Leptospirosis in Emergency Medicine Clinical Presentation

Leptospirosis infection has protean manifestations. As a result, it is frequently misdiagnosed. Approximately 15-40% of exposed patients who do not become ill have serologic evidence of past infection. This statistic includes 15% of abattoir workers, packinghouse workers, and veterinarians.

• The incubation period is usually 7-12 days, with a range of 2-20 days.
• Approximately 90% of patients manifest a mild anicteric form of the disease, and approximately 5-10% have the severe form with jaundice, otherwise known as Weil disease.
• The natural course of leptospirosis falls into 2 distinct phases: septicemic and immune. During a brief period of 1-3 days between the 2 phases, the patient shows some improvement.

  • First stage
    • This stage is called the septicemic or leptospiremic stage because the organism may be isolated from blood cultures, cerebrospinal fluid (CSF), and most tissues.
    • During this stage, which lasts about 4-7 days, the patient develops a nonspecific flulike illness of varying severity.
    • It is characterized by fever, chills, weakness, and myalgias, primarily affecting the calves, back, and abdomen.
    • Other symptoms include sore throat, cough, chest pain, hemoptysis, rash, frontal headache, photophobia, mental confusion, and other symptoms of meningitis.
    • Because of the abrupt nature of the onset, the patient can often tell exactly when the symptoms started.
    • During the 1-3 day period of improvement that follows the first stage, the temperature curve falls and the patient may become afebrile and relatively asymptomatic. The fever then recurs, indicating the onset of the second stage when clinical or subclinical meningitis appears.
  • Second stage
    • This stage is called the immune or leptospiruric stage because circulating antibodies may be detected or the organism may be isolated from urine; it may not be recoverable from blood or CSF.
    • This stage occurs as a consequence of the body's immunologic response to infection and lasts 0-30 days or more.
    • Disease referable to specific organs is seen. These organs include the meninges, liver, eyes, and kidney. An example of leptospirosis affecting the liver is seen in the image below. Silver stain, liver, fatal human leptospirosis. (This image is in the public domain and thus free of any copyright restrictions. Courtesy of the Centers for Disease Control/Dr. Martin Hicklin.)
    • Nonspecific symptoms, such as fever and myalgia, may be less severe than in the first stage and last a few days to a few weeks.
    • Many patients (77%) experience headache that is intense and poorly controlled by analgesics; this often heralds the onset of meningitis.
    • Aseptic meningitis is the most important clinical syndrome observed in the immune anicteric stage. Meningeal symptoms develop in 50% of patients. Cranial nerve palsies, encephalitis, and changes in consciousness are less common. Mild delirium may also be seen. Symptoms may be nonspecific, and a viral etiology may be suspected. Meningitis usually lasts a few days but occasionally lasts 1-2 weeks. Death is extremely rare in the anicteric cases.
    • Leptospires may be isolated from the blood for 24-48 hours after jaundice appears. Abdominal pain with diarrhea or constipation (30%), hepatosplenomegaly, nausea, vomiting, and anorexia are also seen.
    • Uveitis (2-10%) can develop early or late in the disease and has been reported to occur as late as one year after initial illness. Iridocyclitis and chorioretinitis are other late complications that may persist for years. These symptoms first manifest 3 weeks to 1 month after exposure. Subconjunctival hemorrhage is the most common ocular complication of leptospirosis, occurring in as many as 92% of patients. Leptospires may be present in the aqueous humor.
    • Renal symptoms (eg, azotemia, pyuria, hematuria, proteinuria, and oliguria are seen in 50% of patients with leptospirosis. Leptospires may be present in the kidney.
    • Pulmonary manifestations occur in 20-70% of patients, usually have a benign course, and may occur in both the icteric and anicteric forms of the disease. However, pulmonary involvement is the main cause of death due to leptospirosis in some countries, usually as a result of pulmonary hemorrhage or acute respiratory distress syndrome. Indeed, the severe pulmonary form of leptospirosis (SPFL) is considered to be one of the major causes of death in patients with severe leptospirosis.
    • Adenopathy, rashes, and muscular pain are also seen.
• Clinical syndromes are not specific to the serotype, although some manifestations may be seen more commonly with some serotypes.
• Often, the serovar helps determine some of the more characteristic clinical manifestations, but any leptospiral serovar can lead to the signs and symptoms seen with this disease. For example, jaundice is seen in 83% of patients with L icterohaemorrhagiae infection and in 30% of patients infected with L pomona. A characteristic pretibial erythematous rash is seen in patients with L autumnalis infection. Similarly, GI symptoms predominate in patients infected with L grippotyphosa. Aseptic meningitis commonly occurs in those infected with L pomona or L canicola.
• Weil syndrome is the severe form of leptospirosis and primarily manifests as profound jaundice, renal dysfunction, hepatic necrosis, pulmonary dysfunction, and hemorrhagic diathesis.

  • It occurs at the end of the first stage and peaks in the second stage; however, the patient's condition can deteriorate suddenly at any time. Often, the transition between the stages is obscured.
  • Fever may be marked during the second stage.
  • Criteria to determine the development of Weil disease are not well defined.
  • Pulmonary manifestations include cough, dyspnea, chest pain, bloodstained sputum, hemoptysis, and respiratory failure.
  • Vascular and renal dysfunction accompanied by jaundice develop 4-9 days after onset of disease, and jaundice may persist for weeks.
  • Patients with severe jaundice are more likely to develop renal failure, hemorrhage, and cardiovascular collapse. Hepatomegaly and tenderness in the right upper quadrant may be present.
  • Oliguric or anuric acute tubular necrosis may occur during the second week due to hypovolemia and decreased renal perfusion.
  • Multiorgan failure, rhabdomyolysis, adult respiratory distress syndrome, hemolysis, splenomegaly, congestive heart failure, myocarditis, and pericarditis may also occur.
  • Weil syndrome carries a mortality rate of 5-10%. The most severe cases of Weil syndrome, with hepatorenal involvement and jaundice, have a case-fatality rate of 20-40%. The mortality rate is usually higher for older patients.
• Leptospirosis may present with a macular or maculopapular rash, abdominal pain that resembles acute appendicitis, or generalized enlargement of lymphoid glands, resembling infectious mononucleosis. It may also present as aseptic meningitis, encephalitis, or fever of unknown origin.
• Leptospirosis should be considered when a patient has a flulike disease with aseptic meningitis or disproportionately severe myalgia.

• First stage: Common physical findings include fever; subconjunctival suffusion; pharyngeal injection; splenomegaly; hepatomegaly; mild jaundice; muscle tenderness; lymphadenopathy; and a macular, maculopapular, erythematous, urticarial, or hemorrhagic rash.
• Second stage: Physical findings depend on organ involvement.

  • General - Adenopathy, rash, fever, bleeding, signs of hypovolemia/cardiogenic shock
  • Icteric - Jaundice, hepatomegaly, abdominal tenderness, signs of coagulopathy
  • Pulmonary - Cough, hemoptysis, dyspnea, respiratory distress
  • Neurologic - Cranial nerve palsies, confusion, changes in consciousness, delirium, other signs of meningitis
  • Ocular - Subconjunctival hemorrhage, uveitis, signs of iridocyclitis or chorioretinitis
  • Hematologic - Bleeding, petechiae, purpura, ecchymosis, splenomegaly, abdominal tenderness
  • Cardiac - Signs of congestive heart failure, pericarditis