Acute renal failure: a common manifestation of leptospirosis

Fulminant Leptospirosis Presenting with Rapidly Developing Acute Renal Failure and Multiorgan Failure

Leptospirosis, caused by pathogenic spirochetes of the Leptospira genus, is a common zoonosis in tropical and subtropical regions and can lead to an epidemic following heavy rainfall or flooding. The primary reservoirs of Leptospira include rodents, wild animals, dogs, cats, amphibians, and others, but the brown rat (Rattus norvegicus) remains the main source of human Leptospirosis. Humans are often accidental hosts and they can be infected through cuts, abrasions, mucosa, conjunctiva, or by ingesting contaminated water. The clinical manifestation of leptospirosis can vary from mild, nonspecific symptoms to a fatal outcome involving liver and renal failure, pulmonary hemorrhage, meningitis, and septic shock. The severity of fatal outcomes is likely to be due to virulence factors, host susceptibility, and epidemiological conditions. L. interrogans are associated with high-risk individuals, particularly patients older than 60 years of age in clinical settings. The current case study showed a foreign worker who presented with rapidly deteriorating clinical signs of fever, jaundice, impaired consciousness, and oliguric acute renal failure. Drawing from our experience, it is advisable to consider the possibility of leptospirosis diagnosis in patients who show clinical symptoms such as fever, hepatic failure with jaundice, and acute renal failure. This is particularly important for those individuals with a prior history of pathogen exposure. This case study had a strong suspicion of leptospirosis, which was confirmed by the microscopic agglutination test (MAT) and, later, the patient's recovery following treatment.

Long-term kidney outcomes after leptospirosis: a prospective multicentre cohort study in Thailand

BACKGROUND

Leptospirosis is one of the most important public-health zoonotic diseases in the tropics that can cause severe organ dysfunction and death. Currently there are insufficient data on long-term renal dysfunction in patients after leptospirosis infection.

METHODS

A prospective multicentre cohort study was conducted at 15 hospitals in the Sisaket province of Thailand. Confirmed leptospirosis patients admitted from 1 December 2015 to 30 November 2018 were followed between 1 February 2020 and 31 October 2020 (median 4.1 years after hospital discharge). The primary outcome was a composite of major kidney adverse events (MAKEs) including all-cause mortality, dialysis and new-onset chronic kidney disease (CKD).

RESULTS

Of the 217 confirmed leptospirosis cases enrolled, 32.7% were classified as having severe leptospirosis. Fifteen cases (6.9%) were deceased at the time of hospital admission. After a median follow-up time of 4.18 years, 30 patients had died and 33 patients developed CKD. Patients with severe leptospirosis had a significantly higher risk of MAKEs {adjusted hazard ratio 2.45 [95% confidence interval (CI) 1.44-4.18]}. Patients with intensive care unit admission, pulmonary haemorrhage and acute kidney injury also had a higher risk of MAKEs and all-cause mortality. Participants with severe leptospirosis in the follow-up cohort showed a higher risk of developing CKD compared with non-severe leptospirosis [adjusted odds ratio 3.22 (95% CI 1.04-9.96)], especially renal magnesium and phosphate wasting.

CONCLUSION

Leptospirosis patients, especially severe leptospirosis, are associated with long-term kidney sequelae. Our finding reflects the importance of long-term follow-up and the urgent need for specific interventions.

Leptospirosis: Prognostic Model for Patient Mortality in the Transcarpathian Region, Ukraine

Background: Leptospirosis is a bacterial zoonosis of worldwide distribution with a wide spectrum of clinical presentations that range from subclinical or mild to severe and fatal outcomes. Identifying clinical predictors for the severe form of the disease is critical to reduce disease complications and death. As a result, we conducted a retrospective case-control study to identify clinical markers of mortality in leptospirosis patients from the Transcarpathian region. Materials and Methods: The study used 102 medical records of patients with leptospirosis in the period from 2009 to 2019. There were 26 fatal cases and 76 survivors. Predictors were examined using univariate and bivariate statistics. Results: Fatal and nonfatal groups did not differ in age or gender composition (p > 0.5), nor did they differ in signs or symptoms, except that oliguria occurred significantly more often in fatal cases (p < 0.001). Laboratory diagnostic tests, however, differed between outcomes in 7/9 recorded variables; primarily associated with liver and kidney function as well thrombocytopenia and elevated white blood cell counts for fatal cases (p < 0.01 for all variables). Conclusions: Logistic regression analysis indicated that a combination of creatinine levels and direct bilirubin levels were the best predictors of patient outcome. The specificity of the model was 90.9% and the area under the receiver operator characteristic function as 93.6%. This model can be used when a patient is admitted to a hospital to better characterize patient risk.

A Rare Presentation of Leptospirosis: Dysarthria and Guillain-Barré Syndrome

Leptospirosis can present with severe cases such as polymyositis, peripheral neuropathy, and rarely, Guillain-Barré Syndrome (GBS). This paper reports a case who presented with dysarthria and GBS. A female patient presented with complaints of weakness, dizziness, diarrhea, and dysarthric. Her assessments included muscle strength globally 4/5 and deep tendon reflexes as hypoactive. An electromyographic examination was performed with the increase of weakness in the lower extremities, which indicated findings compatible with GBS. Antibodies against Leptospira biflexa serovar Patoc 1 at 1/400 titer were detected in the microscopic agglutination test (MAT). Neurological involvement in leptospirosis cases can range from meningoencephalitis to GBS.

Determinants of prolonged hospitalization and mortality among leptospirosis patients attending tertiary care hospitals in northeastern state in peninsular Malaysia: A cross sectional retrospective analysis

Background

Leptospirosis is the most common anthropozoonosis worldwide and imposes a major public health problem in many tropical countries. It is a leading cause of disease burden in form of mortality, morbidity and hospital admission. Identifying patients at high risk for mortality or for prolonged hospitalization may save lives and preserve economy. The aim of the current study is to identify significant factors associated with disease mortality and prolonged hospitalization.

Design

Cress-sectional retrospective study.

Settings

Tertiary care teaching hospitals in Kelantan, Peninsular Malaysia.

Participants

Adult patients proven to have leptospirosis depending on IgM ELISA were classified into two classes depending on prolonged hospitalization (&gt;7 days or ≤ 7 days) and mortality (fatal cases or non-fatal cases). Patients' clinico-laboratory data were compared according to these two outcomes using the appropriate statistical test.

Results

Of the 525 patients enrolled, 136 (25.9%) had prolonged hospitalization. The mean length of stay was 6.77 ± 5.68 days. Logistic regression analysis identified acute kidney injury (AKI) (OR 2.3), Jaundice (OR 2.7), elevated alanine aminotransferase (ALT) (OR 2), and prolonged prothrombin time (PT) (OR 1.9) independently associated with prolonged hospitalization. Case fatality rate was 6.48% and around one third of fatal cases had prolonged hospitalization of more than seven days. Factors associated with leptospirosis mortality included age &gt;40 years (p &lt; 0.001), patients presented with tachypnea (p = 0.002), pulmonary infiltrate (p &lt; 0.001), T-wave changes (p &lt; 0.001), atrial fibrillation (p = 0.013), conducting abnormality (p &lt; 0.001), chronic kidney diseases (p &lt; 0.001), multiple organ dysfunctions (p &lt; 0.0010), respiratory failure (p &lt; 0.001), pneumonia (p &lt; 0.001), sepsis (p = 0.004), low venous PH (p = 0.042), AKI (P &lt; 0.001), elevated AST (p &lt; 0.001) or ALT (p = 0.004), hypoalbuminemia (p &lt; 0.001), rhabdomyolysis (p &lt; 0.001), severe thrombocytopenia (p = 0.042), prolonged PT (p &lt; 0.001) or prolonged aPTT (p &lt; 0.017).

Conclusions

Significant proportion of leptospirosis patients (25.9%) had prolonged hospital stay and less proportion died (6.48%). Early identifying patients with factors associated with prolonged hospitalization and death will positively impact practitioners' decisions regarding the proper and fast course of management including ICU admission.

The COVID-19 Mirage: A Young Biologist With an Atypical Presentation of a Zoonotic Disease During the COVID-19 Pandemic

COVID-19 has become one of the main causes of febrile illness among emergency department patients and is always a differential diagnosis to keep in mind. Nonetheless, some patients with a history of exposure, persistent fever, and suspicion of COVID-19 end up having entirely different etiologies. Here, we present the case of a 29-year-old male biologist with an uncommon presentation of a zoonotic disease, characterized by unspecific signs and symptoms, which led to a delayed diagnosis, causing significant emotional distress in the patient. We also coin the term “COVID-19 Mirage," to serve as a constant reminder for clinicians of the effect that COVID-19 has caused on the differential diagnosis of fever of unknown etiology.

Unhappy Triad: Infection with Leptospira spp. Escherichia coli and Bacteroides uniformis Associated with an Unusual Manifestation of Portal Vein Thrombosis

Portal vein thrombosis (PVT) is a rare disease with an incidence of 0.7/100,000 inhabitants per year. Septic PVT (pylephlebitis) usually occurs secondary to infection in the anatomic region drained by the portal venous system. We report on a 76-year-old German male who was admitted with a history of recurrent fever and acute renal failure. Blood cultures taken on admission showed Escherichia coli, as well as Bacteroides uniformis after an extended incubation period of 90 h. In addition, infection with Leptospira spp. was diagnosed serologically. Computerized tomography of the abdomen revealed an extensive PVT along with signs of colonic diverticulitis. Symptoms resolved under prolonged antimicrobial therapy with beta-lactams and adequate heparinization. A myeloproliferative disorder could be excluded. There was no evidence of an underlying coagulation disorder. Imaging controls showed an almost complete resolution of the PVT after 6 months of anticoagulation therapy. To the best of our knowledge, this is the first report of such an “unhappy triad,” which includes atypical manifestations of leptospirosis and involvement of other intestinal bacteria.

Acute kidney injury with partial Fanconi syndrome in a patient with leptospirosis: a case report

Background

Leptospirosis is an underdiagnosed bacterial infection with nonspecific symptoms, hence, a diagnostic challenge. Identifying a case of leptospirosis in Switzerland is uncommon. Although kidney complications are frequent in severe forms, including tubular dysfunction, observing this complication is rare in our country. We report the case of a patient with leptospirosis and kidney dysfunction, which was notable for proximal tubulopathy. This case report describes the diagnosis and management of this patient’s tubular dysfunction.

Case presentation

A 34-year-old Caucasian male known for alcohol and drug abuse presented to our emergency department suffering from severe pain in the lower limbs, jaundice, and fever with flu-like symptoms. Physical examination was not contributory. Blood tests showed cytopenia, elevated inflammatory markers, acute kidney injury, and altered liver function tests with predominant cholestasis. Urinalysis showed proteinuria and significant glycosuria without concomitant hyperglycemia. Leptospirosis was suspected and confirmed by both positive serum polymerase chain reaction and elevated immunoglobulin M for Leptospira interrogans. The patient was treated with intravenous amoxicillin–clavulanate and doxycycline for 7 days. After antibiotic treatment, symptoms disappeared, and kidney dysfunction completely resolved.

Conclusion

Our case focuses on the description of leptospirosis-related acute kidney injury with proximal tubular dysfunction, which is a rare finding in Switzerland.

Pica (Allotriophagy): An Underestimated Risk Factor for Severe Leptospirosis (Weil's Diseases)? Report of a Leptospira Septic Shock Successfully Managed with ECMO

Leptospirosis is a zoonosis caused by infection with pathogenic strains of the bacterium Leptospira. The disease can be complicated by pulmonary hemorrhages and acute respiratory distress syndrome, with the mortality rate increasing to 51–100%. We report the case of a 37-year-old man who was admitted to the emergency department with a 6-day history of fever, weakness, vomiting and diarrhea, followed by jaundice. On admission, he presented leukocytosis, thrombocytopenia and acute liver and kidney injuries. His clinical course was critical, as it was immediately complicated by sepsis and severe respiratory failure, requiring haemodialysis, mechanical ventilation and broad-spectrum antibiotic therapy. In the following days, a veno-venous extracorporeal membrane oxygenation (VV-ECMO) was started due to a dramatic deterioration in respiratory function; 20 h later, it was switched to veno-arterial ECMO because of refractory cardiogenic shock. Hantavirus or Leptospira infection etiology was suspected, so penicillin G and methylprednisolone were initiated as an empirical therapy and subsequently confirmed after a laboratory diagnosis of leptospirosis. Although the clinical course was further complicated by hemorrhagic pneumonia, a gradual, full recovery occurred, and the patient was discharged from the hospital. After excluding other sources of contact with Leptospira-infected material, an unsuspected abnormal eating behavior was identified as the most probable cause of the patient’s Leptospira infection.

Leptospirosis With Acute Renal Failure and Vasculitis: A Case Report

Leptospirosis is a zoonotic disease that occurs worldwide. Various clinical manifestations of leptospirosis can be seen. In this article, we present a case with acute renal failure, severe vasculitis and hyperbilirubinemia occurring simultaneously with leptospirosis. A 45-year-old male patient presented with fever, myalgia, jaundice and reddish skin lesions and anuria. Physical examination findings were icteric sclera, large tender hepatomegaly, and lower extremities' cutaneous necrosis due to vasculitis. Hemodialysis was started. Kidney biopsy revealed degenerative changes of proximal tubules, some of them containing bile casts. Microscopic agglutination test was positive and consistent with leptospirosis. Intravenous ampicillin and oral tetracycline were started. Methylprednisolone 60 mg per day was given for skin vasculitis. Hemodialysis therapy was discontinued. All clinical findings gradually regressed.

A simple score to predict severe leptospirosis

Background

The case-fatality rate of severe leptospirosis can exceed 50%. While prompt supportive care can improve survival, predicting those at risk of developing severe disease is challenging, particularly in settings with limited diagnostic support.

Methodology/Principal findings

We retrospectively identified all adults with laboratory-confirmed leptospirosis in Far North Queensland, Australia, between January 1998 and May 2016. Clinical, laboratory and radiological findings at presentation were correlated with the patients’ subsequent clinical course. Medical records were available in 402 patients; 50 (12%) had severe disease. The presence of oliguria (urine output ≤500 mL/24 hours, odds ratio (OR): 16.4, 95% confidence interval (CI): 6.9–38.8, p<0.001), abnormal auscultatory findings on respiratory examination (OR 11.2 (95% CI: 4.7–26.5, p<0.001) and hypotension (systolic blood pressure ≤100 mmHg, OR 4.3 (95% CI 1.7–10.7, p = 0.002) at presentation independently predicted severe disease. A three-point score (the SPiRO score) was devised using these three clinical variables, with one point awarded for each. A score could be calculated in 392 (98%) patients; the likelihood of severe disease rose incrementally: 8/287 (3%), 14/70 (20%), 18/26 (69%) and 9/9 (100%) for a score of 0, 1, 2 and 3 respectively (p = 0.0001). A SPiRO score <1 had a negative predictive value for severe disease of 97% (95% CI: 95–99%).

Conclusions/Significance

A simple, three-point clinical score can help clinicians rapidly identify patients at risk of developing severe leptospirosis, prompting early transfer to referral centres for advanced supportive care. This inexpensive, bedside assessment requires minimal training and may have significant utility in the resource-limited settings which bear the greatest burden of disease.

Leptospirosis, a neglected tropical disease with a global distribution, is estimated to kill 60,000 people every year. Predicting those at risk of developing severe disease is challenging, and a simple scoring system to quantify the risk of severe disease has proven elusive. Identifying the high-risk patient is important, as it might expedite the initiation of life-saving supportive care. This review of 402 adult patients with leptospirosis in tropical Australia determined that three clinical variables identified at presentation independently predicted severe disease (a subsequent requirement for Intensive Care Unit admission, intubation, vasopressor support, renal replacement therapy or the development of pulmonary haemorrhage). These three variables (abnormal auscultatory findings on respiratory examination, hypotension and oliguria) were used to generate a simple, three-point clinical score which can be determined rapidly and reliably at the bedside by health care workers with minimal training. This simple score may help the clinical management of patients with leptospirosis, particularly in lower and middle-income countries that bear the greatest burden of disease.

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.

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.

Determinants of mortality and impact of therapy in patients with leptospirosis admitted for intensive care in a Sri Lankan hospital--a three year retrospective study

INTRODUCTION

Leptospirosis is a disease of epidemic proportions in Sri Lanka. There is paucity of data on the determinants of mortality and impact of therapy in patients with leptospirosis admitted to critical care settings in endemic territories.

METHODOLOGY

This retrospective cross-sectional study was performed in patients with serologically confirmed leptospirosis admitted to the intensive care unit of the General Hospital, Kalutara from January 2011 to April 2014. Associations between socio-epidemiological, clinical and laboratory parameters and patient mortality were examined.

RESULTS

Forty-five patients were included. The mean age was 49.11(SD = 16.95) and majority (92%) were male. Percentage mortality was 44.4%. Patient mortality was associated with age > 40 (p = 0.012), symptoms of uremia (p = 0.017), evidence of CNS involvement (p = 0.039), presence of oliguria (p = 0.002) and anuria (p = 0.014), presence of multi-organ dysfunction syndrome (MODS) (p < 0.001), CRP > 96 (p = 0.036), platelet count < 20,000 (p = 0.045), Potassium > 5.0 (p = 0.05), metabolic acidosis with pH < 7.2 (p = 0.03), INR > 2 (p = 0.037) and requirement of mechanical ventilation (p < 0.001). Cox regression analysis revealed MODS and potassium > 5 to be independently associated with mortality.

CONCLUSIONS

A high mortality rate is noted. The presence of MODS and serum potassium concentration > 5.0 was independently associated with mortality in this retrospective study of patients with confirmed leptospirosis in a critical care setting.

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

Risk factors for intensive care unit admission in patients with severe leptospirosis: a comparative study according to patients' severity

BACKGROUND

The aim of this study is to investigate predictive factors for intensive care unit (ICU) admission among patients with severe leptospirosis.

METHODS

This is a retrospective study with all patients with severe leptospirosis admitted to a tertiary hospital. Patients were divided in ICU and ward groups. Demographical, clinical and laboratory data of the groups were compared as well as acute kidney injury (AKI) severity, according to the RIFLE criteria (R = Risk, I = Injury, F = Failure, L = Loss, E = End-stage kidney disease).

RESULTS

A total of 206 patients were included, 83 admitted to ICU and 123 to ward. Mean age was 36 ± 15.8 years, with 85.9% males. Patients in ICU group were older (38.8 ± 15.7 vs. 34.16 ± 15.9 years, p = 0.037), had a shorter hospital stay (4.13 ± 3.1 vs. 9.5 ± 5.2 days, p = 0.0001), lower levels of hematocrit (29.6 ± 6.4 vs. 33.1 ± 8.6%, p = 0.003), hemoglobin (10.2 ± 2.4 vs. 11.6 ± 1.9 g/dL, p < 0.0001), and platelets (94,427 ± 86,743 vs. 128,896 ± 137,017/mm(3), p = 0.035), as well as higher levels of bilirubin (15.0 ± 12.2 vs. 8.6 ± 9.5 mg/dL, p = 0.001). ICU group also had a higher frequency of severe AKI (RIFLE-"Failure": 73.2% vs. 54.2%, p < 0.0001) and a higher prevalence of dialysis requirement (57.3% vs. 27.6%, p < 0.0001). Mortality was higher among ICU patients (23.5% vs. 5.7%, p < 0.0001). Independent predictors for ICU admission were tachypnea (p = 0.027, OR = 13, CI = 1.3-132), hypotension (p = 0.009, OR = 5.27, CI = 1.5-18) and AKI (p = 0.029, OR = 14, CI = 1.3-150). Ceftriaxone use was a protective factor (p = 0.001, OR = 0.13, CI = 0.04-0.4).

CONCLUSIONS

Independent risk factors for ICU admission in leptospirosis include tachypnea, hypotension and AKI. Ceftriaxone was a protective factor for ICU admission, suggesting that its use may prevent severe forms of the disease.

Proteomic analysis of urine exosomes reveals renal tubule response to leptospiral colonization in experimentally infected rats

Background

Infectious Leptospira colonize the kidneys of reservoir (e.g. rats) and accidental hosts such as humans. The renal response to persistent leptospiral colonization, as measured by urinary protein biosignatures, has not been systematically studied. Urinary exosomes--bioactive membrane-bound nanovesicles--contain cell-state specific cargo that additively reflect formation all along the nephron. We hypothesized that Leptospira-infection will alter the content of urine exosomes, and further, that these Leptospira-induced alterations will hold clues to unravel novel pathways related to bacterial-host interactions.

Methodology/Principal findings

Exosome protein content from 24 hour urine samples of Leptospira-infected rats was compared with that of uninfected rats using SDS-PAGE and liquid chromatography/tandem mass spectrometry (LC-MS/MS). Statistical models were used to identify significantly dysregulated proteins in Leptospira-infected and uninfected rat urine exosomes. In all, 842 proteins were identified by LC-MS/MS proteomics of total rat urine and 204 proteins associated specifically with exosomes. Multivariate analysis showed that 25 proteins significantly discriminated between uninfected control and infected rats. Alanyl (membrane) aminopeptidase, also known as CD13 topped this list with the highest score, a finding we validated by Western immunoblotting. Whole urine analysis showed Tamm-Horsfall protein level reduction in the infected rat urine. Total urine and exosome proteins were significantly different in male vs. female infected rats.

Conclusions

We identified exosome-associated renal tubule-specific responses to Leptospira infection in a rat chronic colonization model. Quantitative differences in infected male and female rat urine exosome proteins vs. uninfected controls suggest that urine exosome analysis identifies important differences in kidney function that may be of clinical and pathological significance.

Leptospirosis is a bacterial disease commonly transmitted from animals to humans. Though this disease affects more than three quarters of a million people every year and takes a disproportionate toll on the poor in in tropical regions, few virulence factors have been identified and very little is known regarding the pathogenesis of leptospirosis. Symptoms vary from fever and fatigue to severe pulmonary hemorrhage and death. Approximately 5–10% of Leptospira infections in humans are chronic (>1 year) and asymptomatic (no overt signs of disease). Nonetheless, very little is known about the clinical significance of these infections. In this report, we show that non-invasive tools namely proteomic analysis of urinary exosomes can be used to identify differences between healthy and Leptospira-infected rat kidney and between Leptospira-infected male and female rat kidney. In future studies, these analyses will be extended to determine clinical significance and extent of renal dysfunction in the asymptomatic human.

Acute kidney injury in a tropical country: a cohort study of 253 patients in an infectious diseases intensive care unit

INTRODUCTION

Acute kidney injury (AKI) is a frequent and potentially fatal complication in infectious diseases. The aim of this study was to investigate the clinical aspects of AKI associated with infectious diseases and the factors associated with mortality.

METHODS

This retrospective study was conducted in patients with AKI who were admitted to the intensive care unit (ICU) of a tertiary infectious diseases hospital from January 2003 to January 2012. The major underlying diseases and clinical and laboratory findings were evaluated.

RESULTS

A total of 253 cases were included. The mean age was 46±16 years, and 72% of the patients were male. The main diseases were human immunodeficiency virus (HIV) infection, HIV/acquired immunodeficiency syndrome (AIDS) (30%), tuberculosis (12%), leptospirosis (11%) and dengue (4%). Dialysis was performed in 70 cases (27.6%). The patients were classified as risk (4.4%), injury (63.6%) or failure (32%). The time between AKI diagnosis and dialysis was 3.6±4.7 days. Oliguria was observed in 112 cases (45.7%). The Acute Physiology and Chronic Health Evaluation (APACHE) II scores were higher in patients with HIV/AIDS (57±20, p-value=0.01) and dengue (68±11, p-value=0.01). Death occurred in 159 cases (62.8%). Mortality was higher in patients with HIV/AIDS (76.6%, p-value=0.02). A multivariate analysis identified the following independent risk factors for death: oliguria, metabolic acidosis, sepsis, hypovolemia, the need for vasoactive drugs, the need for mechanical ventilation and the APACHE II score.

CONCLUSIONS

AKI is a common complication in infectious diseases, with high mortality. Mortality was higher in patients with HIV/AIDS, most likely due to the severity of immunosuppression and opportunistic diseases.

Leptospirosis-associated acute kidney injury: penicillin at the late stage is still controversial

WHAT IS KNOWN AND OBJECTIVE

Some antimicrobial agents are active in vitro against Leptospiras. The use of penicillins at the late stage of leptospirosis is still controversial. We aimed to evaluate the use of penicillin in patients with leptospirosis-associated acute kidney injury (AKI).

METHODS

A retrospective study was conducted of patients with leptospirosis admitted to two hospitals in Fortaleza city, Brazil, between 1985 and 2008. AKI was defined according to the RIFLE and AKIN classifications. Patients were divided in two groups according to whether they were treated with a penicillin or not.

RESULTS

Two hundred and eighty-seven patients were included, with an average age of 36·8±15·6 years and mostly male (80·8%). One hundred and twelve patients (39%) received a penicillin. Patients treated with a penicillin were younger (32±14 years vs. 39±16 years, P=0·0002) and had a shorter hospital stay (8·4±5·0 vs. 11±7·7 days, P<0·0001). There was no difference in the onset of symptoms before hospital admission between the two groups (6·5±3·0 vs. 7·7±4·7, P=0·33). Systolic blood pressure was lower in the penicillin group (111±21 vs. 119±22 mmHg, P=0·04). AKI, need of dialysis and renal recovery at the time of hospital discharge were more frequent in patients who did not use a penicillin (P<0·05). Mortality was similar in both groups (11·6% vs. 13·7%, P=0·60).

CONCLUSION

Treatment of leptospirosis with antibiotics, including the penicillin, remains controversial. The main benefit of using penicillin in the present study was a reduction in the length of hospital stay and fewer complications, such as AKI, but its use was not associated with a decrease in mortality. On balance of risks and benefits, we recommend the use of penicillin in late-stage leptospirosis.

Developing a clinically relevant classification to predict mortality in severe leptospirosis

Background:

Severe leptospirosis requires critical care and has a high mortality. We reviewed the literature to identify factors predicting mortality, and such predictors were classified according to the predisposition, infection, response, organ dysfunction (PIRO) concept, which is a risk stratification model used in severe sepsis.

Material and Methods:

PUBMED was searched for all articles (English), with the key word leptospirosis in any field, within the last 20 years. Data were collected from 45 relevant papers and grouped into each component of the PIRO model.

Results:

The following correlated with increased mortality: predisposition – increasing age and chronic alcoholism; infection - leptospiraemic burden; response - hemodynamic disturbances, leukocytosis; organ dysfunction – multiple organ dysfunction syndrome, pulmonary involvement and acute renal failure.

Conclusions:

Further research is needed to identify the role of infecting serovars, clinical signs, inflammatory markers, cytokines and evidence of hepatic dysfunction as prognostic indicators. It is hoped that this paper will be an initiative to create a staging system for severity of leptospirosis based on the PIRO model with an added component for treatment-related predictors.

Leptospirosis mimicking hemolytic uremic syndrome: a case report

Leptospirosis was diagnosed in a child presenting with acute kidney injury, anemia, and thrombocytopenia. Initial symptoms included abdominal pain and nonbloody diarrhea, followed by fever, vomiting, and skin rash. Leptospirosis was suspected and eventually confirmed. Although leptospirosis is uncommon in temperate climates, it is occurring in increasing numbers of participants in water sports, making it a consideration in the differential diagnosis of hemolytic uremic syndrome.

Leptospirosis in Istanbul, Turkey: a wide spectrum in clinical course and complications

Patients with high fever and multiorgan involvement were investigated for the determination of frequency, clinical course and complications of leptospirosis in Istanbul. Leptospirosis was determined in 22 cases among the 35 hospitalized patients that were pre-diagnosed as leptospirosis according to 'Probable Leptospirosis Diagnosis and Follow-up' form. Among the leptospirosis cases 19 were male and 16 were military staff. Mean age was 35.6 y. Dark field examination (DFE), latex agglutination test (LAG), ELISA IgM, leptospirosis culture (LC) and microscopic agglutination test (MAT) were performed to confirm the diagnoses. The most frequent initial symptoms and findings were fever, fatigue, headache, nausea-vomiting and increased muscle sensitivity. Jaundice was noted only in 2 cases. A 74-y-old female patient died after the recurrence of the disease with severe rhabdomyolysis and pulmonary failure. Sagittal sinus thrombosis, perimyocarditis and chronic renal failure were major complications in another 3 patients. ELISA IgM, LC, DFE, LAG and MAT tests were positive in 68, 72, 82, 100 and 100% of the patients, respectively. As a conclusion, diagnosis of leptospirosis is usually overlooked. Clinical awareness, use of probable leptospirosis diagnosis forms and the application of different laboratory methods in the diagnosis of suspected cases may offer the chance to diagnose the leptospirosis accurately.