Uveitis associated with an epidemic outbreak of leptospirosis

Utility of demographic and clinical signs as diagnostic predictors for leptospiral uveitis: A retrospective study

PURPOSE

Leptospirosis is a waterborne zoonotic disease prevalent in tropical regions, causing significant morbidity and mortality. It can involve any organ in its primary stage, and uveitis is its late complication. While advanced laboratory diagnosis is available only in tertiary care centers globally, a cost-effective bedside assessment of clinical signs and their scoring could offer a provisional diagnosis.

AIM

To analyze the diagnostic potential of demographic and clinical signs in a large cohort of serologically confirmed leptospiral uveitis patients.

METHODS

In this retrospective study, demographic and clinical parameters of 876 seropositive leptospiral uveitis patients and 1042 nonleptospiral uveitis controls were studied. Multivariable logistic regression analysis with bootstrap confidence interval (CI) characterized the diagnostic predictors. The performance of the model was evaluated using the area under the receiver operating curve (AUROC).

RESULTS

Presence of nongranulomatous uveitis (odds ratio [OR] = 6.9), hypopyon (OR = 4.6), vitreous infiltration with membranous opacities (OR = 4.3), bilateral involvement (OR = 4), panuveitis (OR = 3.3), vasculitis (OR = 1.9), disc hyperemia (OR = 1.6), absence of retinochoroiditis (OR = 15), and absence of cystoid macular edema (OR = 8.9) emerged as predictive parameters. The AUROC value was 0.86 with 95% CI of 0.846-0.874. At a cut-off score of 40, the sensitivity and specificity were 79.5 and 78.4, respectively.

CONCLUSION

The study demonstrates that ocular signs can serve as diagnostic predictors for leptospiral uveitis, enabling primary care ophthalmologists to make bedside diagnosis. This can be further confirmed by laboratory methods available at tertiary care centers.

The other great imitator among infectious diseases: Leptospirosis

INTRODUCTION

Leptospirosis is a worldwide zoonosis responsible for highly diverse clinical presentations with a wide range of severity. Variable environment exposures to infected urines of rodents have been described.

OBSERVATION

We report five cases of serologically confirmed leptospirosis leading to hospitalization in an intensive care unit (ICU) of a French center. These patients displayed neurological, respiratory, and abdominal presentation of leptospirosis with variable level of severity. Either professional, leisure related, or daily living exposures have been retrieved.

CONCLUSION

These cases underline the diversity of clinical presentation and environmental exposure of this infectious disease. They highlight the interest of an exhaustive anamnesis with collection of professional activity, environmental exposures, and leisure activities.

Why do Doctors Miss the Diagnosis of Leptospiral Uveitis? Emergence of New Serovars and Challenges in Diagnosis

PURPOSE

Leptospirosis is an endemic disease in India and uveitis is its late complication. Several Indian reports showed diversity of serovars, changing patterns and existence of new serovars. Failure to add new serovars in testing panel result in increased false-negativity in serology.

AIM

To analyse seroprevalence, changing patterns and to discuss the resulting challenges in diagnosis.

METHODS

In this retrospective study covering the period from 1994 to 2020, we analysed data from laboratory records of patients diagnosed with leptospiral uveitis in South India. Microscopic agglutination Test (MAT) and/or Enzyme-Linked Immunosorbent Assay (ELISA) were performed on clinically diagnosed leptospiral uveitis cases from our hospital, as well as on systemic leptospirosis patients from government and private hospitals.

RESULTS

Out of a total of 87 216 new uveitis cases with varying causes over 27 years, 3,658 (4.1%) were clinically diagnosed as leptospiral uveitis. Among them, 1,268 (34.7%) patients were seropositive. In 1994, 92% of clinically diagnosed leptospirosis patients were seropositive in the MAT performed at the Centers for Disease Control and Prevention in Atlanta. However, the positivity rate gradually declined to 35% over the years. The predominant serovars identified were L. autumnalis, L. icterohaemorrhagiae, and L. australis. There were notable variations in the distribution of serovars over the years.

CONCLUSIONS

The data suggest a declining sensitivity of MAT and ELISA, possibly due to the emergence of new serovars. Customizing the panel based on local isolates could enhance the performance of MAT. Critical need is the addition of advanced molecular techniques to improve the diagnosis.

Leptospiral Uveitis: Case Series and Review of Literature

AIM

To present the clinical features and review of literature of leptospiral uveitis.

METHODS

We present clinical features of patients with leptospiral uveitis with positive Leptospira IgM antibodies.

RESULTS

Twenty-six eyes of 24 patients, 11 males (45.8%), were included. The mean age was 37.5 ± 15.6 years. 91.7% had unilateral uveitis, 88.5% panuveitis, 11.5% anterior uveitis, 15.4% had hypopyon, 8% had cataract and 3.8% eyes had cystoid macular edema. Vitritis with characteristic vitreous membranes was an important feature. Retinal and choroidal vasculature were preserved on swept-source optical coherence tomography angiography. Mean presenting BCVA was logMAR0.49 ± 0.41, while final BCVA was logMAR0.04 ± 0.13. The mean duration for complete resolution of uveitis was 39.1 ± 15.5 days. 84.6% eyes achieved BCVA 6/6.

CONCLUSION

Leptospiral uveitis is an under-reported entity. It may present as anterior uveitis or panuveitis. It must be included in the differential diagnosis of non-granulomatous uveitis. The visual prognosis is usually favorable even in severe cases.

Leptospiral uveitis- "Transition 'from epidemic to endemic form" difficulties in laboratory confirmations

Purpose

Leptospirosis is a waterborne zoonotic disease that primarily causes systemic illness, followed by uveitis. After heavy flooding in Madurai district, an epidemic outbreak of systemic and ocular leptospirosis occurred in 1994. Our data shows a transition to endemicity after each epidemic.

Aim

The aim of this study is to report the clinical signs, epidemic outbreaks, and persistent endemicity of leptospiral uveitis, as well as the diagnostic dilemmas associated with it.

Methods

A retrospective analysis of clinical signs was conducted using medical records of leptospiral uveitis patients over a period of 27 years (1994-2020) in a tertiary care eye hospital. The clinical workup of uveitis included a detailed clinical history, systemic, and ophthalmic examination. Microagglutination tests (MATs) was done at the Centers for Disease Control and Prevention (CDC) in Atlanta and later in our regional laboratory. Serum samples were collected from human systemic leptospirosis cases and a small group of animals in and around Madurai.

Results

The first epidemic outbreak resulted in 200 seropositive patients. Subsequent epidemic outbreaks occurred in 1997, 1998, 2001, 2005, and 2012, with Madurai experiencing multiple outbreaks. However, the disease remained endemic, with 25-50 patients being observed per year in between the peaks. Ocular examination revealed acute non-granulomatous uveitis (94.9%), pan uveitis (59.8%), vitreous inflammatory reaction (55.4%), retinal vasculitis (29.5%), disc hyperemia (20.9%), and hypopyon. (16.2%). New serovars emerged every year, resulting in decreased sensitivity of the MAT. Over time, the MAT started to miss diagnoses.

Conclusion

The persistent endemicity of leptospiral uveitis emphasizes the need for accessible diagnostic tests. The low performance of the MAT can be attributable to the use of an older panel. The incorporation of new isolates in the MAT by a national laboratory will improve the accuracy of diagnosis.

Demography and clinical pattern of newly diagnosed uveitis patients in Malaysia

Introduction

Uveitis is one of the common causes of visual impairment in Malaysia. It remains a challenging entity to diagnose and manage due to variation in its clinical presentation. This study aims to observe the demographic and clinical pattern of cases from the participating ophthalmology units in Malaysia.

Methods

This study involved prospective and multicentered data collection for patients newly diagnosed with uveitis from 1^st January 2018 to 31^st December 2018. Variables collected and analyzed included age, gender, ethnicity, nationality, state of origin, laterality, granulomatous or non-granulomatous uveitis, and etiology of uveitis.

Results

A total of 1199 newly diagnosed uveitis patients were analyzed within the study period. There was a significant association between the anatomical location of uveitis with age at presentation. The percentage of patients with anterior uveitis was higher in the ‘40 to 60’ years and ‘above 60’ years age groups at 52.1% (n = 210) and 61.3% (n = 114) respectively. In contrast the percentage of patients with posterior and panuveitis was higher in the 1 to 20 and 20 to 40 years age groups at 51.4% (n = 54) and 48.7% (n = 246) respectively.

Sixty three percent of the patients presented with unilateral uveitis (n = 760, p < 0.001) vs bilateral. Non-granulomatous uveitis comprised 84.5% of all patients (n = 1013, p < 0.001) compared to granulomatous uveitis. Non-infectious etiology contributed to 65.7% of all patients (n = 788, p < 0.001) with the majority being unclassifiable uveitis (n = 686, 57.2%,). Specific inflammatory entities contributed to only 8.5% (n = 102) of the non-infectious causes with Vogt-Koyanagi-Harada (VKH) syndrome being the most common (n = 25, 2.1%,). Infectious uveitis comprised 34.3% (n = 411) with tubercular (TB) uveitis (n = 105, 8.8%) and viral uveitis (n = 107, 8.9%) contributing the most followed by ocular Toxoplasmosis (n = 93,7.8%).]

Conclusion

This study has highlighted the demographic data and common causes of uveitis in Malaysia.

A review of investigated risk factors for developing equine recurrent uveitis

Equine recurrent uveitis (ERU) is an ocular inflammatory disease that can be difficult to manage clinically. As such, it is the leading cause of bilateral blindness for horses. ERU is suspected to have a complex autoimmune etiology with both environmental and genetic risk factors contributing to onset and disease progression in some or all cases. Work in recent years has aimed at unraveling the primary triggers, such as infectious agents and inherited breed-specific risk factors, for disease onset, persistence, and progression. This review has aimed at encompassing those factors that have been associated, implicated, or substantiated as contributors to ERU, as well as identifying areas for which additional knowledge is needed to better understand risk for disease onset and progression. A greater understanding of the risk factors for ERU will enable earlier detection and better prognosis through prevention and new therapeutics.

Infectious Uveitis in Horses and New Insights in Its Leptospiral Biofilm-Related Pathogenesis

Uveitis is a sight-threatening eye disease in equids known worldwide that leads to considerable pain and suffering. By far the most common type of uveitis in Germany and neighboring countries is classical equine recurrent uveitis (ERU), which is caused by chronic intraocular leptospiral infection and is the main cause of infectious uveitis in horses. Other infectious causes are extremely rare and are usually clinically distinguishable from ERU. ERU can be treated very effectively by vitreous cavity lavage (vitrectomy). For proper indications of this demanding surgery, it is necessary to differentiate ERU from other types of uveitis in which vitrectomy is not helpful. This can be conducted on the basis of anamnesis in combination with ophthalmologic findings and by aqueous humor examination. During vitrectomy, vitreous material is obtained. These vitreous samples have historically been used for numerous etiologic studies. In this way, a chronic intraocular leptospiral infection has been shown to be the cause of typical ERU and, among other findings, ERU has also been recognized as a biofilm infection, providing new insights into the pathogenesis of ERU and explaining some thus far unexplainable phenomena of ERU. ERU may not only have transmissible aspects to some types of uveitis in humans but may also serve as a model for a spontaneously occurring biofilm infection. Vitreous material obtained during therapeutically indicated vitrectomy can be used for further studies on in vivo biofilm formation, biofilm composition and possible therapeutic approaches.

Infections and glaucoma

Glaucoma is an intraocular pressure-related ophthalmic disease with multiple causes that results in an optic neuropathy and vision loss. Intraocular pressure elevation is among its strongest risk factors. While glaucoma is mostly primary in etiology, secondary glaucoma is not infrequent. Recognizing its cause is imperative, since treatment is often different depending on the pathophysiologic mechanism. Numerous clinically relevant ophthalmic infections can result in robust inflammatory responses that may result in pressure elevation or intraocular anatomic configurations that predispose to pressure elevation. Knowing the mechanisms by which these infections can lead to glaucoma is critical in treating, and we consolidate what is currently known in regards to how infectious diseases lead to glaucoma.

Spirochetal uveitis: Spectrum of clinical manifestations, diagnostic and therapeutic approach, final outcome and epidemiological data

PURPOSE

Analysis of cases with spirochetal uveitis related to spirochetes in a tertiary referral academic center.

METHODS

Retrospective study of patients diagnosed with uveitis attributed to Treponema pallidum, Leptospira spp. and Borrelia burgdorferi from June 1991 until December 2019.

RESULTS

A total of 57 cases of spirochetal uveitis (22 patients with T. pallidum, 26 with Leptospira spp., and 9 with B. burgdorferi) that consisted 1% of the overall number of uveitics were recorded. All these cases presented with a wide spectrum of clinical presentations (anterior uveitis, posterior uveitis, panuveitis, vasculitis, papillitis, and in some rare cases concomitant posterior scleritis). The treatment included mainly penicillin or doxycycline, while corticosteroids were administered systematically in some cases with Borrelia or Leptospira infection. The final visual outcome was favorable (> 6/10 in Snellen visual acuity) in approximately 76% of our patients.

CONCLUSION

Despite being rare, spirochetal uveitis can be detrimental for the vision and must always be included in the differential diagnosis.

Clinical profile and response to steroids in post-fever retinitis: a nine-year experience from a referral institute in the rural hinterland of Central India

PURPOSE

To describe the demographics, clinical features, and treatment outcomes with systemic steroids in eyes presenting with post-fever retinitis (PFR) from Central India.

METHODS

Single-center, retrospective analysis of 147 eyes of 98 PFR cases between 2011 and 2019.

RESULTS

Mean age of the study cohort was 33.46 ± 12.76 years, with 72 males and 26 females. The mean interval between the onset of fever and the diminution of vision was 21.10 ± 13.54 days (range 0-60 days). The number of PFR cases increased over the nine years with 89 cases (90.1%) presenting during winters. Unilateral involvement was seen in 49 cases, while 49 had bilateral involvement. Clinical characteristics included: multifocal retinitis (n = 122; 61.2%), hemorrhages (n = 132; 89.8%), disc edema (n = 57; 38.8%), anterior chamber reaction (n = 28; 19%), and vitritis (n = 103; 70.1%). Treatment included intravenous followed by oral steroids in 70 patients and oral steroids exclusively in 23; five patients denied treatment. The visual acuity improved from 1.09 ± 0.52 LogMAR to 0.29 ± 0.42 LogMAR (p < 0.05).

CONCLUSION

There has been an increase in the prevalence of PFR cases over the last decade with clustering during the winters. Multifocal retinitis, retinal hemorrhages, and vitritis were the most common clinical findings in our series. The retinitis resolved with improvement in vision following steroid therapy in all eyes.

Epidemic retinitis and community outbreaks

Purpose:

The objective of this study was to correlate seasonal variation of epidemic retinitis (ER) with concurrent community outbreaks.

Methods:

This is a retrospective, observational, comparative study conducted in a tertiary care eye hospital in south India. Monthly variation in number of ER cases in comparison with reported community outbreaks by Integrated Disease Surveillance Program (IDSP) from 2009 to 2020 in the same region were studied. Month-wise graphs against number of patients were plotted for ER and for each community outbreak.

Results:

ER was diagnosed in 163 patients. Diagnosis of presumed rickettsial ER was made in 48 cases (29.44%), chikungunya in 5, dengue in 3 and typhoid in 6 cases, while in other cases the etiological diagnosis remained uncertain (n = 101). Multiple positive serological tests were seen in 6 patients (Weil Felix Test (WFT) with WIDAL in 4 and chikungunya IgM with WFT in 2 patients). Relevant reported outbreaks by IDSP were: Pyrexia of unknown origin (PUO) (n = 5148), Chikungunya (n = 6577), Dengue (n = 7350), Measles (n = 1422), Mumps (n = 881), Rubella (n = 288), Malaria (n = 2262), Chicken Pox (n = 2385), Typhoid (n = 597), Kyasanur Forest Disease (n = 381), Scrub Typhus (n = 13), Typhus fever (n = 4), Japanese Encephalitis (n = 15). None of the outbreak graphs pattern was identical or similar to the graph of ER. Inverse relation of the graph of dengue outbreak with ER was observed.

Conclusion:

Inverse correlation between dengue and ER should be further studied for causation, which we believe may prove dengue as least common cause. Reporting of rickettsial outbreaks should be enhanced by undertaking statewide awareness and procurement of gold standard tests.

Rapid maturation of unilateral cataract in leptospirosis

Leptospirosis is a bacterial cause for nongranulomatous uveitis in tropical countries. It is known to cause rapid maturation of cataract in young adults. Here we present six patients who had presenting sign as fully matured pearly white unilateral cataract without history of any trauma in their first visit. All except one patient were positive for leptospirosis by ELISA testing. Histopathological analyses of those lenses showed globular degeneration.

Pediatric Uveitis and Scleritis in a Multi-Ethnic Asian Population

PURPOSE

To describe the demographics and clinical characteristics of pediatric uveitis and scleritis at a tertiary eye care center.

METHODS

Clinical records of children with either uveitis or scleritis that presented between January 1989 and January 2016 were reviewed retrospectively.

RESULTS

Seventy-three patients were identified. Fifty-four had uveitis and 19 had scleritis. Posterior uveitis was the most common (27.8%), followed by intermediate uveitis (25.9%), panuveitis (25.9%) and anterior uveitis. Majority were noninfectious uveitis (37.0%), and 29.6% were idiopathic. Common associations were sarcoidosis (14.8%), HLA-B27 haplotype (9.3%) and toxoplasmosis (7.4%). Posterior scleritis was more common (94.7%) than anterior scleritis and majority were idiopathic (68.4%). Delayed patient presentation and presenting visual acuity worse than 0.3 LogMAR were associated with poor visual outcome (p = .03; OR = 0.17; 95% CI, 0.03-0.84 and p = .007; OR = 0.09; 95% CI, 0.02-0.52 respectively).

CONCLUSION

Majority had noninfectious etiologies. Uveitis associated with juvenile idiopathic arthritis was rare.

Pattern of uveitis in a tertiary eye care center of central India: Results of a prospective patient database over a period of two years

Purpose

To identify the pattern of uveitis at a tertiary eye center in the central India and to compare with other reported studies.

Methods

This prospective observational study was undertaken with all new uveitis cases attending the uvea clinic between January 2016 and September 2017. A standard clinical protocol and detailed investigations were done to find out the specific cause of uveitis.

Results

A total of 210 patients with uveitis were evaluated. Anterior uveitis (47.1%) followed by intermediate uveitis (31.90%) were the most common type of uveitis in this study. Specific etiology of uveitis could be established in a majority of cases of uveitis (51.91%), except in intermediate uveitis group where the cause was mostly idiopathic (77.61%).

Conclusion

Tuberculosis (46.29%) and viral etiology (38.88%) were the most common forms of infective uveitis (25.71%), whereas spondyloarthropathy (27.27%) and traumatic cause (14.54%) were the most common in the noninfective group of uveitis (26.19%).

Knowledge, Attitude, and Practice Towards Leptospirosis among Undergraduate and Postgraduate Medical Students in India

Background: Students of medicine in India tend to follow textbooks from western authors for rural pathologies, zoonosis, and this geographical disconnect leads to gaps in familiarity with local diseases.Aim: This study aims to assess knowledge, practices, and attitudes on leptospirosis among undergraduate and postgraduate medical students.Methods: A cross-sectional, self-administered questionnaire study was performed from June 2018 to May 2019 among 778 undergraduate students from six medical colleges of Tamil Nadu and 446 postgraduate students from two postgraduate institutions.Results: The survey of 1224 medical students revealed that the postgraduate medical students' knowledge of leptospirosis was better than undergraduates; however, there were important knowledge gaps in risk factors and management of leptospiral infection.Conclusions: Although the results of the study are encouraging, poor knowledge of risk factors and of diagnosis of leptospirosis can significantly affect the quality of patient care. This calls for multifaceted interventions to improve the medical curriculum.

A Cross-Sectional Assessment of Knowledge, Attitude, and Practice Toward Leptospirosis among Rural and Urban Population of a South Indian District

Back ground: Leptospirosis is one of the common zoonotic diseases, endemic among farmers. Globally, awareness of risk factors is reported to be very low. This study aims to quantitatively analyze the knowledge and attitude related to leptospirosis in Madurai district and to identify misconceptions that result in poor practice.Material & methods: A cross-sectional survey on rural and urban population using a structured, validated questionnaire to assess Knowledge, Attitude and Practice on Leptospirosis.Results: 902 participants from rural and 1074 participants from urban population were enrolled. More than 98% knew seasonal fever to be common during rainy season, of them only 2.8% and 3.6% from rural and urban population mentioned microbes as a cause.Conclusion: Vulnerable populations were found to be less knowledgeable on risk factors and they had poor practice. Education had significant impact on knowledge and attitude of urban population; however, their practice did not improve with education.

Molecular Mimicry between Betaine Aldehyde Dehydrogenase of Leptospira and Retinal Dehydrogenase 1 of Human Lens: A Potential Trigger for Cataract Formation in Leptospiral Uveitis Patients

Purpose: Rapidly progressing cataract is one of the ocular manifestations in leptospiral uveitis patients. We examined whether molecular mimicry between the leptospira antigens and lens proteins exists that could result in cataract in these patients.Methods: Immunoblot analysis using patient sera was done with proteins from normal lens and cataract lens from leptospiral uveitis patients and the cross-reacting lens proteins were identified by mass spectrometry analysis.Results: Retinal dehydrogenase 1 and crystallins (α-B, α-A2, β-B2), were recognized by the antibodies in the serum of leptospiral uveitis patients. And, retinal dehydrogenase 1 is homologous to the leptospiral protein, betaine aldehyde dehydrogenase.Conclusions: Leptospiral uveitis patient serum contains antibodies that cross-react with multiple lens proteins that have a role in maintaining lens transparency. And, these antibodies could act as a potential trigger for cataractogenesis.

Leptospirosis complicated with Guillain Barre syndrome, papillitis and thrombotic thrombocytopenic Purpura; a case report

Background

Leptospirosis is a zoonosis commonly prevalent in tropical countries. Clinical course of leptospirosis varies from mild to severe disease. Here we present a case of leptospirosis complicated with Guillain-Barre Syndrome (GBS), papillitis, and Thrombotic Thrombocytopenic Purpura(TTP).

Case presentation

A 21-year-old Asian male presented with fever, myalgia, oliguria and dyspnoea where he was managed as for leptospirosis complicated with pulmonary haemorrhages and acute renal failure. Leptospirosis was confirmed by Microscopic Agglutination Test(MAT) with a fourfold rise in antibody titre between acute and convalescent serum. The highest antibody titre was against Leptospira antigen serogroup Semaranga (strain Patoc) (1:1280) followed by serogroup Australis (strain Australis) (1:640) and serogroup Autumnalis (strain Bankgkinang) (1:320). Two weeks later he developed blindness, ascending weakness of lower limbs with global areflexia and an acute inflammatory demyelinating polyradiculopathy(AIDP) variant GBS was confirmed with nerve conduction studies. TTP complicated the picture several days later. He was initiated on plasmapheresis where clinical improvement was seen after 14 cycles. He had an incomplete neurological recovery with permanent vision loss but completely recovered from TTP. He also had permanent renal impairment.

Conclusion

Leptospirosis should be suspected and treated empirically in the relevant clinical settings where it can present with an atypical clinical picture as in our case with an acute febrile illness followed by GBS as well as TTP.

Water related ocular diseases

A number of ocular diseases can be attributed to contaminated water and we have coined a term "Water-related ocular diseases (WRODs)" to denote this wide-spectrum of conditions. WRODs are directly related to human contact with water and can occur through toxic, allergic, inflammatory or infective mechanisms. The non-infective causes can include chemicals used to clean swimming pools, oil spills and water-sport related injuries. Similarly, a number of infective organisms causing ocular diseases are transmitted through water. Since, these conditions can occasionally prove devastating, a review was done with the following aims: (i) To study the epidemiology of WRODs (ii) To assess the clinical presentation and current management of WRODs (iii) To highlight the future challenges and possible solutions to these problems. The online search was conducted utilizing search engines such as PubMed, Google Scholar, ClinicalKey and the Virtual Library of the Ministry of Health, Malaysia for relevant terms such as water-borne, swimming pool and eye infections.

Epidemic Retinitis

Purpose: To study demography, seasonal variation, clinical presentation, and treatment outcome of "retinitis post febrile illness." (RpFI) Method: Case records of patients diagnosed as RpFI, from July 2009 to May 2017 were studied retrospectively. Patients with complete follow up were evaluated for treatment and visual outcomes. Results: Two hundred and five eyes of 119 patients were studied. The peak incidence of RpFI was from November to March each year. Diagnosis of fever largely remained unknown. Chikungunya IgM, Dengue IgM, and Weil-Felix test was positive in 22.22%, 15.38%, and 39.75%, respectively, in investigated cases. The mean visual acuity at presentation and at resolution was 20/63 and 20/32, respectively, in 122 eyes with complete follow up. Conclusion: We suggest a term "Epidemic Retinitis" for RpFI due to its seasonal variation and to differentiate it from other sporadic forms of retinitis. Although RpFI has aggressive presentation, it resolves over 3-4 months and the overall visual outcome is satisfactory.

Leptospirosis-associated catastrophic respiratory failure supported by extracorporeal membrane oxygenation

A previously healthy, 39-year-old obese farmer, arrived hypotensive and tachycardic, with fever, myalgia, headache, abdominal pain, diarrhea, and progressive dyspnea. Ten days before symptoms onset, he was in direct contact with mice and working in a contaminated drain. Patient laboratory showed acute kidney injury and thrombocytopenia. Chest X-ray exhibited bilateral diffuse interstitial infiltrates. First-line empirical antibiotics were started and influenza discarded. Patient evolved with severe respiratory failure, associated with hemoptysis, and rapidly severe hemodynamic compromise. Despite neuromuscular blockade and prone positioning, respiratory failure increased. Accordingly, veno-venous ECMO was initiated, with bilateral femoral extraction and jugular return. After ECMO connection, there was no significant improvement in oxygenation, and low pre-membrane saturations and low arterial PaO2 of the membrane showed that we were out of the limits of the rated flow. Thus, a second membrane oxygenator was installed in parallel. Afterward, oxygenation improved, with subsequent perfusion enhancement. Regarding etiology, due to high suspicion index, Leptospira serology was performed, coming back positive and meropenem was maintained. The patient ultimately recovered and experience excellent outcome. The clinical relevance of the case is the scared evidence of leptospirosis-associated severe respiratory failure treated with ECMO. This experience emphasizes the importance of an optimal support, which requires enough membrane surface and flow for an obese, highly hyperdynamic patient, during this reversible disease. A high index of suspicion is needed for an adequate diagnosis of leptospirosis to implement the correct treatment, particularly in the association of respiratory failure, pulmonary hemorrhage, and an epidemiological-related context.

Leptospirosis Presenting with Rapidly Progressing Acute Renal Failure and Conjugated Hyperbilirubinemia: A Case Report

Patient: Male, 53

Final Diagnosis: Leptospirosis

Symptoms: —

Medication: —

Clinical Procedure: None

Specialty: Infectious Diseases

Infectious optic neuropathies: a clinical update

Different forms of optic neuropathy causing visual impairment of varying severity have been reported in association with a wide variety of infectious agents. Proper clinical diagnosis of any of these infectious conditions is based on epidemiological data, history, systemic symptoms and signs, and the pattern of ocular findings. Diagnosis is confirmed by serologic testing and polymerase chain reaction in selected cases. Treatment of infectious optic neuropathies involves the use of specific anti-infectious drugs and corticosteroids to suppress the associated inflammatory reaction. The visual prognosis is generally good, but persistent severe vision loss with optic atrophy can occur. This review presents optic neuropathies caused by specific viral, bacterial, parasitic, and fungal diseases.

Atypical manifestations of leptospirosis

Leptospirosis is an illness with a wide spectrum of clinical manifestations and severe illness affects nearly all organ systems. Serious and potentially life-threatening clinical manifestations of acute leptospirosis are caused by both direct tissue invasion by spirochaetes and by the host immune responses. In its severe form, leptospirosis can cause multi-organ dysfunction and death in a matter of days. Therefore it is critical to suspect and recognize the disease early, in order to initiate timely treatment. While the classical presentation of the disease is easily recognized by experienced clinicians practising in endemic regions, rarer manifestations can be easily missed. In this systematic review, we summarize the atypical manifestations reported in literature in patients with confirmed leptospirosis. Awareness of these unusual manifestations would hopefully guide clinicians towards early diagnosis.

Leptospiral uveitis - there is more to it than meets the eye!

Leptospirosis, caused by pathogenic species of genus Leptospira, is a highly prevalent zoonotic disease throughout many parts of the world, and an important emerging disease within the United States. Uveitis is a common complication of systemic infection in humans. A similar condition in horses is characterized by recurrent bouts of inflammation. In this article, we review advances in our understanding of leptospiral uveitis and its pathogenic mechanisms.

Outpatient follow-up of patients hospitalized for acute leptospirosis

OBJECTIVE

The outcome of leptospirosis after the resolution of acute disease, either spontaneously or after treatment, is not well described. The aim of this study was to assess the possible sequelae of acute leptospirosis after hospital discharge.

METHODS

We report here a prospective study carried out in São Paulo, Brazil in which patients hospitalized for leptospirosis were followed in the outpatient setting.

RESULTS

Forty-seven patients were serially assessed: 32 severe and 15 mild cases. Early and late complications were not common in either group, but subjective complaints were common in the first few weeks after hospital discharge (53% of severe cases, 40% of mild cases). Two patients had continuing complaints: one had profound general malaise and the other developed new onset panic disorder. The sample analyzed represented 26% of the patients hospitalized with leptospirosis in the city of São Paulo during the study period. The duration of follow-up was an average of approximately 20 days at the first visit, and approximately 40 days at the second visit. Forty-seven patients came for one follow-up visit and 22 of the same patients had two follow-up visits.

CONCLUSIONS

While two of 47 patients reported continuing symptoms after hospitalization for acute leptospirosis, no definitive, objective evidence of chronic sequelae due to this infection was proven. While preliminary, these observations point to the need for a prospective, rigorous and systematic study to definitively determine and characterize late complications and chronic disease after acute leptospirosis.

A pre- and post-treatment evaluation of vision-related quality of life in uveitis

Aim:

To study the effect of treatment on vision-related quality of life (VR-QOL) in uveitis patients.

Materials and Methods:

Interviewer-administered questionnaire-based evaluation of visual function and VR-QOL in Tamil-speaking adult patients with active uveitis at presentation and follow-up by the same interviewer.

Results:

Ninety-eight patients participated in this study. There was a statistically significant improvement in VR-QOL in all the scales following treatment (P < 0.001). Patients with chronic uveitis showed better improvement upon treatment than patients with acute uveitis. The visual symptoms scale showed moderate gains following treatment (effect size 0.56). Persons with bilateral disease had poorer mean scores compared to those with unilateral disease. Visual acuity was closely correlated with VR-QOL scores.

Conclusion:

The VR-QOL measurement has shown that it is sensitive to demonstrate the problems of patients with uveitis irrespective of their demographic profile. The scores improved significantly in patients with uveitis following treatment and have shown close correlation to visual acuity thus demonstrating that VR-QOL is effective in assessing the response to treatment.

The C-terminal variable domain of LigB from Leptospira mediates binding to fibronectin

Adhesion through microbial surface components that recognize adhesive matrix molecules is an essential step in infection for most pathogenic bacteria. In this study, we report that LigB interacts with fibronectin (Fn) through its variable region. A possible role for LigB in bacterial attachment to host cells during the course of infection is supported by the following observations: (i) binding of the variable region of LigB to Madin-Darby canine kidney (MDCK) cells in a dose-dependent manner reduces the adhesion of Leptospira, (ii) inhibition of leptospiral attachment to Fn by the variable region of LigB, and (iii) decrease in binding of the variable region of LigB to the MDCK cells in the presence of Fn. Furthermore, we found a significant reduction in binding of the variable region of LigB to Fn using small interfering RNA (siRNA). Finally, the isothermal titration calorimetric results confirmed the interaction between the variable region of LigB and Fn. This is the first report to demonstrate that LigB binds to MDCK cells. In addition, the reduction of Fn expression in the MDCK cells, by siRNA, reduced the binding of LigB. Taken together, the data from the present study showed that LigB is a Fn-binding protein of pathogenic Leptospira spp. and may play a pivotal role in Leptospira-host interaction during the initial stage of infection.

PREVALENCE OF ANTI-LEPTOSPIRA SPP. ANTIBODIES IN SWINE SLAUGHTERED IN THE PUBLIC SLAUGHTERHOUSE OF PATOS CITY, PARAÍBA STATE, NORTHEAST REGION OF BRAZIL

ABSTRACT A serologic survey was conducted among 131 swine slaughtered in the public slaughterhouse of Patos city, Northeast region of Brazil, to determine the prevalence of anti-Leptospira spp. agglutinins. For serologic diagnosis of leptospirosis, the microscopic agglutination 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 131 swine analyzed, 44 were seropositive for at least one Leptospira spp. serovar, resulting in a seroprevalence of 33.6% (95% CI = 25.5% 42.4%). The most frequent serovar was Pomona, with 38 (29.0%; 95% CI = 21.4% 37.6%) reactant sera. Other reactant serovars and respective prevalence were: Pyrogenes (2.3%; 95% CI = 0.5% 6.5%), Canicola (1.5%; 95% CI = 0.2% 5.4%) and Shermani (0.8%; 95% CI = 0.02% 4.2%). There was statistical difference in seroprevalence to serovar Pomona compared with others reactant serovars (P < 0.0001).

LruA and LruB antibodies in sera of humans with leptospiral uveitis

Uveitis can be a serious complication of leptospirosis. Previous studies indicated that the leptospiral lipoproteins LruA and LruB are expressed in the eyes of uveitic horses and that antibodies directed against those proteins show in vitro cross-reactivity with components of equine lens, ciliary body, and/or retina. We now demonstrate that sera from a significant proportion of humans who have leptospiral uveitis also contain antibodies against LruA and LruB. Different categories of nonleptospiral uveitis and autoimmune uveitis were also screened; patients diagnosed with Fuchs uveitis or Behçet's syndrome produced antibodies that cross-reacted with LruA and LruB, suggesting similarities of the autoimmune responses in those diseases with those of leptospiral uveitis.

Systemic leptospirosis followed by salmonella vertebral osteomyelitis without sickling or immunosuppression

STUDY DESIGN

The clinical history of a healthy young patient who acquired systemic leptospirosis followed by salmonella vertebral osteomyelitis was studied in detail, and compared to the histories of leptospirosis and salmonella vertebral osteomyelitis reported in the literature.

OBJECTIVE

To alert the medical community about this unusual association of infectious diseases in a healthy patient without sickling or immunosuppression.

SUMMARY OF BACKGROUND DATA

Human leptospirosis has been intensively studied, and there are several reports of salmonella vertebral osteomyelitis in patients without sickling. However, the combination of these entities in a single healthy patient is unexpected.

METHODS

The extensive literature on human leptospirosis and salmonella vertebral osteomyelitis was reviewed in detail, in correlation with this patient's clinical history and imaging studies.

RESULTS

The patient had no previous medical history. He contracted systemic leptospirosis when swimming in a lake contaminated with the urine of infected animals. As his leptospirosis symptoms resolved with doxycycline, he experienced increasing thoracolumbar spine pain, because of salmonella vertebral osteomyelitis, which responded to amoxicillin.

CONCLUSION

Leptospirosis may have caused gut mucosal vasculitis, allowing salmonella to enter the bloodstream and infect the spine.

Immunogenicity of the recombinant leptospiral putative outer membrane proteins as vaccine candidates

Leptospiral putative outer membrane proteins (OMPs) are likely to be essential components of more effective vaccines. Recently completed genomic sequences of Leptospira allowed us to target putative OMPs for the development of recombinant vaccines. We focused on 12 putative OMPs that had no homology with other organisms listed in the NCBI database except MceI and MceII of Leptospira, which are approximately 25% homologous to MceI of Mycobacterium tuberculosis. All putative OMPs were cloned, expressed and purified as glutathione-S-transferase (GST) fusion proteins. Primary screening for immunoprotective potential was performed in hamsters challenged with an LD50 inoculum of low passage serovar Pomona. Out of these 12 OMPs three fusion proteins viz. rLp1454, rLp1118 and rMceII were found to be protective in a hamster model of leptospirosis. The protective efficacy was evaluated on the basis of survival, histopathological lesions in vital organs and antibody responses against each antigen. All the recombinant proteins were able to enhance the survival and reduce the histopathological lesions. In contrast, control animals immunized with rGST demonstrated low survival and had significant lesions. Further, these three proteins were evaluated for synergistic protective efficacy as compared to LigA, which has already been established as a protective antigen. Our results indicate that rLp1454, rLp1118, and rMceII showed protection individually and synergistically against serovar Pomona infection, which may help us to develop a multicomponent vaccine for leptospirosis.

La leptospirose: une cause inhabituelle d'uvéite antérieure

INTRODUCTION

Leptospirosis is an anthropozoonosis, which affect 100000 people by year worldwide.

CASE REPORT

Leptospirosis and IgA deficiency were revealed in a young man by acute anterior uveitis, after canyoning practice in the French West Indies.

DISCUSSION

Uveitis should be added to the ocular phenotype of leptospirosis.

Leptospirosis: pathogenesis, immunity, and diagnosis

PURPOSE OF REVIEW

Leptospirosis is among the most important zoonotic diseases worldwide. Completion of the genomic sequences of leptospires has facilitated advances in diagnosis and prevention of the disease, and yielded insight into its pathogenesis. This article reviews this research, emphasizing recent progress.

RECENT FINDINGS

Leptospirosis is caused by a group of highly invasive spiral bacteria (spirochetes) that can infect both people and animals. Spirochetes can survive in the environment and host, and therefore outer membrane and secretory proteins that interact with the host are of considerable interest in leptospire research. The genetic approach to studying pathogenesis is hindered by fastidious growth of pathogenic leptospires. Integrated genomic and proteomic approaches, however, have yielded enhanced understanding of the pathogenesis of leptospirosis. Furthermore, studies of innate immune response to the organism have enhanced our understanding of host susceptibility and resistance to infection. In-silico analysis and high-throughput cloning and expression have had major impacts on efforts to develop vaccine candidates and diagnostic reagents.

SUMMARY

In the future, we must effectively utilize the wealth of genetic information to combat the disease. More studies into genetics, immune mechanisms that may be exploited to prevent leptospirosis, and pathogenesis of the disease are necessary.