Uveitis associated with an epidemic outbreak of leptospirosis

Leptospirosis and panuveitis in a dog

A case of panuveitis as a result of leptospiral infection in an 8-year-old Jack Russell Terrier is reported. Mild hyphema, aqueous flare, and partial serous retinal detachments were noted in both eyes on initial ophthalmic examination. The serum microscopic agglutination testing for Leptospira serovarieties revealed titers of 1 : 12 800 for Leptospira canicola and 1 : 200 for Leptospira icterohemorrhagiae. With medical therapy, the panuveitis resolved and functional vision was regained. Four weeks after the initial presentation, convalescent titers were 1 : 200 for L. canicola and 1 : 100 for L. icterohemorrhagiae. The incidence of leptospirosis, along with difficulties diagnosing, and current medical therapies for this disease are also discussed.

Leptospirosis in the tropics and in travelers

Leptospirosis, caused by spirochetes of the genus Leptospira, has increasingly been recognized to affect travelers and residents in tropical settings. A zoonotic disease, leptospirosis is transmitted to humans through environmental surface waters contaminated by the urine of chronically infected mammals. Outcome of infection varies, ranging from acute febrile illness (including self-resolving undifferentiated fever) to aseptic meningitis to a fulminant syndrome of jaundice, oliguric renal failure, pulmonary hemorrhage, and refractory shock. Hospitalized cases have mortality rates as high as 25%. A recent clinical trial showed that third-generation cephalosporin is as effective as doxycycline and penicillin in the treatment of acute disease. Doxycycline is effective in preventing leptospirosis in travelers. No protective vaccine is currently available.

Ocular penetration of oral doxycycline in the horse

OBJECTIVE

To investigate intraocular penetration of orally administered doxycycline in the normal equine eye and to compare intraocular and serum doxycycline concentrations. Procedures Six mares were administered doxycycline at 10 mg/kg every 12 h by nasogastric tube for 5 days. Blood, aqueous, and vitreous samples were collected on days 1 and 5. All samples were assayed for doxycycline concentrations. Aqueous and vitreous samples were also assayed for protein quantitation.

RESULTS

Doxycycline was rapidly absorbed after the first dose (T(max) value of 1.42 +/- 1.28 h); and elimination of doxycycline occurred slowly (median t(1/2) = 10.88 h). Doxycycline could not be detected in the aqueous on days 1 and 5, nor could it be detected in the vitreous on day 1. On day 5, the mean vitreous doxycycline concentration was 0.17 +/- 0.04 microg/mL at 2 h after drug administration.

CONCLUSIONS

Repeated oral administration of doxycycline in the horse resulted in steady state serum concentrations of < 1 microg/mL; however, it did not result in appreciable concentrations of drug in the aqueous and vitreous in normal eyes.

FREQUENCY OF ANTI-LEPTOSPIRES AGGLUTININS IN SOWS FROM A SWINE HERD IN THE IBIÚNA MUNICIPALITY, STATE OF SÃO PAULO, BRAZIL

ABSTRACT A serologic survey was conducted among 164 sows from a single farrow-to-finish swine herd located in the Ibiúna municipality, state of São Paulo, Brasil, to determine the frequency of antileptospires agglutinins. For detection of anti-leptospires antibodies, the microscopic serumagglutination test (MAT) was carried out using live cultures of 22 pathogenic and two saprophytic Leptospira spp. serovars. The most frequent serovar was found crossing the results of frequency and titer of agglutinins, and sera presenting equal titers for two or more serovars were not considered for this analysis. Of the 164 sows, 27 (16.5%) were seropositive for at least one Leptospira spp. serovar. The most frequent serovar was Hardjo (Hardjobovis), with 13 (54.2%) reactant sera. Other reactant serovars and respective frequency were: Shermani (16.6%), Bratislava (12.5%), Autumnalis (12.5%) and Icterohaemorrhagiae (4.2%).

Nouveaux concepts étiologiques dans l’uvéite

Uveitis remains an important cause of visual impairment, particularly in young patients. Idiopathic forms of intraocular inflammation should no longer be regarded as a presumed clinical entity, and the ophthalmologist must reconsider the specific etiology of primary uveitis when the clinical examination does not yield a definitive diagnosis or when the course of the disease on corticosteroids remains atypical. Laboratory tests based on serum analysis have limited value and should not be considered as diagnostic proof in different clinical presentations. The diagnostic management of infectious uveitis has been greatly improved by the use of molecular techniques applied to ocular fluids and tissues. Polymerase chain reaction (PCR) technology is a powerful tool that should be proposed in atypical cases of uveitis or retinitis of unclear but potentially infectious origin. This strategy is a major step before using unconventional and new immunomodulatory agents such as anti-TNF-alpha molecules. Under strict experimental conditions including adequate testing to rule out a possible contamination, PCR and its variants have changed our practical approach to intraocular inflammatory disorders and have provided new details for the understanding of infectious uveitis. The concept of pathogen-induced intraocular inflammation can be revisited in the light of molecular data obtained after anterior chamber paracentesis or diagnostic vitrectomy.

The wandering eye: eye infection in the returning traveller

The eye may represent the presenting features of an illness in the returning traveller. In other patients it may serve as a useful marker of severity. Clinicians seeing this group of patients need to have an understanding of the ocular mainfestations of travel related illnesses. The article reviews the features of major imported infections such as malaria, dengue and brucella, in addition to other clinically important conditions that may present to ophthalmologists and travel health specialists.

Host-inducible immunogenic sphingomyelinase-like protein, Lk73.5, of Leptospira interrogans

Leptospira interrogans causes a variety of clinical syndromes in animals and humans. Although much information has accumulated on the importance of leptospiral lipopolysaccharide in protective antibody responses, relatively little is known about proteins that participate in immune responses. Identification of those proteins induced only in the host is particularly difficult. Using a novel double-antibody screen designed to identify clones in a gene library of L. interrogans serovar Pomona expressing host-inducible proteins, we have characterized a gene (lk75.3) encoding a sphingomyelinase-like preprotein of 648 amino acids with cytotoxic activity for equine pulmonary endothelial cells and weak hemolytic activity for equine and rabbit erythrocytes. lk73.5 was found as a single gene copy in all serovars of L. interrogans but not in other Leptospira spp. except L. inadai. The open reading frame (ORF) for Lk73.5 is followed by another partially homologous sequence containing an ORF (sph-like 2) for a 28.7-kDa peptide. Lk73.5 and Sph-like 2 share 95.1 and 97.7% amino acid identity with putative sphingomyelinases Sph2 and Sph1 (N terminus) from L. interrogans serovar Lai (S.-X. Ren, G. Fu, X.-G. Jiangk, R. Zeng, Y.-G. Miao, H. Xu, Y.-X. Zhang, H. Xiong, G. Lu, L.-F. Lu, H.-Q. Jiang, J. Jia, Y.-F. Tu, J.-X. Jiang, W.-Y. Gu, Y.-Q. Zhang, Z. Cai, H.-H. Sheng, H.-F. Yin, Y. Zhang, G.-F. Zhu, M. Wank, H.-L. Huangk, Z. Qian, S.-Y. Wang, Wei Ma, Z.-J. Yao, Y. Shen, B.-Q. Qiang, Q.-C. Xia, X.-K. Guo, A. Danchinq, I. S. Girons, R. L. Somerville, Y.-M. Wen, M.-H. Shik, Z. Chen, J.-G. Xuk, and G.-P. Zhao, Nature 422:88-893, 2003). Substantial homologies to sphingomyelinases from other leptospiras and other bacteria are also present. Lk73.5 was not detected in leptospiras cultured at 30 or 37 degrees C. The recombinant protein reacted strongly with sera from recently infected mares but not with sera from horses vaccinated with commercial pentavalent bacterin. The host-inducible immunogenic Lk73.5 should have value in distinguishing vaccine from infection immune response.

Leptospirosis: a zoonotic disease of global importance

In the past decade, leptospirosis has emerged as a globally important infectious disease. It occurs in urban environments of industrialised and developing countries, as well as in rural regions worldwide. Mortality remains significant, related both to delays in diagnosis due to lack of infrastructure and adequate clinical suspicion, and to other poorly understood reasons that may include inherent pathogenicity of some leptospiral strains or genetically determined host immunopathological responses. Pulmonary haemorrhage is recognised increasingly as a major, often lethal, manifestation of leptospirosis, the pathogenesis of which remains unclear. The completion of the genome sequence of Leptospira interrogans serovar lai, and other continuing leptospiral genome sequencing projects, promise to guide future work on the disease. Mainstays of treatment are still tetracyclines and beta-lactam/cephalosporins. No vaccine is available. Prevention is largely dependent on sanitation measures that may be difficult to implement, especially in developing countries.

Field application of Lepto lateral flow for rapid diagnosis of leptospirosis

The Lepto lateral flow assay for leptospirosis was evaluated at a primary health centre in the Andaman Islands, where leptospirosis is endemic. One hundred and seventeen suspected patients were included in the study; acute serum samples were collected from all of them and convalescent samples from 104. The standard criteria for diagnosis of leptospirosis were: (i) isolation of leptospires from blood, (ii) seroconversion in microscopic agglutination test (MAT) with a minimum titre of 100, (iii) a fourfold rise in titre in MAT or (iv) a MAT titre of 400 or more if only a single sample was available. The results of the lateral flow test were compared with these criteria. Lepto lateral flow had sensitivity of 52.9 % (37/70) in the first week of illness and 86 % (49/57) during weeks 2-4. The corresponding specificities were respectively 93.6 % (44/47) and 89.4 % (42/47). The sensitivity was 34.3 % (12/35) on days 2-3 of the illness, 63.3 % (14/22) on days 4-5 and 84.6 % (11/13) at the end of the first week. The test had a positive predictive value of 92.5 % (37/40) during the first week and 90.7 % (49/54) subsequently. Corresponding negative predictive values were respectively 57.1 % (44/77) and 84 % (42/50). Agreement of the results with the standard criteria was low during the first week, but high during weeks 2-4, with a kappa value of 0.7491. The positivity rates of the tests showed a logarithmic relationship with the MAT titres of samples (r(2) = 0.9271). All indices of validity and utility of lateral flow were similar to those of IgM ELISA and Lepto dipstick. The test can be performed at the bedside of the patient, as whole blood can also be used for testing.

Identification and evaluation of LPS antigen for serodiagnosis of uveitis associated with leptospirosis

Leptospirosis is a widespread zoonotic disease that affects all mammals in different parts of the world. Though there are many commercial kits available for the diagnosis of systemic leptospirosis, the nature of the antigen has not been described. Therefore, identification of a specific antigen is important. Since ocular involvement in leptospirosis has been reported, there is a need to identify and characterize the leptospiral antigen for diagnosis of uveitis associated with past leptospiral infection (leptospiral uveitis) and for confirming the clinical diagnosis. Seven-day-old culture of Leptospira biflexa serovar Patoc was used for preparing the antigen. The present study included serum samples from 81 patients with clinical criteria for leptospiral uveitis, 15 cataract controls and 15 non-leptospiral uveitis controls. Serum samples were assayed by ELISA using our antigenic preparation and by a microscopic agglutination test (MAT) using 19 serovars. The antigen prepared had 280 micro g LPS ml(-1) and no detectable amount of protein. Silver-staining of SDS-PAGE for protein and LPS, dot blot and Western blot analysis and proteinase K and periodate treatment showed that LPS (13-21 kDa and 28 kDa) in our preparation was the relevant antigen for serodiagnosis. IgG antibodies showed reactivity in both leptospiral uveitis patients and controls. However, on the basis of IgM response to LPS, 48 % of the leptospiral uveitis patients were significantly positive compared with controls; 58 % of leptospiral uveitis patients and none of the controls were positive for MAT. When MAT and IgM ELISA results were considered together, 77 % were significantly positive. LPS is identified as a candidate antigen for serodiagnosis of leptospiral uveitis and has sensitivity and specificity of 48 and 90 %, respectively, in ELISA for IgM antibodies. Confirmation of clinical diagnosis with a specific laboratory test would help to initiate the most appropriate treatment for leptospiral uveitis.

Ocular leptospirosis

Uveitis is a well-known late complication of systemic leptospirosis, a zoonotic disease caused by the water-borne spirochete Leptospira. Although it is one of the world's most widespread febrile diseases, it remains underdiagnosed, mainly because of protean manifestations, lack of awareness, and nonavailability of laboratory support. Systematic collection of published literature was conducted using Medline, the Cochrane library, and bibliographies of retrieved reports. Articles directly applicable to ocular leptospirosis and current reports on the epidemiology, basic research, clinical presentations, and management of leptospirosis were reviewed. Changing trends in risk factors and an expanding spectrum of ocular and systemic findings have been reported. Molecular research on leptospirosis has shown remarkable progress; several rapid diagnostic modalities are currently under study. Awareness of this entity is absolutely essential to arrive at an accurate diagnosis and to prevent its potential reversible and irreversible ocular complications.

Cloning and molecular characterization of an immunogenic LigA protein of Leptospira interrogans

A clone expressing a novel immunoreactive leptospiral immunoglobulin-like protein A of 130 kDa (LigA) from Leptospira interrogans serovar pomona type kennewicki was isolated by screening a genomic DNA library with serum from a mare that had recently aborted due to leptospiral infection. LigA is encoded by an open reading frame of 3,675 bp, and the deduced amino acid sequence consists of a series of 90-amino-acid tandem repeats. A search of the NCBI database found that homology of the LigA repeat region was limited to an immunoglobulin-like domain of the bacterial intimin binding protein of Escherichia coli, the cell adhesion domain of Clostridium acetobutylicum, and the invasin of Yersinia pestis. Secondary structure prediction analysis indicates that LigA consists mostly of beta sheets with a few alpha-helical regions. No LigA was detectable by immunoblot analysis of lysates of the leptospires grown in vitro at 30 degrees C or when cultures were shifted to 37 degrees C. Strikingly, immunohistochemistry on kidney from leptospira-infected hamsters demonstrated LigA expression. These findings suggest that LigA is specifically induced only in vivo. Sera from horses, which aborted as a result of natural Leptospira infection, strongly recognize LigA. LigA is the first leptospiral protein described to have 12 tandem repeats and is also the first to be expressed only during infection. Thus, LigA may have value in serodiagnosis or as a protective immunogen in novel vaccines.

Evaluation of the clinical utility of a rapid blood test for human leptospirosis

A rapid assay device for the detection of Leptospira-specific immunoglobulin M (IgM) antibodies was applied on whole blood samples collected from a group of consecutive patients admitted with clinical suspicion of leptospirosis to a district hospital in Kerala, India. The hospital is located in an area that is endemic for leptospirosis. The results of the rapid assay showed an agreement of 94.3% with those of an IgM ELISA routinely used for the serodiagnosis of leptospirosis. The rapid assay was simply performed by the addition of 10 microL blood to the sample well of a plastic assay device followed by the addition of 130 microL sample fluid. The assay was read after 10 min by visual inspection and was scored positive when staining of the antigen line in the test zone was observed. The assay utilizes stabilised components and can be stored without the need for refrigeration. These characteristics make the assay ideal in areas where the disease is common and where laboratory support is not routinely available.

Leptospirosis

Leptospirosis is a globally important zoonotic disease that affects humans on all continents, in both urban and rural contexts, and in temperate and tropical climes. Leptospirosis is a disease of the environment; transmission depends on interactions between humans and mammalian reservoir hosts. A variety of infectious diseases that present as undifferentiated febrile syndromes, such as malaria, dengue and influenza, as well as viral hemorrhagic fevers can mimic leptospirosis. The importance of pulmonary hemorrhage as a lethal complication of leptospirosis has become more widely recognized. In contrast to textbook dogma, population-based studies indicate that there is a poor correlation between infecting leptospiral strain and clinical expression of disease. Genetic transformation of a Leptospira sp. has now been reported, which should allow for detailed analysis of a variety of leptospiral genes. Publication of the whole Leptospira genome is eagerly awaited. Following recent reports of a new, highly effective conjugate typhoid vaccine, new efforts to find leptospirosis vaccines should include the manufacture and testing of conjugate leptospiral lipopolysaccharide vaccines. Recent advances, particularly in epidemiology, molecular genetics and pathogenesis, are placing leptospirosis at the cutting edge of biomedical science.

Serum and vitreous humor antibody titers in and isolation of Leptospira interrogans from horses with recurrent uveitis

OBJECTIVE

To measure antibody titers against Leptospira interrogans in serum and vitreous humor and determine the prevalence of L interrogans in vitreous humor of horses with recurrent uveitis.

DESIGN

Cross-sectional study.

ANIMALS

242 horses (270 eyes) with recurrent uveitis undergoing vitrectomy and 39 control horses (54 eyes) without any history or clinical signs of recurrent uveitis undergoing euthanasia or enucleation for unrelated reasons.

PROCEDURE

Serum and vitreous humor were tested for antibodies against 13 serovars of L interrogans. Vitreous humor was submitted for leptospiral culture; isolates were typed to the serogroup level.

RESULTS

Leptospira interrogans was isolated from vitreous humor from 120/229 (52%) horses (126/252 [50%] eyes) with recurrent uveitis but was not isolated from vitreous humor from 36 eyes of 21 control horses. Duration of recurrent uveitis was > or = 1 year for 45 of the 120 (38%) horses from which the organism was isolated. Geometric mean antibody titers against L interrogans in the vitreous humor and serum of horses with recurrent uveitis were 1:1,332 and 1:186, respectively. Only 91 of 120 (76%) horses from which the organism was isolated had a 4-fold or greater difference between serum and vitreous humor antibody titers.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that persistent ocular infection with L interrogans is common in horses with recurrent uveitis. A 4-fold increase in vitreous humor versus serum antibody titers may not be a sensitive test for the diagnosis of L interrogans-induced recurrent uveitis. We hypothesize that the immune component of recurrent uveitis can be directly induced and maintained by persistent infection of the eye with L interrogans.

Leptospirosis

Leptospirosis is a worldwide zoonotic infection with a much greater incidence in tropical regions and has now been identified as one of the emerging infectious diseases. The epidemiology of leptospirosis has been modified by changes in animal husbandry, climate, and human behavior. Resurgent interest in leptospirosis has resulted from large outbreaks that have received significant publicity. The development of simpler, rapid assays for diagnosis has been based largely on the recognition that early initiation of antibiotic therapy is important in acute disease but also on the need for assays which can be used more widely. In this review, the complex taxonomy of leptospires, previously based on serology and recently modified by a genotypic classification, is discussed, and the clinical and epidemiological value of molecular diagnosis and typing is also evaluated.

Canine systemic bacterial infections

Although systemic bacterial diseases are an uncommon cause of uveitis in dogs, they should be included in the differential diagnoses for uveitis. A work-up for uveitis should include tests for B. canis and B. burgdorferi. If an aqueous centesis is performed, Leptospira titers or PCR can be performed on the aqueous humor and the serum. Better documentation of the role of Leptospira and B. burgdorferi in uveitis in the dog is needed. Any suspected cases should be worked-up thoroughly. If the dog does prove to be positive for the organism, the case should be submitted to a peer-reviewed journal.

Infectious causes of uveitis in the developing world

Infectious causes of uveitis are common in the developing world and include some causes that are rarely encountered in industrialized nations, such as tuberculosis, leptospirosis, leprosy, onchocerciasis, and cystercicosis. Ocular toxoplasmosis occurs in all countries but is more common in Central and South America, the South Pacific, and western Europe. AIDS-related opportunistic infections occur wherever HIV infection is prevalent, including North and South America, western and eastern Europe, the former Soviet Union, sub-Saharan Africa, and South and Southeast Asia. Physicians who care for patients in the developing world should consider these infectious possibilities whenever their patients develop uveitis.

Clinical aspects of ocular leptospirosis in New Caledonia (South Pacific)

PURPOSE

The incidence of leptospirosis is very high in New Caledonia (average annual incidence rate: 180/100 000 of the population). To investigate the role of pathogenic leptospires as an aetiological agent of ocular diseases, we report the results of a 5-year survey in New Caledonia.

METHODS

We reviewed 13 patients (corresponding to 17 investigated pathologic eyes) retrospectively. The selection of patients was based on epidemiological data, initial clinical examination, biological confirmation of leptospirosis according to reference procedures and a specific polymerase chain reaction assay. The anatomic criteria of uveitis and the criteria describing the evolution of the disease were those recommended by the International Uveitis Study Group.

RESULTS

Consequent rates of optic neuritis (65%), posterior uveitis (35%), secluded pupil (24%), interstitial keratitis (18%) and pars planitis (12%) were found. Our rates of recurrence (46%) and of ophthalmic complications (82%) were substantial; some symptoms indicated brain involvement.The final visual damage was severe in 35% of eyes.

CONCLUSIONS

Microagglutination and polymerase chain reaction hybridization are complementary tests for the diagnosis of Leptospira-induced ophthalmic lesions. Before deciding on treatment, one must consider the ability of virulent leptospires to persist in immunologically privileged sites such as aqueous humor, cerebrospinal fluid and eukaryotic cells. Polymerase chain reaction is a useful tool for the diagnosis of Leptospira-induced ocular complications, which are probably misdiagnosed if based only on routine laboratory tests. It enables early diagnosis and early specific treatment that now consists of quinolone and cyclines.

Leptospirosis

Leptospirosis, a waterborne spirochetal illness, is common in tropical climates. Rodents and wild animals are the most common reservoirs for this widespread zoonosis. Human disease is acquired by contact with urine or tissues of an infected animal or through contaminated water and soil. Systemic leptospirosis is characterized by its multisystem involvement, protean manifestation, and varying severity. The clinical presentation ranges from occult infection to fatal complications like hepatorenal failure. Early diagnosis is important to halt the fulminate course. The microagglutination test is considered the gold standard serological test for leptospirosis, although molecular techniques are now under study. Treatment of systemic leptospirosis includes penicillin or tetracycline in addition to supportive treatment. Ocular involvement occurs during the immunological phase of the disease. One or both eyes may be involved, typically with a panuveitis often accompanied by retinal periphlebitis and hypopyon. In general, leptospiral uveitis has a good prognosis and the patient recovers full vision in spite of severe panuveal inflammation. Awareness of this infectious uveitic entity is essential not only in order to differentiate it from other severe autoimmune uveitides, but also to reduce the percentage of idiopathic uveitis in endemic areas.