Journal of Postgraduate Medicine
 Open access journal indexed with Index Medicus & ISI's SCI  
Users online: 58  
Home | Subscribe | Feedback | Login 
About Latest Articles Back-Issues Article Submission Resources Sections Etcetera Contact
 
  NAVIGATE Here 
  Search
 
 :: Next article
 :: Previous article 
 :: Table of Contents
  
 RESOURCE Links
 ::  Similar in PUBMED
 ::  Search Pubmed for
 ::  Search in Google Scholar for
 ::Related articles
 ::  Article in PDF (232 KB)
 ::  Citation Manager
 ::  Access Statistics
 ::  Reader Comments
 ::  Email Alert *
 ::  Add to My List *
* Registration required (free) 

  IN THIS Article
 ::  Abstract
 ::  Classical featur...
 ::  Unusual manifest...
 ::  Conclusions
 ::  References

 Article Access Statistics
    Viewed22520    
    Printed325    
    Emailed23    
    PDF Downloaded1032    
    Comments [Add]    
    Cited by others 13    

Recommend this journal


 


 
SYMPOSIUM
Year : 2005  |  Volume : 51  |  Issue : 3  |  Page : 179-183

Unusual clinical manifestations of leptospirosis


Department of Medical Microbiology, Aberdeen Royal Infirmary, Aberdeen, Scotland, United Kingdom

Correspondence Address:
A M Bal
Department of Medical Microbiology, Aberdeen Royal Infirmary, Aberdeen, Scotland
United Kingdom
Login to access the Email id


PMID: 16333189

Get Permissions


 :: Abstract 

Leptospirosis has protean clinical manifestations. The classical presentation of the disease is an acute biphasic febrile illness with or without jaundice. Unusual clinical manifestations may result from involvement of pulmonary, cardiovascular, neural, gastrointestinal, ocular and other systems. Immunological phenomena secondary to antigenic mimicry may also be an important component of many clinical features and may be responsible for reactive arthritis. Leptospirosis in early pregnancy may lead to fetal loss. There are a few reports of leptospirosis in HIV- infected individuals but no generalisation can be made due to paucity of data. It is important to bear in mind that leptospiral illness may be a significant component in cases of dual infections or in simultaneous infections with more than two pathogens.


Keywords: Cardiac arrhythmia, Cholecystitis, Congenital infection, Guillain-Barre syndrome, Pancreatitis, Pancytopenia, Pregnancy, Leptospirosis


How to cite this article:
Bal A M. Unusual clinical manifestations of leptospirosis. J Postgrad Med 2005;51:179-83

How to cite this URL:
Bal A M. Unusual clinical manifestations of leptospirosis. J Postgrad Med [serial online] 2005 [cited 2014 Dec 19];51:179-83. Available from: http://www.jpgmonline.com/text.asp?2005/51/3/179/19017


Leptospirosis is a zoonosis that is caused by the spirochete Leptospira interrogans . The species has several serological variants - the serovars. Antigenically related serovars are grouped together into serogroups. Serovar distribution varies with the geographical region. Recently, DNA relatedness studies have classified the genus Leptospira into 13 species. However, serovar based taxonomy continues to have epidemiological value.[1]

Leptospirosis classically manifests as a biphasic illness. The first phase is characterised by high fever and coincides with leptospiremia. This is followed by a brief period when the patient is afebrile. Fever returns heralding the second phase of illness that may be accompanied by jaundice and renal failure. During this period, leptospires are not found in the blood but are excreted in the urine. Unfortunately, classical presentation is not synonymous with the most common presentation, a fact not always appreciated in clinical medicine. Leptospirosis has protean manifestations and rare and unusual presentations should be kept in mind in relevant epidemiological scenario.

This communication intends to summarise the unusual clinical features of leptospirosis. A thorough knowledge of clinical manifestations is especially valuable in communities that lack diagnostic facilities and hence the need for clinical judgement and suspicion is paramount.


 :: Classical features of leptospirosis Top


Leptospirosis classically presents as a biphasic illness. The first phase of the disease is commonly referred to as the septicemic phase. It is characterised by fever, headache, myalgia, conjunctival congestion and a host of non-specific features that may include mild cough, lymphadenopathy, rash, anorexia, nausea, and vomiting. This phase is followed by a brief afebrile period of variable duration that, in turn, is followed by the immune phase of illness. The common organs involved during this phase are the liver and kidneys. Both organ derangements are reversible. The severe form of leptospirosis, also known as Weil's disease, is characterised by a fulminant course with rapid onset of hepatic and renal failure and high mortality. In a retrospective report of 34 patients with leptospirosis, the common clinical features included fever (100%), headache (75%), myalgia (55%), arthralgia (45%) and vomiting (39%).[2] In one of the largest reported series that included 353 cases, fever, headache, myalgia, chills, and anorexia were present in more than 80% of patients.[3] Interestingly, an association between severity of illness and infection with serovar Icterohaemorrhagiae was also observed. During the epidemic in Mumbai in the year 2000, the common clinical signs and symptoms included fever, headache, myalgia, conjunctival suffusion and cough with hemoptysis.[4]

In an endemic area, suspecting leptospirosis on clinical grounds should not be very difficult. However, the disease is not commonly thought of and hence the diagnosis is often missed due to lack of awareness amongst the medical and medical support team. As an aid to clinical diagnosis, Faine proposed a clinical scoring system.[5] In my own experience, the scoring system had a moderately good sensitivity (81.8%) and specificity (72.9%). The positive predictive value was 40.9% and the negative predictive value was 94.5% when compared with serology.[6] In one published work, the sensitivity, specificity, positive predictive value and negative predictive value of the scoring system was reported to be 81.8%, 72.9%, 40.9% and 94.5% respectively when compared with serology.[6] Use of the scoring system would help exclude the diagnosis of leptospirosis. Modifications in the scoring system have been proposed recently and merit further evaluation.[7]

In an endemic area, leptospirosis is often confused with dengue fever due to the similarities of clinical features. LaRocque and colleagues summarised the data regarding clinical presentations of the two illnesses comparing 938 patients of dengue fever with 63 patients of leptospirosis.[8] Presence of rash, pruritus and a positive tourniquet test was significantly associated with dengue fever. Karande and colleagues in their report of a concurrent epidemic of leptospirosis and dengue fever in Mumbai, noted that clinical features such as conjunctival suffusion, hemorrhage, abdominal pain, hepatosplenomegaly and edema were significantly associated with leptospirosis, while arthralgia was significantly associated with dengue fever.[9]

Although no single clinical feature is pathognomonic of leptospirosis, a cluster of findings should lead to clinical suspicion. Therapy should be initiated on the basis of clinical judgement, as laboratory confirmation can be delayed by days and weeks or is unavailable in several regions and early institution of appropriate therapy is known to reduce mortality.[10]

Severe leptospirosis may carry a high mortality if treatment is not instituted early. Poor prognostic markers in leptospirosis include hypotension (relative risk [RR]= 10.3), oliguria (RR = 8.8), hyperkalemia (RR= 5.9), and presence of pulmonary rales (RR= 5.2).[11] Other studies have reported dyspnea (odds ratio [OR]= 11.7), white blood cell count greater than 12,900/mm[3] (OR= 2.5), repolarization abnormalities on electrocardiograms (OR= 5.9), alveolar infiltrates (OR= 7.3),[12] hemoptysis, metabolic acidosis, and thrombocytopenia as markers of increased mortality. In hospitals that have adequate facilities,[13] patients with these risk factors should preferably be treated in an intensive care unit.


 :: Unusual manifestations of leptospirosis Top


Pulmonary involvement

Although pulmonary involvement is not uncommon in leptospirosis, it is usually not suspected. In one study, 10 out of 176 hospital admissions with community-acquired pneumonia had positive leptospiral serology although only one patient had documented seroconversion.[14] Severe hemorrhagic pneumonitis may be a prominent manifestation of infection.[15] Three radiographic patterns have been described in patients with pulmonary involvement during leptospiral infection- small nodular densities, diffuse ground glass densities and rarely, confluent areas of consolidation.[16] Pulmonary involvement may be the presenting feature of the illness or may complicate a frankly icteric disease.[17] Epidemic leptospirosis with pulmonary haemorrhage without jaundice or renal failure has been reported.[18] Severe pulmonary involvement in leptospirosis has been reported from Andaman and Nicobar islands. Serovar Grippotyphosa and more recently,[19] serovar Valbuzzi ,[20] have caused such outbreaks. Independent predictors of mortality in pulmonary leptospirosis include hemodynamic disturbance, serum creatinine level more than 265.2 µmol/L and serum potassium level more than 4.0 µmol/L.[21] Karande and colleagues[22] recently reported a case of pneumonia in a nine-year-old boy who presented with fever, cough, hemoptysis, and conjunctival suffusion. The patient was diagnosed to be suffering from leptospirosis following a rise in titer of antibodies reactive with serovar Australis. An autopsy study has reported the presence of diffuse bilateral pulmonary hemorrhage in fatal cases of leptospirosis.[23] A rare case of lung abscess due to leptospirosis has been reported in literature.[24]

Neurological manifestations

Although asymptomatic aseptic meningitis is a common feature of leptospirosis, severe symptomatic involvement is rare. Rare clinical presentations include myeloradiculopathy, myelopathy and cerebellar dysfunction.[25] Kavitha and Shastry[26] reported a case of transverse myelitis following leptospirosis. Their patient presented with fever and jaundice and subsequently developed weakness of lower limbs and urinary retention. Sensory perceptions were decreased below T4 level and the illness was consistent with transverse myelitis. The patient had a positive anti-leptospira IgM serology. Costa et al[27] reported a rare case of facial palsy following leptospiral infection. The patient had a clinical illness consistent with leptospirosis. The authors did not perform microagglutination test (MAT) that is generally believed to be the confirmatory test. However, seroconversion was observed the macroagglutination test. Although comparative clinical trials are lacking due to rarity of presentation, doxycycline has been used in such cases[28] Mumford et al[29] have reported a case of fatal leptospirosis with flaccid paraplegia in a patient with biochemical evidence of renal and hepatic involvement. Guillain Barre syndrome has been reported following an illness consistent with leptospirosis.[30] This patient had a history of fever, myalgia, and headache three weeks prior to the onset of paraplegia. The serum sample at the onset of the neurological illness had a titre of 6400 and a later sample had a titre of 800 with strongest reactivity to serovar Copenhageni. It is interesting to note that it was the falling titre and not the rising titre that was a clue to diagnosis as the patient presented comparatively late in illness. Because of the time lag between icteric illness and neurological manifestations, it may not be possible to obtain a culture confirmation or a rising antibody titre. An absence of such a confirmation therefore should not rule out an association. Whether leptospires are causally related to such neurologic illness is a matter of conjecture. Treatment of neurological sequelae is supportive. It is unlikely that treatment of underlying cause will alter the natural course of the neurological illness.

Ocular manifestations

Ocular manifestations of leptospirosis can lead to significant morbidity. During the acute phase of illness, conjunctival congestion is a common clinical finding.[31] Uveitis is a rare sequel of the disease. It usually presents as a panuveitis with or without hypopyon. Visual damage can occur in as many as 35% of patients.[32] Topical quinolones have been used to treat such infections.[33] A majority (95.5%) of 73 cases of leptospiral uveitis reported by Rathinam et al[32] had panuveitis, retinal periphlebitis (51.4%) and hypopyon (12.6%). A few patients had anterior uveitis without hypopyon (2.7%) and isolated vitreous inflammatory reaction (1.8%).

Gastrointestinal manifestations

Pai and Adhikari reported a rare case of pancreatitis following leptospirosis.[34] Hyperamylasemia was persistent but returned to normal in three months following the institution of leptospira-specific therapy. There are other reports too of pancreatitis complicating leptospirosis.[35] Monno and Mizushima reported a rare case of acute acalculous cholecystitis in a patient with infection due to serovar Autumnalis.[36] In an outbreak of leptospirosis reported from the United States, two out of 22 hospitalised patients had symptoms suggestive of acute cholecystitis. Gross examination of the gall bladders removed at surgery revealed thickened walls with smooth serosal surface and bile-stained mucosa. Calculi were not found. The submucosal tissue had mononuclear cell infiltration and also showed edematous changes. Leptospires were detected by immunohistochemistry techniques. Staining for the granular and filamentous antigens was found positive in the vessel walls and also in the submucosa.[37] Paz and colleagues [38] reported a case of enteritis in an Israeli patient who had a history of travel to Thailand, a region where leptospirosis is an emerging disease.[39] The patient presented with fever, diarrhea, and vomiting and leptospiral serology was performed because creatinine levels were high. The patient had a rising antibody titers detected by MAT. He was treated with penicillin and azithromycin along with intravenous fluids. Peritonitis is another rare manifestation of leptospirosis.[40]

Cardiac involvement

An analysis of data of 50 patients with serologically proven leptospirosis demonstrated that 70% of the patients had electrocardiographic abnormalities, with atrial fibrillation being the commonest major arrhythmia noted.[41] Thirty-six percent of the patients had conduction system abnormalities and 30% had T wave changes. Another series has reported AV block in 44% of patients with leptospirosis.[42] A glycoprotein fraction of leptospiral cell wall has been incriminated in the pathogenesis of these rhythm disturbances. This protein is thought to inhibit the Na-K ATPase and may be responsible for the arrhythmia.[43] Univariate analysis has shown that cardiac arrhythmia is more common in patients dying of leptospirosis than in the survivors.[44] Other reported cardiac abnormalities include myocarditis [45] and pericarditis.[46] In seven cases of fatal leptospirosis, petechial haemorrhages were found in the heart and the pericardium in all the autopsy specimens and interstitial myocarditis was found in five specimens.[47] In another study, acute coronary arteritis was found in 70% of patients who died of leptospirosis and evidence of aortitis was present in more than half.[48] One case of leptospira endocarditis, possibly caused by serovar Icterohaemorrhagiae has been reported in literature.[49]

Musculoskeletal symptoms

Various musculoskeletal abnormalities have been reported in patients with leptospiral infection. In a case reported by Coursin and colleagues,[50] a 63-year-old man presented with multiorgan dysfunction and rhabdomyolysis. Although myalgia and mild elevation of muscle enzymes are common in leptospirosis, severe involvement of muscle tissue is rare. A fatal case of rhabdomyolysis was reported by O'Leary et al.[51] In this report, acute infection with leptospira belonging to serogroup Grippotyphosa was diagnosed on the basis of serology. Skeletal muscle involvement independently correlates with the severity of disease.[52]

Hematological manifestations

Somers et al[53] reported a rare case of erythroid hypoplasia in a case of leptospirosis. The patient presented with fever, jaundice, shortness of breath, and meningism. His haematologic parameters showed normocytic normochromic anaemia, reticulocytopenia, and thrombocytopenia. Severe erythroid hypoplasia was observed on bone marrow examination. It is possible that this complication results from a direct action of toxic leptospiral products on the progenitor cells of the marrow. Stefos and colleagues reported two cases of pancytopenia following infection with leptospira.[54] Interestingly, neither patient had a history of jaundice. According to Bishara and co-workers,[55] pancytopenia could occur in as many as 28% of patients with leptospirosis. Most of the infections in their series of cases were caused by leptospira belonging to serogroup Icterohaemorrhagiae and it is possible that infection with this serogroup is associated with hematologic abnormalities. Isolated thrombotic thrombocytopenia purpura has been reported following infection with leptospires.[56]

Immunological manifestations

Rare immune-mediated manifestations of leptospirosis include antiphospholipid syndrome[57] and reactive arthritis.[58] Such manifestations are likely to be a result of an immunologic cross reactivity. Antibodies generated in response to leptospiral infection may cross react with host antigens and could lead to an inflammatory response. Finsterer et al[59] have reported an interesting case of carpal tunnel syndrome in a pet-shop worker who was later found to have a positive leptospiral IgG and IgM serology. Symptoms improved on doxycycline therapy, although the antibody levels remained elevated over the next three years. Explaining the disappearance of symptoms is difficult especially because the patient continued to have high antibody titres and hence immunological cross reactivity could still have taken place. The authors hypothesized that persistence of antibodies could be the result of re-exposure at workplace or a long- term immunological response. However, this does not necessarily explain the resolution of symptoms. A plausible explanation is that immune-mediated illness is caused by antigen-antibody complexes rather than by cross-reactive antibodies. Doxycycline therapy, by eradicating the leptospires and thereby removing the source of antigens, could prevent the formation of the immune complexes leading to a decrease in the inflammatory response.

Endocrine abnormalities

Panidis et al[60] described a rare case of male hypogonadism, presumably related to hormone deficiency at the hypothalamus-pituitary level, following leptospirosis. Abnormalities in hormonal secretion have been found in experimental infection in animals,[61] but there is paucity of data regarding the incidence and effects of such abnormalities following infection in humans.

Leptospirosis in pregnancy and congenital leptospirosis

In a review of 15 patients with documented leptospirosis late in pregnancy, Shaked et al[62] found that eight women had abortions, two delivered healthy babies, four delivered babies who had signs of active leptospirosis and in one case, the clinical outcome was not stated. Carles et al[63] reported 11 cases of leptospirosis in pregnant women in French Guiana and foetal death occurred in more than 50% of the cases. Chedraui and San Miguel[64] reported a case of leptospirosis in a 28-week pregnant patient. The patient presented with fever, myalgia and jaundice and serology was positive for serovar Icterohaemorrhagiae. The patient was treated with penicillin and delivered a healthy baby at 37 weeks. Leptospirosis, early in pregnancy often leads to abortion. Congenital infections are rare and long-term serious effects have not been documented. Hence, leptospirosis acquired in pregnancy is not an indication for its termination. In one report, transmission of infection to infant was thought to have taken place through the breastmilk.[65]

Leptospirosis in HIV seropositive individuals

Jones and Kim[66] reported a case of leptospirosis in a patient with acquired immunodeficiency syndrome. The patient initially presented with non-specific illness but later developed jaundice, renal failure and acute respiratory distress syndrome. The recovery was probably slower than is usual for leptospirosis and there was residual renal impairment. Others have reported a similar clinical course of illness as in non-immunocompromised patients.[67]

Leptospirosis with concomitant illnesses

Because of epidemiological similarities, it is not unusual to experience concurrent epidemics of leptospirosis with other infections such as dengue fever.[8],[9],[68] Dual infection in the same patient is however rarely reported. Kaur and John[69] reported dual infection with leptospira and dengue fever virus. Markotic and colleagues[70] reported dual infection with leptospira and dobrava virus in a Croatian soldier while Kudesia et al[71] reported hanta virus and leptospira coinfection. Simultaneous infection with leptospira and Hepatitis E virus has been reported from China.[72] Liver biopsy from this patient showed evidence of fibrosis that is considered unusual in Hepatitis E and it is possible that infection with leptospira might have influenced the pathological process. Kaushik and colleagues [73] described a case of leptospirosis with concomitant Hepatitis B. Herpes simplex virus pneumonitis was diagnosed at autopsy in a patient who had died of leptospirosis[74] and viral superinfection could possibly have resulted from a transient immunosuppression associated with the disease or its treatment. Wongsrichanalai et al[75] reported two cases of dual infection with malaria parasites and leptospira. One patient was infected with Plasmodium falciparum and the other with P. vivax. Co-infection with three different pathogens has also been reported in what probably is an extremely rare event. Lu and Tseng [76] described a Taiwanese patient with fever and pneumonia in whom blood cultures grew  Burkholderia pseudomallei Scientific Name Search nd serological tests were consistent with scrub typhus and leptospirosis. Melioidosis is an emerging disease in Taiwan and B. pseudomallei shares similar ecological niche with leptospira and Orientia tsutsugamushi , the causative organism of scrub typhus. It is important to look for leptospirosis in an appropriate setting particularly if the patient does not show clinical signs of improvement despite pathogen-directed therapy for an established alternative infectious etiology.


 :: Conclusions Top


It is imperative that a high index of suspicion for the disease be maintained particularly in endemic areas. There is a need for increasing the awareness of the disease so that timely therapy can be instituted to patients. An effective network of clinicians, medical microbiologists, public health doctors and program managers needs to be in place during epidemics. It is equally important to collect and report data to a centralised surveillance cell so that future planning and monitoring can be done easily. Clinicians need to be aware of the possibility of leptospirosis, even if the illness presents with unusual features. A problem-solving approach to the clinical suspicion and diagnosis of leptospirosis has recently been elucidated and could be a useful guide for doctors.[77]

 
 :: References Top

1.Levett PN. Leptospirosis. In : Mandell GL, Bennett JE, Dolin R, editors. Principles and Practice of Infectious Diseases . 6th edn. Philadelphia: Elsevier Churchill Livingstone; 2005. p. 2789-95.  Back to cited text no. 1    
2.Jaureguiberry S, Roussel M, Brinchault-Rabin G, Gacouin A, Le Meur A, Arvieux C, et al . Clinical presentation of leptospirosis: a retrospective study of 34 patients admitted to a single institution in metropolitan France. Clin Microbiol Infect 2005;11:391-4.  Back to cited text no. 2    
3.Katz AR, Ansdell VE, Effler PV, Middleton CR, Sasaki DM. Assessment of the clinical presentation and treatment of 353 cases of laboratory-confirmed leptospirosis in Hawaii, 1974-1998. Clin Infect Dis 2001;33:1834-41.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Bharadwaj R, Bal AM, Joshi SA, Kagal A, Pol SS, Garad G, et al . An urban outbreak of leptospirosis in Mumbai, India. Jpn J Infect Dis 2002;55:194-6.  Back to cited text no. 4    
5.Faine S. The acute infection in man. In : Guidelines for the control of leptospirosis. Geneva: World Health Organisation; 1982. p. 43-54.  Back to cited text no. 5    
6.Bal AM, Kakrani AL, Bharadwaj RS, Kagal AS, Joshi SA, Arjunwadkar VP. Evaluation of clinical criteria for the diagnosis of leptospirosis. J Assoc Physic Ind 2002;50:394-6.  Back to cited text no. 6  [PUBMED]  
7.Shivakumar S, Shareek PS. Diagnosis of leptospirosis utilizing modified Faine's criteria. J Assoc Physicians India 2004;52:678-9.  Back to cited text no. 7  [PUBMED]  
8.LaRocque RC, Breiman RF, Ari MD, Morey RE, Janan FA, Hayes JM, et al . Leptospirosis during Dengue Outbreak, Bangladesh. Emerg Infect Dis 2005;11:766-9.  Back to cited text no. 8    
9.Karande S, Gandhi D, Kulkarni M, Bharadwaj R, Pol S, Thakare J, et al . Concurrent Outbreak of Leptospirosis and Dengue in Mumbai, India, 2002. J Trop Pediatr 2005;51:174-81.  Back to cited text no. 9    
10.Watt G, Padre LP, Tuazon ML, Calubaquib C, Santiago E, Ranoa CP, et al . Placebo-controlled trial of intravenous penicillin for severe and late leptospirosis. Lancet 1988;1:433-5.  Back to cited text no. 10    
11.Panaphut T, Domrongkitchaiporn S, Thinkamrop B. Prognostic factors of death in leptospirosis: a prospective cohort study in Khon Kaen, Thailand. Int J Infect Dis 2002;6:52-9.  Back to cited text no. 11  [PUBMED]  
12.Dupont H, Dupont-Perdrizet D, Perie JL, Zehner-Hansen S, Jarrige B, Daijardin JB. Leptospirosis: prognostic factors associated with mortality. Clin Infect Dis 1997;25:720-4.  Back to cited text no. 12  [PUBMED]  
13.Tantitanawat S, Tanjatham S. Prognostic factors associated with severe leptospirosis. J Med Assoc Thai 2003;86:925-31.   Back to cited text no. 13  [PUBMED]  
14.Perani V, Farina C, Maggi L, Michetti G, Moioli F, Pizzocaro P, et al . Pneumonia due to Leptospira spp.: results of an epidemiological and clinical study. Int J Tuberc Lung Dis 1998;2:766-70.  Back to cited text no. 14    
15.Allen P, Raftery S, Phelan D. Massive pulmonary haemorrhage due to leptospirosis. Intensive Care Med 1989;15:322-4.  Back to cited text no. 15  [PUBMED]  
16.Im JG, Yeon KM, Han MC, Kim CW, Webb WR, Lee JS, et al . Leptospirosis of the lung: radiographic findings in 58 patients. AJR Am J Roentgenol 1989;152:955-9.  Back to cited text no. 16    
17.Teglia OF, Battagliotti C, Villavicencio RL, Cunha BA. Leptospiral pneumonia. Chest 1995;108:874-5.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]
18.Trevejo RT, Rigau-Perez JG, Ashford DA, McClure EM, Jarquin-Gonzalez C, Amador JJ, et al . Epidemic leptospirosis associated with pulmonary hemorrhage-Nicaragua, 1995. J Infect Dis 1998;178:1457-63.  Back to cited text no. 18    
19.Sehgal SC, Murhekar MV, Sugunan AP. Outbreak of leptospirosis with pulmonary involvement in north Andaman. Indian J Med Res 1995;102:9-12.  Back to cited text no. 19  [PUBMED]  
20.Vijayachari P, Sehgal SC, Goris MG, Terpstra WJ, Hartskeerl RA. Leptospira interrogans serovar Valbuzzi: a cause of severe pulmonary haemorrhages in the Andaman Islands. J Med Microbiol 2003;52:913-8.  Back to cited text no. 20  [PUBMED]  [FULLTEXT]
21.Marotto PC, Nascimento CM, Eluf-Neto J, Marotto MS, Andrade L, Sztajnbok J, et al . Acute lung injury in leptospirosis: clinical and laboratory features, outcome, and factors associated with mortality. Clin Infect Dis 1999;29:1561-63.  Back to cited text no. 21    
22.Karande S, Satam N, Kulkarni M, Bharadwaj R, Pol S. Leptospiral pneumonia. Indian J Pediatr 2005;72:86.  Back to cited text no. 22  [PUBMED]  [FULLTEXT]
23.Yersin C, Bovet P, Merien F, Clement J, Laille M, Van Ranst M, et al . Pulmonary haemorrhage as a predominant cause of death in leptospirosis in Seychelles. Trans R Soc Trop Med Hyg 2000;94:71-6.  Back to cited text no. 23    
24.Winter RJ, Richardson A, Lehner MJ, Hoffbrand BI. Lung abscess and reactive arthritis: rare complications of leptospirosis. Br Med J (Clin Res Ed) 1984;288:448-9.  Back to cited text no. 24    
25.Panicker JN, Mammachan R, Jayakumar RV. Primary neuroleptospirosis. Postgrad Med J 2001;77:589-90.  Back to cited text no. 25  [PUBMED]  [FULLTEXT]
26.Kavitha S, Shastry BA. Leptospirosis with transverse myelitis. J Assoc Physicians India 2005;53:159-60.  Back to cited text no. 26  [PUBMED]  
27.Costa E, Sacramento E, Lopes AA, Bina JC. Facial nerve palsy associated with leptospirosis. Rev Soc Bras Med Trop 2001;34:219-20.  Back to cited text no. 27  [PUBMED]  [FULLTEXT]
28.Sharma OP, Eltahir N, Roy M. Facial palsy in a patient with leptospirosis: causal or accidental. Sarcoidosis Vasc Diffuse Lung Dis 1999;16:104-6.  Back to cited text no. 28    
29.Mumford C, Dudley N, Terry H. Leptospirosis presenting as a flaccid paraplegia. Postgrad Med J 1990;66:218-20.  Back to cited text no. 29  [PUBMED]  
30.Bal AM, Bharadwaj RS, Gita N, Joshi SA, Thakare JP. Guillain-Barre syndrome in a pediatric patient following infection due to Leptospira. Jpn J Infect Dis 2003;56:29-31.  Back to cited text no. 30  [PUBMED]  [FULLTEXT]
31.Martins MG, Matos KT, da Silva MV, de Abreu MT. Ocular manifestations in the acute phase of leptospirosis. Ocul Immunol Inflamm 1998;6:75-9.  Back to cited text no. 31  [PUBMED]  
32.Rathinam SR, Rathnam S, Selvaraj S, Dean D, Nozik RA, Namperumalsamy P. Uveitis associated with an epidemic outbreak of leptospirosis. Am J Ophthalmol 1997;124:71-9.  Back to cited text no. 32  [PUBMED]  
33.Mancel E, Merien F, Pesenti L, Salino D, Angibaud G, Perolat P. Clinical aspects of ocular leptospirosis in New Caledonia (South Pacific). Aust N Z J Ophthalmol 1999;27:380-6.  Back to cited text no. 33  [PUBMED]  [FULLTEXT]
34.Pai ND, Adhikari P. Painless pancreatitis: a rare manifestation of leptospirosis. J Assoc Physic Ind 2002;50:1318-9.  Back to cited text no. 34  [PUBMED]  
35.Edwards CN, Evarard CO. Hyperamylasemia and pancreatitis in leptospirosis. Am J Gastroenterol 1991;86:1665-8.  Back to cited text no. 35  [PUBMED]  
36.Monno S, Mizushima Y. Leptospirosis with acute acalculous cholecystitis and pancreatitis. J Clin Gastroenterol 1993;16:52-4.  Back to cited text no. 36  [PUBMED]  
37.Guarner J, Shieh WJ, Morgan J, Bragg SL, Bajani MD, Tappero JW, et al . Leptospirosis mimicking acute cholecystitis among athletes participating in a triathlon. Hum Pathol 2001;32:750-2.  Back to cited text no. 37    
38.Paz A, Krimerman S, Potasman I. Leptospirosis masquerading as infectious enteritis. Trav Med Infect Dis 2004;2:89-91.  Back to cited text no. 38    
39.Tangkanakul W, Smits HL, Jatanasen S, Ashford DA. Leptospirosis: an emerging health problem in Thailand. Southeast Asian J Trop Med Public Health 2005;36:281-8.  Back to cited text no. 39    
40.Handa R, Sood A, Wali JP. Peritonitis complicating leptospirosis. Postgrad Med J 1995;71:250.  Back to cited text no. 40    
41.Rajiv C, Manjuran RJ, Sudhayakumar N, Haneef M. Cardiovascular involvement in leptospirosis. Indian Heart J 1996;48:691-4.  Back to cited text no. 41  [PUBMED]  
42.Trivedi SV, Bhattacharya A, Amichandwala K, Jakkamsetti V. Evaluation of cardiovascular status in severe leptospirosis. J Assoc Physic Ind 2003;51:951-3.  Back to cited text no. 42  [PUBMED]  
43.Younes-Ibrahim M, Burth P, Castro-Faria M, Cheval L, Buffin-Meyer B, Marsy S, et al . Effect of Leptospira interrogans endotoxin on renal tubular Na,K-ATPase and H,K-ATPase activities. Ann N Y Acad Sci 1997;834:684-6.  Back to cited text no. 43    
44.Daher E, Zanetta DM, Cavalcante MB, Abdulkader RC. Risk factors for death and changing patterns in leptospirosis acute renal failure. Am J Trop Med Hyg 1999;61:630-4.  Back to cited text no. 44  [PUBMED]  [FULLTEXT]
45.Edwards CN, Nicholson GD, Hassell TA, Everard CO, Callender J. Leptospirosis in Barbados. A clinical study. West Indian Med J 1990;39:27-34.  Back to cited text no. 45  [PUBMED]  
46.Farkas PS, Knapp AB, Lieberman H, Guttman I, Mayan S, Bloom AA. Markedly elevated creatinine phosphokinase, cotton wool spots, and pericarditis in a patient with leptospirosis. Gastroenterology 1981;80:587-9.  Back to cited text no. 46  [PUBMED]  
47.Ramachandran S, Perera MV. Cardiac and pulmonary involvement in leptospirosis. Trans R Soc Trop Med Hyg 1977;71:56-9.  Back to cited text no. 47  [PUBMED]  
48.de Brito T, Morais CF, Yasuda PH, Lancellotti CP, Hoshino-Shimizu S, Yamashiro E, et al . Cardiovascular involvement in human and experimental leptospirosis: pathologic findings and immunohistochemical detection of leptospiral antigen. Ann Trop Med Parasitol 1987;81:207-14.  Back to cited text no. 48    
49.Cornaert P, Masson P, Forzy G, Graux P, Camblin J, Dutoit A, et al . Infectious endocarditis caused by rare germs. Review of the literature apropos of 2 cases. Ann Cardiol Angeiol 1987;36:87-93.  Back to cited text no. 49    
50.Coursin DB, Updike SJ, Maki DG. Massive rhabdomyolysis and multiple organ dysfunction syndrome caused by leptospirosis. Intensive Care Med 2000;26:808-12.  Back to cited text no. 50  [PUBMED]  [FULLTEXT]
51.O'Leary FM, Hunjan JS, Bradbury R, Thanakrishnan G. Fatal leptospirosis presenting as musculoskeletal chest pain. Med J Aust 2004;180:29-31.  Back to cited text no. 51    
52.Watt G, Padre LP, Tuazon M, Calubaquib C. Skeletal and cardiac muscle involvement in severe, late leptospirosis. J Infect Dis 1990;162:266-9.  Back to cited text no. 52    
53.Somers CJ, Al-Kindi S, Montague S, O'Connor R, Murphy PG, Jeffers M, et al . Erythroid hypoplasia associated with leptospirosis. J Infect 2003;47:85-6.   Back to cited text no. 53    
54.Stefos A, Georgiadou SP, Gioti C, Loukopoulos A, Ioannou M, Pournaras S, et al . Leptospirosis and pancytopenia: two case reports and review of the literature. J Infect (In Press).   Back to cited text no. 54    
55.Bishara J, Amitay E, Barnea A, Yitzhaki S, Pitlik S. Epidemiological and clinical features of leptospirosis in Israel. Eur J Clin Microbiol Infect Dis 2002;21:50-2.  Back to cited text no. 55    
56.Laing RW, Teh C, Toh CH. Thrombotic thrombocytopenic purpura (TTP) complicating leptospirosis: a previously undescribed association. J Clin Pathol 1990;43:961-2.  Back to cited text no. 56    
57.Tattevin P, Dupeux S, Hoff J. Leptospirosis and the antiphospholipid syndrome. Am J Med 2003;114:164.  Back to cited text no. 57    
58.Pappas G, Akritidis N, Christou L, Mastora M, Tsianos E. Unusual causes of reactive arthritis: Leptospira and Coxiella burnetii. Clin Rheumatol 2003;22:343-6.  Back to cited text no. 58    
59.Finsterer J, St φllberger C, Sehnal E, Stanek G. Mild leptospirosis with three-year persistence of IgG- and IgM-antibodies, initiallymanifesting as carpal tunnel syndrome. J Infect 2005;51:E67-70.  Back to cited text no. 59    
60.Panidis D, Rousso D, Skiadopoulos S, Vavilis D, Kalogeropoulos A. Hypothalamic-pituitary deficiency after Weil's syndrome: a case report. Fertil Steril 1994;62:1077-9.  Back to cited text no. 60    
61.Bielaaski A, Raeside JI. Plasma concentrations of steroid hormones in sows infected experimentally with Leptospira pomona or porcine enterovirus strain T1 in late gestation. Res Vet Sci 1977;22:28-34.  Back to cited text no. 61    
62.Shaked Y, Shpilberg O, Samra D, Samra Y. Leptospirosis in pregnancy and its effect on the fetus: case report and review. Clin Infect Dis 1993;17:241-3.  Back to cited text no. 62    
63.Carles G, Montoya E, Joly F, Peneau C. Leptospirosis and pregnancy. Eleven cases in French Guyana. J Gynecol Obstet Biol Reprod 1995;24:418-21.  Back to cited text no. 63    
64.Chedraui PA, San MG. A case of leptospirosis and pregnancy. Arch Gynecol Obstet 2003;269:53-4.  Back to cited text no. 64    
65.Bolin CA, Koellner P. Human-to-human transmission of Leptospira interrogans by milk. J Infect Dis 1988;158:246-7.  Back to cited text no. 65    
66.Jones S, Kim T. Fulminant leptospirosis in a patient with human immunodeficiency virus infection: case report and review of the literature. Clin Infect Dis 2001;33:31-3.  Back to cited text no. 66    
67.Neves ES, Pereira MM, Galhardo MC, Caroli A, Andrade J, Morgado MG, et al . Leptospirosis patient with AIDS: the first case reported. Rev Soc Bras Med Trop 1994;27:39-42.  Back to cited text no. 67    
68.Flannery B, Pereira MM, Velloso L de F, Carvalho C de C, De Codes LG, Orrico G de S, et al . Referral pattern of leptospirosis cases during a large urban epidemic of dengue. Am J Trop Med Hyg 2001;65:657-63.  Back to cited text no. 68    
69.Kaur H, John M. Mixed infection due to leptospira and dengue. Indian J Gastroenterol 2002;21:206.  Back to cited text no. 69  [PUBMED]  [FULLTEXT]
70.Markotic A, Kuzman I, Babic K, Gagro A, Nichol S, Ksiazek TG, et al . Double trouble: hemorrhagic fever with renal syndrome and leptospirosis. Scand J Infect Dis 2002;34:221-4.  Back to cited text no. 70    
71.Kudesia G, Christie P, Walker E, Pinkerton I, Lloyd G. Dual infection with leptospira and hantavirus. Lancet 1988;1:1397.  Back to cited text no. 71    
72.Suzuki A, Kumashiro R, Shirachi M, Kuroki M, Suzuki H, Tanikawa K, et al . Markedly prolonged jaundice from simultaneous infection with hepatitis E virus and leptospira. Kurume Med J 2003;50:155-9.  Back to cited text no. 72    
73.Kaushik SP, Yim HB, Tan CC. Weils' syndrome and concomitant hepatitis B infection. Singapore Med J 1999;40:104-5.  Back to cited text no. 73    
74.Bek M, Koppl H, Schwarzkopf G, Freudenberg N. Weil's disease and necrotizing herpes pneumonia as the cause of death of a 39-year-old sewage drain worker. Pathologe 1996;17:471-6.  Back to cited text no. 74    
75.Wongsrichanalai C, Murray CK, Gray M, Miller RS, McDaniel P, Liao WJ, et al . Co-infection with malaria and leptospirosis. Am J Trop Med Hyg 2003;68:583-5.  Back to cited text no. 75    
76.Lu PL, Tseng SH. Fatal septicemic melioidosis in a young military person possibly co-infected with Leptospira interrogans and Orientia tsutsugamushi. Kaohsiung J Med Sci 2005;21:173-8.  Back to cited text no. 76    
77.Kaul DR, Flanders SA, Saint S. Clinical problem-solving. Clear as mud. N Engl J Med 2005;352:1914-8.  Back to cited text no. 77    



This article has been cited by
1 Diagnosis of acute leptospirosis
Toyokawa, T., Ohnishi, M., Koizumi, N.
Expert Review of Anti-Infective Therapy. 2011; 9(1): 111-121
[Pubmed]
2 Leptospirosis in the Czech Republic and potential for laboratory diagnosis | [Leptospiróza v České republice a možnosti laboratorní diagnostiky]
Smetana, J., Čermáková, Z., Boštíková, V., Kučerová, P., Prášil, P., Pavliš, O., Chlíbek, R.
Epidemiologie, Mikrobiologie, Imunologie. 2010; 59(4): 159-167
[Pubmed]
3 Aspergillus pancarditis manifesting as hospital-acquired infection: Report of two cases and review of literature
Vaideeswar, P.
Cardiovascular Pathology. 2010; 19(6): e253-e257
[Pubmed]
4 Leptospirosis as a cause of intrauterine fetal demise: Short report of rare presentation
Gainder, S., Singla, R., Dhaliwal, L., Suri, V.
Archives of Gynecology and Obstetrics. 2010; 281(6): 1061-1063
[Pubmed]
5 Leptospirosis | [Leptospirosis]
García-Vázquez, E., Herrero, J.A., Hernández, A., Gómez, J.
Medicine. 2010; 10(57): 3896-3902
[Pubmed]
6 Of guinea pigs and men - An unusual case of jaundice
Pischke, S., Ehmer, U., Schedel, I., Gratz, W.F., Wedemeyer, H., Ziesing, S., Bange, F.C., (...), Strassburg, C.P.
Zeitschrift fur Gastroenterologie. 2010; 48(1): 33-37
[Pubmed]
7 Small Animal Zoonoses and Immuncompromised Pet Owners
Mani, I., Maguire, J.H.
Topics in Companion Animal Medicine. 2009; 24(4): 164-174
[Pubmed]
8 Weilćs disease in a patient with chronic viral hepatitis and history of alcohol abuse
Christou, L., Kalambokis, G., Tsianos, E.V.
Internal Medicine. 2008; 47(10): 933-937
[Pubmed]
9 Overlapping clinical features of lupus and leptospirosis
Barnabe, C., Fahlman, N.
Clinical Rheumatology. 2008; 27(Suppl 1): 23-25
[Pubmed]
10 Hemorrhagic pulmonary leptospirosis: Three cases from the Yucatan peninsula, Mexico
Zavala-Velázquez, J., Cárdenas-Marrufo, M., Vado-Solís, I., Cetina-Cámara, M., Cano-Tur, J., Laviada-Molina, H.
Revista da Sociedade Brasileira de Medicina Tropical. 2008; 41(4): 404-408
[Pubmed]
11 Cardiovascular lesions in leptospirosis: An autopsy study
Chakurkar G, Vaieleeswar P, Pandit SP, et al.
JOURNAL OF INFECTION. 2008; 56(3): 197-203
[Pubmed]
12 Acute lung injury and multi-organ dysfunction; an unusual manifestation of leptospirosis
Subash GS, Harling D
BRITISH JOURNAL OF ANAESTHESIA. 2007; 98 (4): 549-550
[Pubmed]
13 Bilateral acute keratouveitis in leptospirosis: A new entity
Gupta, A., Guinar, D.P., Srinivasan, R., Kaliaperumal, S.
Indian Journal of Ophthalmology. 2007; 55(5): 399
[Pubmed]



 

Top
Print this article  Email this article
Previous article Next article
Online since 12th February '04
© 2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
Published by Medknow