The role of Leptospira spp. in horses affected with recurrent uveitis in the UK

Preliminary evaluation of safety and migration of immune activated mesenchymal stromal cells administered by subconjunctival injection for equine recurrent uveitis

Introduction

Equine recurrent uveitis (ERU), an immune mediated disease characterized by repeated episodes of intra-ocular inflammation, affects 25% of horses in the USA and is the most common cause of glaucoma, cataracts, and blindness. Mesenchymal stromal cells (MSCs) have immunomodulatory properties, which are upregulated by preconditioning with toll-like receptor agonists. The objective was to evaluate safety and migration of TLR-3 agonist polyinosinic, polycytidylic acid (pIC)-activated MSCs injected subconjunctivally in healthy horses prior to clinical application in horses with ERU. We hypothesized that activated allogeneic MSCs injected subconjunctivally would not induce ocular or systemic inflammation and would remain in the conjunctiva for >14 days.

Methods

Bulbar subconjunctiva of two horses was injected with 10 × 106 pIC-activated (10 μg/mL, 2 h) GFP-labeled MSCs from one donor three times at two-week intervals. Vehicle (saline) control was injected in the contralateral conjunctiva. Horses received physical and ophthalmic exams [slit lamp biomicroscopy, rebound tonometry, fundic examination, and semiquantitative preclinical ocular toxicology scoring (SPOTS)] every 1-3 days. Systemic inflammation was assessed via CBC, fibrinogen, and serum amyloid A (SAA). Horses were euthanized 14 days following final injection. Full necropsy and histopathology were performed to examine ocular tissues and 36 systemic organs for MSC presence via IVIS Spectrum. Anti-GFP immunohistochemistry was performed on ocular tissues.

Results

No change in physical examinations was noted. Bloodwork revealed fibrinogen 100-300 mg/dL (ref 100-400) and SAA 0-25 μg/mL (ref 0-20). Ocular effects of the subjconjucntival injection were similar between MSC and control eyes on SPOTS grading system, with conjunctival hypermia, chemosis and ocular discharge noted bilaterally, which improved without intervention within 14 days. All other ocular parameters were unaffected throughout the study. Necropsy and histopathology revealed no evidence of systemic inflammation. Ocular histopathology was similar between MSC and control eyes. Fluorescent imaging analysis did not locate MSCs. Immunohistochemistry did not identify intact MSCs in the conjunctiva, but GFP-labeled cellular components were present in conjunctival phagocytic cells.

Discussion

Allogeneic pIC-activated conjunctival MSC injections were well tolerated. GFP-labeled tracking identified MSC components phagocytosed by immune cells subconjunctivally. This preliminary safety and tracking information is critical towards advancing immune conditioned cellular therapies to clinical trials in horses.

Risk factors for a first episode of primary uveitis in the UK and proportion of cases that experience recurrence following this first episode

BACKGROUND

Risk factors for a first episode of primary uveitis in horses have not been determined. In addition, disease progression and the proportion of horses that develop recurrence following the original episode are not known.

OBJECTIVES

To determine the risk factors for the development of a first episode of primary uveitis in horses in the UK and to document the proportion of cases that experience recurrence following this first episode.

STUDY DESIGN

Prospective case-control longitudinal study.

METHODS

Horses with a first episode of primary uveitis between July 2014 and August 2018 were recruited to the study. For each case, two controls were selected. A questionnaire was completed for each horse and multivariable logistic regression analysis was carried out to identify associations between horse and management-level variables and the risk of uveitis. Each case was then followed longitudinally to determine the rate of recurrence of uveitis.

RESULTS

Twenty-three cases and 46 controls were recruited. Being close to a pig farm (OR 27.8, CI 1.31-592.06) and a recent history of flooding of the pasture (OR 15.43, CI 2.80-84.98) was associated with increased risk of uveitis. Being in the same owner's possession for a longer amount of time had a protective effect (OR 0.79, CI 0.68-0.93). Horses recovered uneventfully following treatment and showed no evidence of recurrence in 59.1% of the cases (n = 13). In five horses (22.7%), the initial episode of uveitis could not be controlled and required surgical therapy. Recurrence was observed in four horses (18.2%).

MAIN LIMITATIONS

Small sample size. Recall bias from owners for some of the data. Possibility of selection bias.

CONCLUSIONS

Clinicians can use this information to identify horses with increased risk of uveitis and provide advice to the owners of these horses. The proportion of cases that experience recurrence appears low in the UK.

Comparison of Two Leptospira Type Strains of Serovar Grippotyphosa in Microscopic Agglutination Test (MAT) Diagnostics for the Detection of Infections with Leptospires in Horses, Dogs and Pigs

Simple Summary

Leptospires are bacteria of major health concern as they can cause severe systemic diseases in humans and animals alike. In routine diagnostics, the detection of a leptospirosis heavily relies on the analysis of specific antibodies that were generated by the immune system of an infected species. The most widely used test for the detection of such antibodies is the microscopic agglutination test which itself depends on defined types of laboratory grown Leptospires, so-called serovars. A good judgment of the behaviour of these serovars is vital for interpreting test results and clearly defining what type of Leptospires the patient is infected with as this may have implications for therapy and prognosis. In the following, a study on the reaction pattern of a certain type of serovars named ‘Grippotyphosa’ that itself can be divided into two differently reacting subtypes was conducted. It turned out that, depending on the animal species sampled, a differing reaction patterns to the two Grippotyphosa subtypes in the diagnostic test reflected different distribution of these subtypes in the respective populations. In the future, these insights will further improve test performance and assessment or results.

Abstract

The MAT test is of great importance in the diagnosis of leptospiral infections. Based on various differences, the serovar Grippotyphosa has been divided into two types, Moskva V and Duyster. Differences or similarities of the two type strains in the context of leptospiral diagnostics have not yet been elucidated in more detail; therefore both strains were analysed in MAT diagnostics for the detection of leptospiral infections in pigs, dogs and horses. Serum samples from 2996 pigs, 55 dogs and 35 horses, as well as vitreous and/or aqueous fluid samples from these and 13 additional horses were analysed by MAT; available supplementary samples were tested for leptospires by PCR. In pigs, 92.6% of the samples with both strains received an identical titre result in the MAT test, whereas in dogs and horses only 53.0% and 43.6% had concordant results. Since infections with the serovar Grippotyphosa occur more frequently in dogs and horses overall, more differences were observed here. In the case of discrepant serological results, supplementary samples and PCR examinations were not able to add information on the true status. Further analyses of follow-up studies or at least serum pairs from dogs and horses infected with the serovar Grippotyphosa are necessary.

Analysis of 1840 Equine Intraocular Fluid Samples for the Presence of Anti-Leptospira Antibodies and Leptospiral DNA and the Correlation to Ophthalmologic Findings in Terms of Equine Recurrent Uveitis (ERU)—A Retrospective Study

Simple Summary

In horses, the chronic intraocular leptospiral infection has been shown to cause equine recurrent uveitis (ERU). This inflammatory ophthalmic disease recurs for years and usually leads to blindness. Only recently it was found that biofilm formation of the leptospires in the vitreous cavity leads to uveitis recurrences and prevents effective elimination of the infection by antibiotics or by the immune system. The most effective treatment is vitrectomy (lavage of the vitreous cavity), which mechanically removes the biofilm infection. This surgery has been performed in horses for more than 30 years, and thousands of intraocular specimens have been analyzed for antibodies directed against leptospires and by PCR for leptospiral DNA. For the present study, medical records were retrospectively analyzed. Complete medical and laboratory records were available for 1800 intraocular specimens from horses treated from 2002 to 2017 (1387 specimens from ERU-eyes, 237 specimens from eyes affected with another type of uveitis, and 216 specimens from healthy eyes). In 83% of intraocular samples from ERU eyes, antibodies were detectable, and especially the detection of immunoglobulin A (IgA) seems to play an important role. In 72% of the intraocular specimens, leptospiral DNA was detectable by PCR. No antibodies were detectable in the samples from eyes with another type of uveitis or in the samples from healthy eyes. A PCR was positive in only one sample from a healthy eye. These results with a very high number of intraocular specimens demonstrate the great importance of an intraocular leptospiral infection for ERU. It can be concluded that for a reliable diagnosis of intraocular leptospiral infection or to reliably exclude an infection, multiple tests should be applied.

Abstract

In the equine clinic of the LMU in Munich, therapeutic vitrectomies have been routinely performed in horses for three decades. The vitreous samples obtained during vitrectomies were usually tested for anti-Leptospira antibodies and for more than 20 years also by PCR for leptospiral DNA. If the indication for surgery was ophthalmologically inconclusive, an aqueous humor was collected preoperatively and examined for evidence of leptospiral infection. In this study, medical records from 2002 to 2017 were analyzed. Records for 1387 eyes affected by equine recurrent uveitis (ERU) and 237 eyes affected by another type of uveitis met the inclusion criteria. A total of 216 samples from healthy eyes were used as controls. In 83% of intraocular samples from ERU eyes, antibody titers of 1:100 or higher were detectable by microscopic agglutination test (MAT). Similarly, 83% of intraocular samples had anti-Leptospira antibodies detected by ELISA. In 72% of the intraocular specimens, leptospiral DNA was detectable by PCR. No antibodies were detectable in the samples from eyes with another type of uveitis or in the samples from healthy eyes. A PCR was positive in only one sample from a healthy eye. These results with a very high number of intraocular specimens demonstrate the great importance of an intraocular leptospiral infection for ERU. It can be concluded that for a reliable diagnosis of intraocular leptospiral infection or to reliably exclude an infection multiple tests should be applied.

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.

Detection of Anti-LipL32 Antibodies in Serum Samples from Horses with Chronic Intraocular Infection with Leptospira spp

Equine recurrent uveitis (ERU) is typically caused by chronic intraocular leptospiral infection in warm-blooded horses in central Europe. The most effective therapy for leptospiral-induced ERU is the surgical removal of diseased vitreous (vitrectomy). Since vitrectomy is a highly specialized and invasive surgery, the indication must be determined very carefully. In order to obtain evidence of intraocular leptospiral infection by laboratory diagnostics in questionable leptospiral ERU-cases, sampling of aqueous humor is required, because serum tests using microscopic agglutination test (MAT) are too unspecific. The SNAP Lepto is a cross-species rapid test for the detection of anti-Lipl32 antibodies that has a high sensitivity (0.97) and specificity (1.00) for the detection of anti-leptospiral antibodies using aqueous humor or vitreous samples, which is comparable to MAT. To evaluate sensitivity and specificity of SNAP Lepto using serum, serum samples from 90 horses with confirmed leptospiral ERU and from 103 ocularly healthy horses were tested by both MAT and SNAP Lepto. Sensitivity was similar for both tests (0.82 vs. 0.79), but specificity was lower for MAT (0.52 vs. 0.95). Sensitivity and specificity are therefore lower in serum samples compared to intraocular samples, however, the SNAP Lepto is far superior to MAT and suitable as a screening method using equine serum.

Serological Survey of Leptospira Infection in Arabian Horses in Poland

Leptospirosis is one of the most common zoonotic infections worldwide, including in most livestock, some companion animals, horses, wildlife, and humans. Epidemiological estimation of its prevalence in all species is difficult due to the variety of clinical presentations and challenges regarding laboratory diagnosis. The purpose of this study was to measure the seroprevalence of leptospiral infection in Arabian horses kept in the largest breeding farms in Poland, representing over 15% of the Polish Arabian horse population. Leptospira antibodies were detected by MAT (cut-off 1:100) in 33.2% of serum samples (204 of 615 animals) (CI 95%: 29.6–37.0%), most frequently reacting with the serovar Grippotyphosa, similar to previous reports in populations of randomly selected horses. These results indicated high Leptospira seropositivity, thus, although any form of clinical leptospirosis is rare, it may be postulated that the leptospiral exposure is widespread.

Seroprevalence of Leptospira spp. in Horses in Israel

Leptospirosis has been reported in both humans and animals in Israel but has not been reported in horses. In 2018, an outbreak of Leptospira spp. serogroup Pomona was reported in humans and cattle in Israel. In horses, leptospirosis may cause equine recurrent uveitis (ERU). This report describes the first identification of Leptospira serogroup Pomona as the probable cause of ERU in horses in Israel, followed by an epidemiological investigation of equine exposure in the area. Serologic exposure to Leptospira was determined by microscopic agglutination test (MAT) using eight serovars. In 2017, serovar Pomona was identified in a mare with signs of ERU. Seven of thirteen horses from that farm were seropositive for serogroup Pomona, of which three had signs of ERU. During the same time period, 14/70 horses from three other farms were positive for serogroup Pomona. In 2015, two years prior to this diagnosis, 259 horses from 21 farms were sampled and one horse tested seropositive for serovar Icterohaemorrhagiae. In 2018, one year later, 337 horses were sampled on 29 farms, with none testing seropositive. Although horses are not considered a major host of Leptospira spp., it appears that horses may be infected, and clinically affected, in the course of an outbreak in other species. The identification of leptospirosis in stabled horses may impose a significant zoonotic risk to people.

Equine leptospirosis: Experimental challenge of Leptospira interrogans serovar Bratislava fails to establish infection in naïve horses

BACKGROUND

Little information is available about experimental inoculation of leptospirosis in horses and the pathogenicity of Leptospira interrogans serovar Bratislava in this host.

OBJECTIVES

To determine the serological, clinical, pathological and haematological responses of horses to L. interrogans serovar Bratislava strain PigK151.

STUDY DESIGN

Randomised controlled in vivo experiment.

METHODS

Ten seronegative female foals were divided into 2 groups, control (n = 4) and challenged (n = 6). The challenged group received 1 × 10⁹ leptospires divided equally between topical ocular and intraperitoneal injections. Blood and urine samples were analysed. The temperature was recorded daily for the first 9 days, then weekly. Sera were tested by microscopic agglutination test (MAT). Automated complete blood count, differential and chemistry panel were performed. Histopathological analysis was performed on sections of liver, kidney, urinary bladder, uterine body and pineal gland. Sample culturing was performed from blood, urine, liver, kidney, reproductive tract and vitreous humour.

RESULTS

No pyrexia was noted. PCR and culture were negative from all samples. Differences between groups were found in CBC, differential counts and serum biochemistry panel (or profile), suggesting that leptospiral challenge triggered an inflammatory response. No evidence of leptospirosis was found from histopathological analysis. All challenged foals developed a humoral response. The MAT allowed the confirmation of the infecting serovar at a later stage, but it also revealed cross-reactive results that were further explained by genomic analysis.

MAIN LIMITATIONS

This experimental challenge had two main limitations: (a) the results might have varied if another strain from the same serovar had been used and (b) the use of another route of infection and a higher bacterial dose might have achieved colonisation.

CONCLUSIONS

Based on these findings, it may suggest that L. interrogans serovar Bratislava is neither pathogenic nor host-adapted serovar for horses, although these results might have varied if another strain from the same serovar had been used instead.

Leptospiral antibody prevalence and surgical treatment outcome in horses with Equine Recurrent Uveitis (ERU) in Switzerland

OBJECTIVE

To evaluate leptospiral antibody prevalence in 65 horses with ERU and compare outcome in 36 surgically treated eyes (2010-2015).

PROCEDURES

Retrospective data analysis of horses with ERU (n = 65). C-value calculation with microagglutination assay titer (MAT) results for Leptospira spp. Evaluation of follow-up data after pars plana vitrectomy (PPV, n = 21 eyes) and suprachoroidal cyclosporine device implantation (SCDI, n = 15 eyes). Differences between groups were statistically analyzed using Fishers exact test, significance set at P < .05.

RESULTS

Positive leptospiral titers were found in 28/65 blood, 31/65 aqueous humor (AH), and 19/20 vitreal (post-PPV) samples. The most common intraocular serovars were Leptospira interrogans grippotyphosa, pomona, and bratislava. Intraocular antibody production was suspected in samples of 22 horses (c-values > 1). Mean follow-up of surgical cases was 3.8 years (PPV) and 3.4 years (SCDI). PPV was performed in 21 eyes with positive, SCDI in 15 eyes with negative leptospiral test results. Uveitis recurred less often after PPV (2/21) compared to SCDI (6/15, P = .04). Retinal detachment occurred after PPV only (5/21, SCDI 0/15, P = .06), whereas only SCDI-treated eyes were enucleated (PPV 0/21, SCDI 3/15, P = .06). Blindness or visual impairment was equally likely to occur in both treatment groups after surgery (PPV 7/21, SCDI 7/15, P = .5).

CONCLUSIONS

Leptospiral antibody prevalence is high in horses with ERU in Switzerland. Recurrence of uveitis is uncommon following PPV in the present study; an increased risk of retinal detachment exists. Enucleation is more often warranted in horses after SCDI in this study due to a higher uveitis recurrence.

Risk factors for equine recurrent uveitis in a population of Appaloosa horses in western Canada

OBJECTIVE

To characterize clinical manifestations, measure frequency, and evaluate risk factors for equine recurrent uveitis (ERU) in Appaloosa horses in western Canada.

ANIMALS

145 Appaloosa horses.

PROCEDURES

Ophthalmic examinations were completed and eyes were classified as having no or mild clinical signs, or moderate, or severe damage from ERU. Clinical signs, age, sex, base coat color, and pattern were recorded. Whole blood and/or mane hair follicles were collected for DNA extraction, and all horses were tested for the leopard complex (LP) spotting pattern allele. Pedigree analysis was completed on affected and unaffected horses, and coefficients of coancestry (CC) and inbreeding (COI) were determined.

RESULTS

Equine recurrent uveitis was confirmed in 20 (14%) horses. The mean age of affected horses was 12.3 years (±5.3; range 3-25). Age was a significant risk factor for ERU diagnosis (OR_year  = 1.15) and classification (OR_year  = 1.19). The fewspot coat pattern was significantly associated with increased risk for ERU compared to horses that were minimally patterned or true solids. The LP/LP genotype was at a significantly greater risk for ERU compared to lp/lp (OR = 19.4) and LP/lp (OR = 6.37). Classification of ERU was greater in the LP/LP genotype compared to LP/lp. Affected horses had an average CC of 0.066, and there was a significant difference in the distribution of CC for affected horses versus the control group (P = .021). One affected horse was the sire or grandsire of nine other affected.

CONCLUSIONS

Age, coat pattern, and genetics are major risk factors for the diagnosis and classification of ERU in the Appaloosa.

Leptospira Seroprevalence in Bardigiano Horses in Northern Italy

A cross-sectional study was carried out in Bardigiano horses in the Province of Parma, Northern Italy, to assess the seroprevalence of Leptospira spp. and to investigate risk factors associated with the infection. A representative sample of 134 horses from 43 farms was selected by stratified systematic randomization. Blood sera were examined by MAT for the presence of antibodies against seven Leptospira serovars. Ninety animals (67.2%; 95% Confidence Interval 63.2-71.1) and 41 farms (95.3%; 95% CI 92.2-98.5%) were found positive to at least one of the serovars. The most frequently detected reactions were against serovar Bratislava (41.8%), followed by Canicola (36.6%), Tarassovi (28.4%), Copenhageni (17.9%), Pomona (10.4%) and Hardjo (2.2%). None of the sera reacted against serovar Grippothyphosa. Forty-eight horses (53.3% of the seropositives) were positive for more than one serovar and 21 (15.7% of the seropositives) had serum titres ≥ 1000. Bratislava was the serovar providing the highest antibody titres. Prevalence was significantly higher between adult horses and in farms lacking rodent control (p = 0.006 and p = 0.025, respectively). No significant gender or housing-related difference in seroprevalence was found. The anamnestic data suggest that the infection in Bardigiano horses is subclinical in most of the cases. The high seroprevalence indicates that Bardigiano horses living in the investigated area are at high risk of exposure and infection by Leptospira spp.

Equine uveitis in the UK: a retrospective study (2008-2018)

BACKGROUND

Uveitis appears to be less prevalent in the UK compared with other parts of the world and studies characterising the disease in the UK are lacking. The objectives of this retrospective study were to describe acute and recurrent cases presenting for management of uveitis in a referral hospital on the North West of England and compare the signalment of horses presenting with uveitis with the equine hospital population during the same period.

METHODS

Medical records of horses presented to the referral Equine Hospital, University of Liverpool with signs of uveitis between 2008 and 2018 were reviewed and clinical details extracted.

RESULTS

Seventy horses presented with uveitis; 33 were classified as acute and 37 as recurrent cases. Sixteen of the horses were affected bilaterally. More bilateral cases were classified as recurrent than acute (P=0.04). No differences in age or sex were noted between acute and recurrent cases, or between cases and the general hospital population. Warmbloods and Appaloosas were over-represented when compared with the general hospital population (P<0.001). Twenty-one horses (30 per cent, 95 per cent CI 20.5 to 41.4) underwent surgery for the control of the uveitis. Fourteen of the 70 horses (20.0 per cent, 95 per cent CI 12.3 to 30.8) underwent enucleation.

CONCLUSION

While relatively uncommon in the UK, uveitis can affect horses from a relatively young age. The disease appears to have a relatively higher frequency than expected in Warmbloods and Appaloosas. It is more likely that a recurrent case will have both eyes affected.

Detection of intraocular Leptospira spp. by real-time polymerase chain reaction in horses with recurrent uveitis in Belgium

BACKGROUND

Equine recurrent uveitis (ERU) has been associated with Leptospira spp. infection. No information exists concerning the prevalence of Leptospira-associated ERU in Belgium and about the sensitivity of detection of Leptospira in different ocular media.

OBJECTIVES

To establish the prevalence of intraocular Leptospira spp. in ERU-affected and healthy eyes of horses examined at the Equine Clinic of the University of Liège by real-time PCR and to compare the results of the aqueous and vitreous humour of the same eye.

STUDY DESIGN

Cross-sectional.

METHODS

Sixty-six eyes from 59 client-owned horses with a diagnosis of equine recurrent uveitis (ERU-group) were studied from May 2015 to December 2017. Fifty healthy eyes from 28 euthanised horses for unrelated reasons examined during the same period were included in the control group. Intraocular fluids (aqueous and/or vitreous humours) from ERU-affected eyes were sampled and analysed by real-time PCR for Leptospira spp. Aqueous and vitreous humours from the control group were processed in the same way.

RESULTS

Both groups were comparable regarding age, sex, eye sampled (OS/OD), humours sampled (aqueous/vitreous humour) but not regarding breeds, with an over-representation of Warmbloods and Appaloosas in the ERU-group. The prevalence of Leptospira spp. was 30.3% (20/66 eyes) in the ERU-group. Leptospira spp. DNA was identified in 11 aqueous and 17 vitreous humours with eight horses testing positive in both humours, nine horses testing positive for vitreous humour alone and third horses for aqueous humour alone. The phi-correlation between aqueous and vitreous humour Leptospira-PCR results is 0.47 suggesting a low association. All the control eyes were negative.

MAIN LIMITATIONS

The diagnostic method selected for this study (lipL32 qPCR) did not allow identification of the serovars.

CONCLUSIONS

Leptospirosis is a potential cause of ERU in Belgium. Testing both intraocular media is advised whenever possible. The Summary is available in Spanish - see Supporting Information.