Leptospirosis in Emergency Medicine Workup

  • Author: Judith Green-McKenzie, MD, MPH; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Jan 13, 2010
 

Laboratory Studies

Definitive diagnosis is suggested by isolation of the organism by culture or a positive result on the microscopic agglutination test (MAT). An example of this is shown in the image below.

Darkfield microscopy of leptospiral microscopic agDarkfield microscopy of leptospiral microscopic agglutination test. (This image is in the public domain and thus free of any copyright restrictions. Courtesy of the Centers for Disease Control/Mrs. M. Gatton.)

Only specialized laboratories perform serologic tests; hence, the decision to treat should not be delayed while waiting for the test results.

  • Cultures
    • Isolating the organism by culture allows definitive diagnosis.
    • Leptospires remain viable in anticoagulated blood for as long as 11 days; hence, specimens can be mailed to a reference laboratory for culture. The infecting serovar can be isolated only by culture.
    • Blood cultures may be negative if drawn too early or too late. Leptospires may not be detected in the blood until 4 days after the onset of symptoms (7-14 d after exposure). Once the immune system is activated, blood cultures may again become negative.
    • Leptospires may be isolated from the cerebrospinal fluid (CSF) within the first 10 days.
    • Leptospires may be isolated from the urine for several weeks after the initial infection. In some patients, urine cultures may remain positive for months or years after the onset of illness. Positive urine cultures may take as long as 8 weeks to grow.
  • MAT
    • A 4-fold rise in convalescent titers is considered a positive result.
    • A presumed diagnosis is made by observing an antibody titer of greater than or equal to 1:100 in the MAT in conjunction with symptoms consistent with the disease.
    • The MAT uses a battery of live leptospiral strains.
    • The antibody response does not reach detectable levels until the second week of illness, and it can be affected by treatment.
  • Macroscopic slide agglutination test
    • This test allows a presumptive diagnosis.
    • Clinical illness consistent with leptospirosis must be present to support the diagnosis.
    • This test, which uses killed antigen, is useful for screening but is not specific.
  • Other tests: Other tests include an indirect hemagglutination test, a microcapsule agglutination test, an immunoglobulin M (IgM) enzyme-linked immunoabsorbent assay (ELISA), and a dark-field examination of blood or urine.
    • More recently, rapid commercial tests have been made available, such as the Dip-S-Ticks (PanBio, Inc; Baltimore, Maryland), which detects leptospira antibodies.
    • Nucleic acid amplification (polymerase chain reaction [PCR])–based techniques have been developed to diagnose leptospirosis. PCR-based techniques are unable to identify the infecting serovar. This factor reduces its epidemiologic and public health value
    • The dark-field examination frequently leads to misdiagnosis and should not be used.
    • The ELISA uses a broadly reactive antigen and is a standard serologic procedure, as is the MAT.[9] Because it detects IgM, it may be useful for diagnosis of new infections within 3-5 days.
  • Laboratory studies (general)
    • In patients with mild disease, elevated erythrocyte sedimentation rates and peripheral leukocytosis (3,000-26,000 x 109/L) with a left shift are noted.
    • Aminotransferases may be mildly elevated up to 200 U/L; serum bilirubin and alkaline phosphatase levels may also be elevated.
    • Urinalysis may reveal the following:
      • Proteinuria may be present.
      • Leukocytes, erythrocytes, hyaline casts, and granular casts may be present in the urinary sediment.
    • CSF studies may reveal the following:
      • When the CNS becomes involved, polymorphonuclear leukocytes initially predominate and are later replaced by monocytes.
      • CSF protein may be normal or elevated, whereas glucose levels remain normal.
      • CSF pressure is normal, but a lumbar puncture can relieve the headache.
  • Laboratory studies (Weil disease)
    • Patients may exhibit mild thrombocytopenia (as many as 50%), which is often accompanied by renal failure.
    • Azotemia and renal failure are other prominent characteristics.
    • Marked leukocytosis may be present.
    • Prothrombin times may be elevated.
    • Creatine phosphokinase (CPK) levels are elevated in as many as 50% of patients; acutely, jaundice in Weil disease is associated with very high CPK level, but transaminases are only modestly elevated.
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Imaging Studies

  • In severe disease, a patchy alveolar pattern may be revealed on lung radiography findings, corresponding to alveolar hemorrhage.
  • Most radiographic changes occur in the periphery of the lower lobes.
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Other Tests

  • Electrocardiographic (ECG) abnormalities are common during the leptospiremic phase of Weil syndrome.
  • In severe cases, congestive heart failure and cardiogenic shock may occur.
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Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Judith Green-McKenzie, MD, MPH  Associate Professor, Director of Clinical Practice, Occupational Medicine Residency Director, University of Pennsylvania School of Medicine

Judith Green-McKenzie, MD, MPH is a member of the following medical societies: American College of Occupational and Environmental Medicine, American College of Physicians, American College of Preventive Medicine, National Medical Association, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

William H Shoff, MD, DTM&H  Director, PENN Travel Medicine, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania

William H Shoff, MD, DTM&H is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Glaxo Smith Kline None None; Glaxo Smith Kline Honoraria Speaking and teaching

Specialty Editor Board

Edmond A Hooker II, MD, DrPH, FAAEM  Assistant Professor, Department of Emergency Medicine, University of Cincinnati College of Medicine

Edmond A Hooker II, MD, DrPH, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Public Health Association, Society for Academic Emergency Medicine, and Southern Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Jeter (Jay) Pritchard Taylor III, MD  Compliance Officer, Attending Physician, Emergency Medicine Residency, Department of Emergency Medicine, Palmetto Health Richland, University of South Carolina School of Medicine; Medical Director, Department of Emergency Medicine, Palmetto Health Baptist

Jeter (Jay) Pritchard Taylor III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

  1. Palaniappan RU, Ramanujam S, Chang YF. Leptospirosis: pathogenesis, immunity, and diagnosis. Curr Opin Infect Dis. Jun 2007;20(3):284-92. [Medline].

  2. Inada R, Ido Y, et al. Etiology, mode of infection and specific therapy of Weil's disease. J Exp Med. 1916;23:377-402.

  3. CDC. From the Centers for Disease Control and Prevention. Update: outbreak of acute febrile illness among athletes participating in Eco-Challenge-Sabah 2000--Borneo, Malaysia, 2000. JAMA. Feb 14 2001;285(6):728-30. [Medline].

  4. CDC. Update: leptospirosis and unexplained acute febrile illness among athletes participating in triathlons--Illinois and Wisconsin, 1998. MMWR Morb Mortal Wkly Rep. Aug 21 1998;47(32):673-6. [Medline].

  5. CDC. Outbreak of leptospirosis among white-water rafters - Costa Rica occupational infections. MMWR. 1997;46(25):77-578. [Medline].

  6. CDC. Outbreak of acute febrile illness and pulmonary hemorrhage--Nicaragua, 1995. JAMA. Dec 6 1995;274(21):1668. [Medline].

  7. Gaynor K, Katz AR, Park SY, Nakata M, Clark TA, Effler PV. Leptospirosis on Oahu: an outbreak associated with flooding of a university campus. Am J Trop Med Hyg. May 2007;76(5):882-5. [Medline].

  8. Cacciapuoti B, Ciceroni L, Maffei C. A waterborne outbreak of leptospirosis. Am J Epidemiol. Sep 1987;126(3):535-45. [Medline].

  9. Vasconcellos FA, Coutinho ML, da Silva EF, et al. Testing different antigen capture ELISA formats for detection of Leptospira spp. in human blood serum. Trans R Soc Trop Med Hyg. Nov 24 2009;[Medline].

  10. [Guideline] Guidugli F, Castro AA, Atallah AN. Antibiotics for preventing leptospirosis. Cochrane Database Syst Rev. 2000;CD001305. [Medline].

  11. Aston JM, Broom JC. Leptospirosis in Man and Animals. Edinburgh and London, England: Livingstone; 1958.

  12. Bajani MD, Ashford DA, Bragg SL, et al. Evaluation of four commercially available rapid serologic tests for diagnosis of leptospirosis. J Clin Microbiol. Feb 2003;41(2):803-9. [Medline].

  13. Carvalho CR, Bethlem EP. Pulmonary complications of leptospirosis. Clin Chest Med. Jun 2002;23(2):469-78. [Medline].

  14. CDC. Brief report: Leptospirosis after flooding of a university campus--Hawaii, 2004. MMWR Morb Mortal Wkly Rep. Feb 10 2006;55(5):125-7. [Medline].

  15. Chu KM, Rathinam R, Namperumalsamy P. Identification of Leptospira species in the pathogenesis of uveitis and determination of clinical ocular characteristics in south India. J Infect Dis. May 1998;177(5):1314-21. [Medline].

  16. Cohen R, LaDou J, eds. Occupational Infections. In: Occupational Environmental Medicine. Connecticut: Appleton & Lange; 1997.

  17. Cole DJ, Hill VR, Humenik FJ. Health, safety, and environmental concerns of farm animal waste. Occup Med. Apr-Jun 1999;14(2):423-48. [Medline].

  18. Corwin A, Ryan A, Bloys W. A waterborne outbreak of leptospirosis among United States military personnel in Okinawa, Japan. Int J Epidemiol. Sep 1990;19(3):743-8. [Medline].

  19. De Serres G, Levesque B, Higgins R. Need for vaccination of sewer workers against leptospirosis and hepatitis A. Occup Environ Med. Aug 1995;52(8):505-7. [Medline].

  20. Dolhnikoff M, Mauad T, Bethlem EP, Carvalho CR. Leptospiral pneumonias. Curr Opin Pulm Med. May 2007;13(3):230-5. [Medline].

  21. Edwards GA, Domm BM. Human leptospirosis. Medicine (Baltimore). Feb 1960;39:117-56. [Medline].

  22. Farrar WE, Mandel GL, Bennett JE, Dolin R, eds. Leptospira species (leptospirosis). In: Principles and Practice of Infectious Diseases. New York, NY: Churchill Livingstone; 1995:2137-41.

  23. Feigin RD, Anderson DC. Human leptospirosis. CRC Crit Rev Clin Lab Sci. Mar 1975;5(4):413-67. [Medline].

  24. Feigin RD, Lobes LA Jr, Anderson D. Human leptospirosis from immunized dogs. Ann Intern Med. Dec 1973;79(6):777-85. [Medline].

  25. Fonseca C, Teixeira M, Romero E. Leptospira DNA detection for the diagnosis of human leptospirosis. J Infect Dis. 2006;52:15-22.

  26. Freedman DO, Woodall J. Emerging infectious diseases and risk to the traveler. Med Clin North Am. Jul 1999;83(4):865-83, v. [Medline].

  27. Griffith ME, Hospenthal DR, Murray CK. Antimicrobial therapy of leptospirosis. Curr Opin Infect Dis. Dec 2006;19(6):533-7. [Medline].

  28. Im JG, Yeon KM, Han MC, et al. Leptospirosis of the lung: radiographic findings in 58 patients. AJR Am J Roentgenol. May 1989;152(5):955-9. [Medline].

  29. Kaufman AF, Wenger JD, Last JM, Wallace RB, eds. Leptospirosis. In: Maxcy-Rosenau-Last Public Health and Preventive Medicine. 13th ed. Norwalk, CT: 1992:264-5.

  30. Lomar AV, Diament D, Torres JR. Leptospirosis in Latin America. Infect Dis Clin North Am. Mar 2000;14(1):23-39, vii-viii. [Medline].

  31. Manzin A, Solforosi L, Clementi M. Dynamics of viral quasispecies in hepatitis C virus infection. Res Virol. Mar-Apr 1997;148(2):171-6. [Medline].

  32. Mulla S, Chakraborty T, Patel M, et al. Diagnosis of leptospirosis and comparison of ELISA and MAT techniques. Indian J Pathol Microbiol. Jul 2006;49(3):468-70. [Medline].

  33. Ooteman MC, Vago AR, Koury MC. Evaluation of MAT, IgM ELISA and PCR methods for the diagnosis of human leptospirosis. J Microbiol Methods. May 2006;65(2):247-57. [Medline].

  34. Pellizzer P, Todescato A, Benedetti P, Colussi P, Conz P, Cinco M. Leptospirosis following a flood in the Veneto area, North-east Italy. Ann Ig. Sep-Oct 2006;18(5):453-6. [Medline].

  35. Shaked Y, Shpilberg O, Samra D. Leptospirosis in pregnancy and its effect on the fetus: case report and review. Clin Infect Dis. Aug 1993;17(2):241-3. [Medline].

  36. Sitprija V, Losuwanrak K, Kanjanabuch T. Leptospiral nephropathy. Semin Nephrol. Jan 2003;23(1):42-8. [Medline].

  37. Skilbeck NW, Miller GT, ALIA. A serological survey of leptospirosis in Gippsland dairy farmers. Med J Aust. May 26 1986;144(11):565-7. [Medline].

  38. Speelman P, Fauci AS, Brainwald E, eds. Leptospirosis. In: Harrison's Principles of Internal Medicine. 14th ed. 1998:756.

  39. Takafuji ET, Kirkpatrick JW, Miller RN, et al. Agricultural Occupational Medicine: An Efficacy Trial of Doxycycline Chemoprophylaxis against Leptospirosis. In: Occupational Medicine. St Louis, MO: Mosby; 1984:310, 497-500, 894-5.

  40. Tappero J, Ashford D, Perkins B. Leptospirosis. In: Principles and Practice of Infectious Disease. 5th ed. New York, NY: Churchill Livingstone; 1998.

  41. Vinetz JM, Glass GE, Flexner CE. Sporadic urban leptospirosis. Ann Intern Med. Nov 15 1996;125(10):794-8. [Medline].

  42. Yang CW, Wu MS, Pan MJ. Leptospirosis renal disease. Nephrol Dial Transplant. 2001;16 Suppl 5:73-7. [Medline].

 
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A scanning electron micrograph depicting Leptospira atop a 0.1-µm polycarbonate filter. (This image is in the public domain and thus free of any copyright restrictions. Courtesy of the Centers for Disease Control/Rob Weyant.)
Darkfield microscopy of leptospiral microscopic agglutination test. (This image is in the public domain and thus free of any copyright restrictions. Courtesy of the Centers for Disease Control/Mrs. M. Gatton.)
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.)
 
 
 
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