncture yielded clear CSF with 55 WBCs/mm3 (all lymphocytes), a normal CSF glucose, and a mildly elevated CSF protein.

• The patient was treated with oral doxycycline and intravenous fluid replacement to enhance urine output. She recovered slowly during the next week. Two weeks after admission to the hospital, a microagglutination assay for Leptospira antibodies was positive at a titre of 1:800.

Questions:

1. How and when did the patient acquire this infection? What was the portal of entry?
2. What animal was the most likely source of infection? How did this animal contaminate the environment with leptospires?
3. In the initial phase of this infection, the patient had a "flu-like illness." How could you diagnose the infection at this stage? Are there any distinguishing clinical signs?
4. Which organ systems were involved in the second phase of this disease?
5. What was the benefit of antibiotics in this case? What was the likely outcome if the patient had not been treated?
6. When the patient was admitted to the hospital, was there a danger that her health care providers or other patients may have become secondarily infected?