Evaluation of four commercially available rapid serologic tests for diagnosis of leptospirosis

Development of a new accurate lateral flow immunoassay for diagnosis of human leptospirosis

PURPOSE

The current diagnostic methods for leptospirosis diagnosis are technically complex and expensive, with limited applicability to specialized laboratories. Furthermore, they lack diagnostic accuracy in the acute stage of the disease, which coincides with a period when antibiotics are highly effective. New simple and accurate tests are mandatory to decentralize and improve diagnosis. Here, we introduced a new lateral flow immunoassay (Lepto-LF) for human leptospirosis.

METHODS

We conducted a double-blinded assay using 104 serum samples from patients with confirmed or discarded diagnosis for leptospirosis. The diagnostic performance of Lepto-LF was estimated across different ranges of days from onset of symptoms (dpo), considering the diagnostic algorithm as reference standard. Additionally, it was compared with the screening methods enzyme-linked immunosorbent assay (IgM-ELISA) and the slide agglutination test using temperature-resistant antigen (SATR).

RESULTS

Lepto-LF exhibited perfect diagnostic performance with a Youden´s index J = 1 from 6 dpo in the acute phase. IgM-ELISA gave slightly lower accuracy with J = 0.91 and 95.5% of both sensitivity and specificity; while SATR showed a markedly inferior yield (J = 0.41, sensitivity = 95.5%, specificity = 45.5%). The performances remained consistent in the convalescence phase of the disease (> 10 dpo).

CONCLUSION

Lepto-LF was found to be a reliable test for simple, rapid and early diagnosis of leptospirosis, resulting a promising tool for decentralizing leptospirosis diagnosis and enabling timely treatment of patients. In addition, Lepto-LF may be employed as confirmatory test, especially in remote areas and vulnerable contexts where the standard MAT is not available.

Accuracy of the Dual Path Platform (DPP) rapid test for the diagnosis of leptospirosis: A multi-center study in six Brazilian states

Leptospirosis is a zoonotic disease with significant global impact and a challenging diagnosis. The utilization of adequately validated rapid tests is relevant for the opportune identification of the disease and for reduction in fatality rates. The present study analyzes the accuracy and reliability of the Dual Path Platform (DPP) assay -produced in Brazil by the Oswaldo Cruz Foundation (Fiocruz)- for diagnosing leptospirosis. Firstly, a serological panel was constructed in the Brazilian Reference Laboratory for Leptospirosis using samples routinely handled by reference laboratories of six Brazilian states. It consisted of 150 positive (according to MAT and IgM-ELISA) and 250 negative samples for leptospirosis. Subsequently, the panel samples were distributed to the reference laboratories for the performance of DPP assays in triplicate. Different measures were used in the assessment of diagnostic quality. Predictive values were estimated for different pre-test probability settings. Sensitivities varied between 67.33 % and 74.00 % and specificities between 93.20 % and 98.40 % in the states, and there were adequate agreements between them. Accuracies were lower for the samples of patients with less than 7 days of symptoms. In contexts of prevalence values up to around 25 %, positive and negative predictive values were around 90 %. However, in situations of high pre-test probabilities, NPVs were low. This study improves understanding of the use of DPP in diagnosing leptospirosis, particularly its application in healthcare settings. As long as the time of symptoms onset and clinical and epidemiological contexts are adequately considered for the interpretation of results, DPP is a valid option to be used in the leptospirosis diagnostic routine.

Use of Advanced Diagnostics for Timely Identification of Travel-associated Leptospira santarosai Infection in Four Adolescents Through Plasma Microbial Cell-free DNA Sequencing With the Karius Test

BACKGROUND

Leptospirosis is an important zoonotic infection worldwide. Diagnosis of leptospirosis is challenging given its nonspecific clinical symptoms that overlap with other acute febrile illnesses and limitations with conventional diagnostic testing. Alternative advanced diagnostics, such as microbial cell-free DNA (mcfDNA), are increasingly being used to aid in the diagnosis of infections and can be applied to pathogens with public health importance such as Leptospira , a nationally notifiable disease.

METHODS

The Karius Test uses plasma mcfDNA sequencing to detect and quantify DNA-based pathogens. This test offered through the Karius lab detected 4 cases of Leptospira santarosai during a 5-month period across the United States in 2021 and were clinically reviewed.

RESULTS

In our case series, 4 adolescents with recent travel to Central America (Costa Rica, n = 3 and Belize, n = 1) from April to August 2021 were diagnosed with leptospirosis. While a large workup was performed in all cases, mcfDNA testing was the first test to detect L. santarosai as the microbiological diagnosis in all cases.

CONCLUSIONS

Results of the Karius Test enabled rapid, noninvasive diagnosis of leptospirosis allowing for targeted therapy. Use of mcfDNA can be utilized for diagnosis of pathogens where conventional testing is challenging or limited. This in turn can enable quick diagnosis for targeted treatment and potentially aid in supporting case definitions of reportable diseases of public health concern.

Accuracy of rapid lateral flow immunoassays for human leptospirosis diagnosis: A systematic review and meta-analysis

BACKGROUND

In the last two decades, several rapid lateral flow immunoassays (LFIs) for the diagnosis of human leptospirosis were developed and commercialized. However, the accuracy and reliability of these LFIs are not well understood. In this study, we aimed to evaluate the accuracy of leptospirosis LFIs as well as the factors affecting the test efficiency using systematic review and meta-analysis.

METHODS AND RESULTS

Original articles reporting the accuracy of human leptospirosis LFIs against microagglutination tests (MAT) or immunofluorescent assays (IFA) were searched from PubMed, Embase, and Scopus, and selected as per pre-set inclusion and exclusion criteria. A total of 49 data entries extracted from 24 eligible records published between 2003 and 2023 were included for meta-analysis. A meta-analysis was performed using STATA. The quality of the included studies was assessed according to the revised QUADAS-2. Only nine studies (32.1%) were considered to have a low risk of bias and no concern for applicability. Pooled sensitivity and specificity were calculated to be 68% (95% confidence interval, CI: 57-78) and 93% (95% CI: 90-95), respectively. However, the ranges of sensitivity (3.6 - 100%) and specificity (53.5 - 100%) of individual entries are dramatically broad, possibly due to the heterogeneity found in both study designs and LFIs themselves. Subgroup analysis demonstrated that IgM detection has better sensitivity than detection of IgG alone. Moreover, the test performance seems to be unaffected by samples from different phases of infection.

CONCLUSIONS

The pooled specificity of LFIs observed is somewhat acceptable, but the pooled sensitivity is low. These results, however, must be interpreted with caution because of substantial heterogeneity. Further evaluations of the LFIs with well-standardized design and reference test will be needed for a greater understanding of the test performance. Additionally, IgM detection type should be employed when leptospirosis LFIs are developed in the future.

Comparative analysis of a novel N-butanol-prepared antigen vs thermo-resistant and sonicated antigens for human leptospirosis detection

The diagnosis of human leptospirosis is mainly based on serological assays. Since the extraction by N-butanol has only been studied as an antigen for the diagnosis of cattle leptospirosis, this study aimed to investigate the feasibility of the N-butanol preparation for the diagnosis of human leptospirosis and compare it with sonicated and thermo-resistant antigens in IgM dot-blot test. Paired serum samples from 147 laboratory-confirmed leptospirosis cases were tested. The control group consisted of 148 serum samples from healthy individuals and nonleptospirosis cases. N-butanol antigens from serovar Copenhageni (ButC3) and serovar Patoc (ButP3) showed reactivity with antileptospiral antibodies from patients with confirmed leptospirosis. In the acute phase, sensitivities of IgM dot-blot assay with ButC3 and ButP3 antigens were 47.6% and 51.0%, respectively. In the convalescent phase, sensitivities were 95.9% (ButC3) and 93.2% (ButP3), and no significant differences were observed among the IgM dot-blot tests with other antigens. The specificity of the IgM dot-blot test with ButC3 antigen was good (92.6%), but with ButP3 (83.1%), it was significantly lower than with the other tests. The IgM dot-blot test described in this study is simple to perform and presents reliable visual results. Antigens prepared by N-butanol proved to be valuable diagnostic markers of leptospirosis.

Leptospirosis-associated meningitis in a patient with sjögren's syndrome: a case report

BACKGROUND

Leptospirosis is a zoonotic disease that afflicts both humans and animals. It progresses from flu-like symptoms to more severe hepatic and renal failure, and may also lead to aseptic meningitis. Individuals with autoimmune diseases (ADs) are potentially more susceptible to Leptospirosis. Thus far, limited data has documented the association between Leptospirosis and autoimmune disorders.

CASE PRESENTATION

The patient had a definitive pathological diagnosis of Sjögren's syndrome (SS). Due to recurrent headaches, the patient sought consultation with a neurologist. Lumbar puncture revealed elevated white blood cells and protein levels in the cerebrospinal fluid, along with decreased glucose. Tuberculous meningitis was suspected. Radiographic imaging exhibited meningeal enhancement, ventricular enlargement, and hydrocephalus. The patient commenced treatment with anti-tuberculosis therapy and corticosteroids. Subsequently, high-throughput sequencing (HTS) of cerebrospinal fluid identified the presence of Leptospira interrogans. The patient was ultimately diagnosed with Leptospiral meningitis, and underwent antimicrobial and immunosuppressive therapy, resulting in stabilization of the condition and gradual symptom recovery.

CONCLUSIONS

The case highlights the challenges in diagnosing and managing leptospirosis-related meningitis in the presence of ADs and emphasizes the importance of utilizing HTS for accurate pathogen detection. The potential correlation between leptospirosis and SS warrants further investigation, as does the need for multidisciplinary involvement in treatment strategies for such complex cases.

Structural and biochemical characterization of Leptospira interrogans Lsa45 reveals a penicillin-binding protein with esterase activity

Leptospirosis is a bacterial disease that affects humans and animals and is caused by Leptospira. The recommended treatment for leptospirosis is antibiotic therapy, which should be given early in the course of the disease. Despite the use of these antibiotics, their role during the course of the disease is still not completely clear because of the lack of effective clinical trials, particularly for severe cases of the disease. Here, we present the characterization of L. interrogans Lsa45 protein by gel filtration, protein crystallography, SAXS, fluorescence and enzymatic assays. The oligomeric studies revealed that Lsa45 is monomeric in solution. The crystal structure of Lsa45 revealed the presence of two subdomains: a large α/β subdomain and a small α-helical subdomain. The large subdomain contains the amino acids Ser122, Lys125, and Tyr217, which correspond to the catalytic triad that is essential for β-lactamase or serine hydrolase activity in similar enzymes. Additionally, we also confirmed the bifunctional promiscuity of Lsa45, in hydrolyzing both the 4-nitrophenyl acetate (p-NPA) and nitrocefin β-lactam antibiotic. Therefore, this study provides novel insights into the structure and function of enzymes from L. interrogans, which furthers our understanding of this bacterium and the development of new therapies for the prevention and treatment of leptospirosis.

Epidemiology of Leptospirosis: The First Literature Review of the Neglected Disease in the Middle East

Leptospirosis is a major zoonotic disease that has emerged worldwide, and numerous studies performed in affected countries have provided epidemiological knowledge of the disease. However, currently, there is inadequate knowledge of leptospirosis in the Middle East. Therefore, we grouped publications from various Middle Eastern countries to acquire a general knowledge of the epidemiological situation of leptospirosis and provide an initial description of the leptospiral relative risk and circulating serogroups. We conducted a detailed literature search of existing studies describing Leptospira prevalence and seroprevalence in Middle Eastern countries. The search was performed using online PubMed and ScienceDirect databases. One hundred and one articles were included in this review. Some countries, including Iran, Turkey, and Egypt, reported more publications compared to others, such as Lebanon, Kuwait, and Saudi Arabia. Frequently, the seroprevalence of leptospirosis varied considerably between and within countries. The prevalence of leptospirosis was comparable in most Middle Eastern countries; however, it varied between some countries. The methods of detection also varied among studies, with the microscopic agglutination test used most commonly. Some hosts were more recurrent compared with others. This review summarizes the epidemiological situation of Leptospira infection in the Middle East, reporting predominant serogroups-Sejroe, Grippotyphosa, Icterohaemorrhagiae, Autumnalis, and Pomona-that were identified in the most commonly tested hosts. Our findings emphasize the need to develop a deeper understanding of the epidemiology of Leptospira spp. and prioritize the disease as a public health problem in this region. To achieve this goal, increased awareness is critical, and more publications related to the topic and following a standardized approach are needed.

Serological Investigation and Epidemiological Analysis of Bovine Leptospirosis in Egypt

Bovine leptospirosis is a bacterial zoonotic disease of worldwide distribution. Little information is available regarding the occurrence of the disease in the Nile Delta provinces, Egypt. The present study investigated the seroprevalence of leptospirosis among cattle from Dakahlia province, Northern Egypt, and identified the individual variables factors associated with infection. To this end, a total of 600 serum samples from cattle of small stakeholders with various clinical manifestations possibly associated with leptospirosis were collected from different localities across Dakahlia province, Egypt. Sera were examined serologically via ELISA to investigate the occurrence of the disease among animals. Chi-square test and multivariable logistic regression analyses were applied to determine the association between hypothesized risk factors and the disease. Interestingly, our findings showed that 39.33% of the examined sera were positive for Leptospira antibodies, with significant differences among different localities. In addition, statistical analysis showed significant differences among age groups. Notably, the highest prevalence rate (22%) was observed in those aged between 3 and 5 years (p < 0.0001), whereas the lowest prevalence (2.66%) was reported in cattle <1 year old (p < 0.0001). Moreover, females had a significantly higher prevalence rate (35.33%) than males (4%) (p < 0.0001). Furthermore, our results showed significant differences in the occurrence of infection and reported clinical signs (p < 0.0001). Multivariable logistic regression identified repeated breeder and drop milk yield as the best predictors for prediction of ELISA results and linear discriminant analysis (LDA) model showed that overall classification accuracy of ELISA result using clinical signs and demographic data as predictors was 70.7%. The current study concluded a relative high prevalence of leptospirosis among cows bred in movable herds and households in the studied area and that age, repeated breeder and drop milk yield can be considered major risk factors associated with infection.

Molecular Diagnostic Methods For The Detection of Leptospirosis

Leptospirosis is a widespread infectious disease caused by the spirochete Leptospira. The clinical features of leptospirosis are fever, headache, vomiting, jaundice, and the acute form of the disease is commonly called Weil’s disease. The microscopic agglutination test (MAT) is a gold standard method used to detect leptospirosis. However, it requires 14 days of time and skilled personnel to detect leptospirosis. Various molecular methods were developed for the rapid detection process, including polymerase chain reaction (PCR), multiplex PCR, nested PCR, real-time PCR, and Loop-mediated isothermal amplification (LAMP). Other immuno-based biosensor kits are readily available for the diagnosis of leptospirosis. Though these methods claim to be highly sensitive and specific, each method has its drawbacks. This review discusses the different molecular diagnostic techniques applied for the diagnosis of leptospirosis; elaborating on each method’s sensitivity, specificity, and detection time and the different samples of water, blood, and urine used.

Role of Diagnostics in Epidemiology, Management, Surveillance, and Control of Leptospirosis

A One Health approach to the epidemiology, management, surveillance, and control of leptospirosis relies on accessible and accurate diagnostics that can be applied to humans and companion animals and livestock. Diagnosis should be multifaceted and take into account exposure risk, clinical presentation, and multiple direct and/or indirect diagnostic approaches. Methods of direct detection of Leptospira spp. include culture, histopathology and immunostaining of tissues or clinical specimens, and nucleic acid amplification tests (NAATs). Indirect serologic methods to detect leptospiral antibodies include the microscopic agglutination test (MAT), the enzyme-linked immunosorbent assay (ELISA), and lateral flow methods. Rapid diagnostics that can be applied at the point-of-care; NAAT and lateral flow serologic tests are essential for management of acute infection and control of outbreaks. Culture is essential to an understanding of regional knowledge of circulating strains, and we discuss recent improvements in methods for cultivation, genomic sequencing, and serotyping. We review the limitations of NAATs, MAT, and other diagnostic approaches in the context of our expanding understanding of the diversity of pathogenic Leptospira spp. Novel approaches are needed, such as loop mediated isothermal amplification (LAMP) and clustered regularly interspaced short palindromic repeats (CRISPR)-based approaches to leptospiral nucleic acid detection.

Serologic titers to Leptospira in vaccinated pigs and interpretation for surveillance

Diagnosis and surveillance of pathogenic Leptospira is difficult as organisms may be intermittently shed and in small numbers. Therefore, serologic testing by the microscopic agglutination test (MAT) is the primary screening method for leptospirosis. While a MAT titer ≥1:100 is considered to be a positive result, interpretation is complicated by the use of commercial vaccines in pigs. Most guidelines for interpretation of MAT titers in pigs were published in the 1970’s and 1980’s, prior to the development of the current multivalent vaccines. We evaluated MAT titers in routinely vaccinated healthy research pigs compared to their unvaccinated cohorts. Our study confirmed previous reports that the Pomona serovar elicits minimal antibody response even after a second booster 6 months after initial vaccination. However, MAT titers of ≥1:3,200 were detected as early as 4 weeks post initial vaccination for serovars Bratislava and Icterohaemorrhagiae and remained as high as ≥1:1,600 prior to booster at 24 weeks post vaccination. Our study determined that high levels of MAT titers can occur from vaccination alone and high titers are not necessarily indicative of infection. Therefore, the interpretation of MAT titers as indicators of Leptospira infection should be readdressed.

Leptospirosis infections among hospital patients, Sarawak, Malaysia

Background

Leptospirosis diagnoses have increased in Sarawak, Malaysia in recent years.

Methods

To better understand the burden of disease and associated risk factors, we evaluated 147 patients presenting with clinical leptospirosis to local hospitals in Sarawak, Malaysia for the presence of Leptospira and associated antibodies. Sera and urine specimens collected during the acute illness phase were assessed via a commercially available rapid diagnostic test (Leptorapide, Linnodee Ltd., Antrim, Northern Ireland), an ELISA IgM assay (Leptospira IgM ELISA, PanBio, Queensland, Australia) and a pan-Leptospira real-time PCR (qPCR) assay to estimate disease prevalence and diagnostic accuracy of each method. Microagglutination testing was performed on a subset of samples.

Results

Overall, 45 out of 147 patients (30.6%) showed evidence of leptospires through qPCR in either one or both sera (20 patients) or urine (33 patients), and an additional ten (6.8%) were considered positive through serological testing, for an overall prevalence of 37.4% within the study population. However, each diagnostic method individually yielded disparate prevalence estimates: rapid test 42.2% for sera and 30.5% for urine, ELISA 15.0% for sera, qPCR 13.8% for sera and 23.4% for urine. Molecular characterization of a subset of positive samples by conventional PCR identified the bacterial species as Leptospira interrogans in 4 specimens. A multivariate risk factor analysis for the outcome of leptospirosis identified having completed primary school (OR = 2.5; 95 CI% 1.0–6.4) and weekly clothes-washing in local rivers (OR = 10.6; 95 CI% 1.4–214.8) with increased likelihood of leptospirosis when compared with those who had not.

Conclusion

Overall, the data suggest a relatively high prevalence of leptospirosis in the study population. The low sensitivities of the rapid diagnostic test and ELISA assay against qPCR highlight a need for better screening tools.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40794-021-00154-2.

Optimizing the microscopic agglutination test (MAT) panel for the diagnosis of Leptospirosis in a low resource, hyper-endemic setting with varied microgeographic variation in reactivity

The microscopic agglutination test (MAT) is the standard serological reference test for the diagnosis of leptospirosis, despite being a technically demanding and laborious procedure. The use of a locally optimised MAT panel is considered essential for proper performance and interpretation of results. This paper describes the procedure of selecting such an optimised panel for Sri Lanka, a country hyper-endemic for leptospirosis. MAT was performed using 24 strains on 1132 serum samples collected from patients presenting with acute undifferentiated fever. Of 24 strains, 15 were selected as the optimised panel, while only 11% of serum samples showed positivity. A geographical variation in predominantly reactive serovars was observed, whereas reactivity was low with the saprophytic strain Patoc. Testing with paired sera yielded a higher sensitivity but provided only a retrospective diagnosis. Serological tests based on ELISA with complementary molecular diagnosis using PCR are a feasible and robust alternative approach to diagnose leptospirosis in countries having a higher burden of the disease.

Leptospiral Infection, Pathogenesis and Its Diagnosis-A Review

Leptospirosis is a perplexing conundrum for many. In the existing literature, the pathophysiological mechanisms pertaining to leptospirosis is still not understood in full. Considered as a neglected tropical zoonotic disease, leptospirosis is culminating as a serious problem worldwide, seemingly existing as co-infections with various other unrelated diseases, including dengue and malaria. Misdiagnosis is also common as non-specific symptoms are documented extensively in the literature. This can easily lead to death, as the severe form of leptospirosis (Weil's disease) manifests as a complex of systemic complications, especially renal failure. The virulence of Leptospira sp. is usually attributed to the outer membrane proteins, including LipL32. With an armament of virulence factors at their disposal, their ability to easily adhere, invade and replicate within cells calls for a swift refinement in research progress to establish their exact pathophysiological framework. As an effort to reconstitute the current knowledge on leptospirosis, the basis of leptospiral infection, including its risk factors, classification, morphology, transmission, pathogenesis, co-infections and clinical manifestations are highlighted in this review. The various diagnostic techniques are also outlined with emphasis on their respective pros and cons.

Spatial autocorrelation and co-occurrence of six serovarieties of Leptospira in goat herds of the State of Guanajuato, Mexico

The epidemiological behavior of six Leptospira serovarieties was analyzed by spatial autocorrelation and co-occurrence of leptospirosis, diagnosed in goat herds located in the State of Guanajuato, Mexico. A total of 1650 goat serum samples were analyzed by microscopic agglutination (MAT). True prevalence (P_v) and 95% confidence interval (CI₉₅) were determined. Spatial autocorrelation was calculated using the spdep package, applying the global Moran's I and local Moran's I of Leptospira in Guanajuato. The probabilistic model of co-occurrence was applied using the co-occur package. Seroprevalence in the State was found to be 45.5% (CI₉₅ 42.96; 48.06%). The highest registered frequency was for the Icterohemorrhagiae serovar (P_v 34.16%; CI₉₅ 31.74, 36.65%), followed by the serovar Hardjo-prajitno (P_v: 6.77%; CI₉₅ 5.33, 8.40%). Other serovarieties showed a P_v < 5%. Global spatial autocorrelation, only for the Icterohemorrhagiae serovar, was I > 1, while local Moran's I revealed that five of the six Leptospira serovarieties were spatially correlated. The probabilistic model of co-occurrence detected negative associations between Icterohemorrhagiae and the other serovarieties. The current study demonstrates the presence of Leptospira in goat herds of the State of Guanajuato. The diagnosed serovarieties show an aggregation pattern associated to risk zones and disease-transmitting vectors. Antibody co-occurrence analysis revealed dominance of the Icterohemorrhagiae serovar. A multidisciplinary approach including spatial epidemiology, ecological analyses, and serological vigilance will generate useful information for the prevention and control of leptospirosis in caprine production units.

Usefulness of Nested Polymerase Chain Reaction with Clinical Specimens for Diagnosis of Leptospirosis: a Case Series and a Review of Literature

A culture of the Leptospira species and the microscopic agglutination test (MAT) are considered as the reference standard for the diagnosis of leptospirosis, but both tests are imperfect for early diagnosis. We describe 4 patients diagnosed with leptospirosis using nested polymerase chain reaction (N-PCR) that targeted the 16S rRNA gene and the passive hemagglutination assay (PHA). In our 4 cases, Leptospira DNA in the urine, plasma, or cerebrospinal fluid (CSF), was detected by N-PCR in the early phase of leptospirosis, except in the sample from the buffy coat. Especially, case 3 showed that N-PCR with the urine and CSF was positive 8 days after symptom onset, but not for the plasma or buffy coat. We report 4 cases of leptospirosis that were diagnosed by N-PCR that targeted the 16S rRNA gene with urine, plasma, or CSF, but not the buffy coat. Three were cured by doxycycline but the case 4 was fatal. Detection of Leptospira DNA by PCR from the urine and CSF, in addition to plasma, may be helpful to confirm the diagnosis.

Leptospira Seroprevalence Among Ugandan Slaughter Cattle: Comparison of Sero-Status With Renal Leptospira Infection

Despite evidence of both human and animal Leptospira exposures in Uganda, the epidemiology of the disease is still not well-investigated. Contact with animals and their environments have been pointed out as potential source of infection with Leptospira species in humans; and cattle may be an important reservoir in Uganda. In this cross-sectional study, we estimated the prevalence of anti-Leptospira antibodies by the standard microscopic agglutination test (MAT); and associated risk factors among slaughtered cattle. We also compared the performance of the MAT used in this study against a lipL32 based real time PCR (qPCR) assay previously conducted on the kidneys and urine of the same slaughter cattle as tested in this reported study. Of 500 cattle sampled, 27.8% (95% CI 23.9-32.0) tested positive (titer ≥ 100) to at least one Leptospira serovar, with the majority of seropositive cattle reacting to serovars Tarassovi (sg Tarassovi) (11.6%), Sejroe (Sg Sejroe) (7.8%), and Australis (Sg Australis) (5.2%). Older animals had 2.8 times (95% CI 1.0-8.2, p-value 0.055) greater odds of being seropositive than younger ones (<1.5 years). The sensitivity and specificity of the MAT over the qPCR were 65.9% (95% CI 50.1-79.5) and 75.9% (95% CI 71.7-79.7), respectively; with a negative predictive value of 95.8% and positive predictive value of 20.9%. In conclusion, slaughter cattle in this study were significantly exposed to pathogenic Leptospira species of mainly the Tarassovi, Sejroe, and Australis serogroups, with seroprevalence being higher among older cattle. The high specificity and negative predictive value of MAT as used in this study when compared to the qPCR assay may imply a rather strong association between seronegativity and absence of renal Leptospira infection. However, MAT predictability for renal Leptospira infection may be interpreted cautiously since predictive values of diagnostic tests are dependent on prevalence.

Challenges in the diagnosis of leptospirosis outwith endemic settings: a Scottish single centre experience

Background Leptospirosis is a zoonotic infection occurring worldwide but endemic in tropical countries. This study describes diagnostic testing for leptospirosis at our institution in Scotland over a 10-year period. Method We identified patients with blood samples referred to the Public Health England reference laboratory for leptospirosis testing between 2006 and 2016. Results A total of 480 samples were sent for IgM ELISA testing with 26 positive results from 14 patients. Two patients met criteria for 'confirmed' leptospirosis (microscopic agglutination test > 1:320 in one case and a positive PCR in the other) and the remaining 12 were 'probable' on the basis of IgM ELISA positivity, though 9 did not have microscopic agglutination testing performed. Nine infections were imported, mostly from Asia and with a history of fresh water exposure. Three co-infections (respiratory syncytial virus, influenza B and Campylobacter sp.) were identified. Conclusions Practical issues with microscopic agglutination testing (insufficient blood sent to reference laboratory) and PCR (travellers returning > 7 days after illness onset) represent challenges to the laboratory confirmation of a clinical diagnosis of leptospirosis. Co-infection and infectious/auto-immune causes of false positive serology should be evaluated.

Diagnostic Testing in Central Nervous System Infection

Patients with central nervous system (CNS) infection experience very high levels of morbidity and mortality, in part because of the many challenges inherent to the diagnosis of CNS infection and identification of a causative pathogen. The clinical presentation of CNS infection is nonspecific, so clinicians must often order and interpret many diagnostic tests in parallel. This can be a daunting task given the large number of potential pathogens and the availability of different testing modalities. Here, we review traditional diagnostic techniques including Gram stain and culture, serology, and polymerase chain reaction (PCR). We highlight which of these are recommended for the pathogens most commonly tested among U.S. patients with suspected CNS infection. Finally, we describe the newer broad-range diagnostic approaches, multiplex PCR and metagenomic sequencing, which are increasingly used in clinical practice.

Leptospira spp., rotavirus, norovirus, and hepatitis E virus surveillance in a wild invasive golden-headed lion tamarin (Leontopithecus chrysomelas; Kuhl, 1820) population from an urban park in Niterói, Rio de Janeiro, Brazil

The world currently faces severe biodiversity losses caused by anthropogenic activities such as deforestation, pollution, the introduction of exotic species, habitat fragmentation, and climate changes. Disease ecology in altered environments is still poorly understood. The golden-headed lion tamarin (GHLT, Leontopithecus chrysomelas) is an endangered species that became invasive in an urban park in Niterói, Rio de Janeiro, Brazil. The initially few invasive GHLT individuals became hundreds, adapted to living in proximity to humans and domestic animals. These GHLTs were captured as part of a conservation project; some animals were translocated to Bahia and some were kept in captivity. This study tested 593 GHLT for Leptospira serology; 100 and 95 GHLT for polymerase chain reaction (PCR) toLeptospira and hepatitis E virus genotype 3 (HEV-3), respectively, and 101 familiar groups for PCR to viruses (rotavirus A, norovirus GI and GII, and HEV-3). One animal had antibodies for Leptospira serovar Shermani and another for serovar Hebdomadis. One saprophyticLeptospira was found by the 16S PCR and sequencing. Viruses were not detected in samples tested. Findings suggest that the epidemiological importance of such pathogens in this GHLT population is either low or nonexistent. These data are important to understand the local disease ecology, as well as monitoring a translocation project, and to contribute data for species conservation.

Development and evaluation of latex agglutination test coating with recombinant antigen, LipL32 for serodiagnosis of human leptospirosis

Leptospirosis is a widespread zoonotic disease caused by Leptospira interrogans. Symptoms of disease range from mild symptoms to serious complications including, jaundice, pulmonary hemorrhage, renal and hepatic failure, which may prove fatal. Clinical presentations of this disease are similar with other febrile illness. Therefore, rapid and appropriated laboratory diagnostic tests are needed to aid clinical case identification. As these reasons, objective of this study is to develop and evaluate a simple latex agglutination test coating with recombinant leptospiral antigens, LipL32 for serodiagnosis of human leptospirosis. Firstly, lipl32 gene was amplified from genomic DNA of Leptospira interogans serovar Pyrogenes. Then PCR product of lipl32 gene was ligated with pGEX-2T plasmid, generating pGRK32 recombinant plasmid. Recombinant GST-LipL32 protein was overexpressed and subsequently purified by using Glutathione-Agarose Resin. Recombinant GST-Lipl32 protein was coated on latex beads for development latex agglutination test (LAT). The relative sensitivity, specificity and accuracy of the developed LAT were compared with indirect immunofluorescences assay (IFA) for detection of anti-leptospiral antibodies in 30 human leptospirosis samples, 30 healthy blood donor samples, 10 dengue fever positive samples, 10 scrub typhus positive samples, and 10 melioidosis samples. Results showed that the developed LAT showed sensitivity, specificity and accuracy: 66.66%, 86.66%, and 80.00%, respectively, comparing with IFA method. Moreover, Kappa analysis showed agreement rate of the two methods were 0.421. It concluded that our developed gave compatible result with IFA. Additionally, Our LAT are simple, rapid and suitable for detection in the field. However, for better sensitivity, diagnostic specificity, positive predictive value, negative predictive value, accuracy and Cohen’s kappa comparison should be done in larger amounts of sera samples.

Evaluation of an in-house LipL32 polymerase chain reaction for diagnosis of leptospirosis and its correlation with various serological diagnostic techniques

Background

Leptospirosis is a zoonotic disease of ubiquitous distribution. During rainy seasons, in spring and summer and also during harvest times, the risk of leptospirosis increases as there are chances of frequent contact with infected rat population which is common in Karnataka as farming is a main source of income to the people here. There is a paucity of data regarding the prevalent serovars from Karnataka. This study was undertaken as an attempt to compare a battery of tools such as immunochromatographic test (ICT), microscopic agglutination test (MAT), immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA) and in-house polymerase chain reaction (PCR) to detect leptospirosis.

Settings and Design

This study using consecutive sampling technique was conducted in a tertiary care centre, Mysore, Karnataka.

Subjects and Methods

Samples from 783 suspected cases of leptospirosis in and around Mysore between April 2013 and April 2016 were processed. Samples from 783 patients suspected of leptospirosis were subjected to ICT, IgM ELISA, MAT and in-house PCR.

Statistical Analysis Used

The statistical analysis was carried out using SPSS software version.

Results

Among 783 samples tested, only 14 (1.7%) were positive by ICT, 341 (44%) were positive by IgM ELISA, 368 (47%) were positive by MAT and 393 (50.2%) were positive by in-house PCR.

Conclusions

Mysore can be considered endemic for leptospirosis. The in-house PCR based on LipL32 gene proved to be useful in the early diagnosis of leptospirosis.

An Improved Enzyme-Linked Immunoassay for the Detection of Leptospira-Specific Antibodies

Leptospirosis is a neglected zoonotic disease with worldwide endemicity and continues to be a significant public health burden on resource-limited populations. Previously, we produced three highly purified recombinant antigens (rLipL32, rLipL41, and rLigA-Rep) and evaluated their performance of detecting Leptospira-specific antibodies in enzyme-linked immunosorbent assay (ELISA) as compared with the microscopic agglutination test (MAT). The overall sensitivity of this assay approached 90%. Recently, another recombinant antigen (rLigB-Rep) was prepared. We tested each individual antigen and a 1:1:1:1 mixture of these four antigens for the detection of Leptospira-specific antibodies in ELISA. The performance of these recombinant antigens was evaluated with a much larger febrile patient panel (337 MAT-confirmed positive sera and 92 MAT-negative sera from febrile patients). Combining the detection results of immunoglobulin M and immunoglobulin G from these four individual antigens, the overall sensitivity was close to 90% but the specificity was only 66%, based on the MAT reference method. The overall sensitivity and specificity of the four-antigen mixture were 82% and 86%, respectively. The mixture of four antigens also exhibited a broader reactivity with MAT-positive samples of 18 serovars from six major pathogenic Leptospira species. Given the limitations of MAT, the data were further analyzed by Bayesian latent class model, showing that ELISA using a 1:1:1:1 mixture still maintained high sensitivity (79%) and specificity (88%) as compared with the sensitivity (90%) and specificity (83%) of MAT. Therefore, ELISA using a mixture of these four antigens could be a very useful test for seroprevalence studies.

IgM ELISA for leptospirosis diagnosis: a systematic review and meta-analysis

Abstract A systematic review with meta-analysis was performed to estimate the accuracy of IgM ELISA for Leptospirosis diagnosis. A search of Medline, Lilacs, Embase, Cochrane Central Register of Controlled Trials and Grey literature (Google Scholar and British Library) was conducted. The medical subject headings (MeSHs) and the words “leptospirosis”, “human leptospirosis” and “IgM ELISA” were used. Fifty-two studies were analyzed, which included 10,775 samples. The pooled sensitivity of all the studies was 86% (CI 95%, 85%-87%) and specificity was 90% (CI 95%, 89%-91%). In studies of the acute phase, the sensitivity and specificity were 84% (CI 95%, 82%-85%) and 91% (CI 95%, 90%-91%), respectively. In conclusion, IgM ELISA is sensitive for use as an initial screen for leptospiral infections.

Sero-epidemiology study of leptospirosis in febrile patients from Terai region of Nepal

BACKGROUND

Leptospirosis is a re-emerging zoonotic disease caused by pathogenic strains of bacteria belonging to genus Leptospira whose symptoms can range from mild clinical manifestations to a severe life threatening illness. This disease may be under-recognized in resource poor settings like Nepal where many clinical laboratories lack appropriate equipment, technology and personnel for proper diagnosis.

METHODS

We used IgM ELISA to estimate the sero-prevalence of leptospirosis in a group of febrile patients in a western region of Nepal. We also tested for possible co-infection with two other common febrile diseases endemic to Nepal including dengue and typhoid fever.

RESULTS

Among samples from 144 febrile patients, 30 (21%) were positive for leptospiral IgM. In univariate analysis, leptospirosis was significantly associated with being of working age (p = 0.019), farming (p = 0.045) and water and animal contact (p = 0.0001). Widal and dengue serological study showed that the majority of leptospirosis infections did not have an alternative diagnosis.

CONCLUSION

As indicated by the study, regular surveillance of animal reservoirs in collaboration with veterinary department and inclusion of leptospirosis as a differential diagnosis of febrile illness is thus recommended based on the current findings.

Evaluation of different serological assays for early diagnosis of leptospirosis in Martinique (French West Indies)

BACKGROUND

Leptospirosis is a potentially life-threatening but curable zoonosis whose prognosis depends on accurate and timely diagnosis. Because of its non-specific clinical presentation, laboratory testing is essential to confirm the diagnosis. Here, we aimed to assess the performance of two enzyme-linked immunosorbent assays (ELISAs) (ELISA Serion and ELISA-Hb Pasteur) and one immunodot (GenBio) using quantitative PCR (qPCR) as gold standard, instead of the traditional microscopic agglutination test, for the diagnosis of acute leptospirosis in an endemic area.

METHODOLOGY/PRINCIPAL FINDINGS

Between January 2011 and December 2012, a total of 122 patients were diagnosed with leptospirosis, as confirmed by qPCR at the University Hospital of Martinique. Among them, 103 had at least one serum sample available for analysis. Performance of each serological assay was evaluated according to days' post onset of symptoms (DPO) and local species diversity (which included L. santarosai, L. interrogans, L. kirschneri, L. borgpetersenii, L. noguchii, and L. kmetyi). Several thresholds were tested to optimize accuracy. When considering the manufacturer's threshold, the sensitivity of ELISA Serion, ELISA-Hb Pasteur and GenBio immunodot was 75%, 67% and 64%, while specificity was 92%, 98% and 100%, respectively. Moreover, the threshold optimization allowed a significant improvement in specificity for the ELISA Serion from 92% to 99% (p<0.05). During the first 5 DPO, sensitivities were 35%, 30% and 42% for ELISA Serion, ELISA-Hb Pasteur and GenBio immunodot, respectively. However, between 6─10 DPO, these sensitivities dramatically increased to reach 86%, 76% and 67%, respectively. Performances of the three assays were not affected by the species studied.

CONCLUSIONS/SIGNIFICANCE

All these serological assays showed the potential for diagnosing leptospirosis after (but not before) 6 days' post onset of symptoms. In a high prevalence setting, where highest specificities are needed, threshold optimizing should be performed for this purpose.

Poor performance of the rapid test for human brucellosis in health facilities in Kenya

Human brucellosis is considered to be an important but typically under-diagnosed cause of febrile illness in many low and middle-income countries. In Kenya, and throughout East Africa, laboratory diagnosis for the disease is based primarily on the febrile antigen Brucella agglutination test (FBAT), yet few studies of the diagnostic accuracy of this test exist. Assessment of the performance of the FBAT is essential for its appropriate clinical use, as well as for evaluating surveillance data reported by public health systems. To assess FBAT performance, we collected sera from people with symptoms compatible with brucellosis attending two health facilities in Busia County, Kenya. Sera were tested using the FBAT and results compared with those from the Rose Bengal Test (RBT), an assay with well-known performance characteristics. Positives on either test were confirmed using the classical serum agglutination test (SAT)-Coombs test combination and a rapid IgM/IgG lateral flow immunochromatography assay (LFA). A questionnaire focussing on known risk factors for exposure to Brucella spp. was also conducted, and relationships with FBAT positivity examined using logistic regression. Out of 825 recruited individuals, 162 (19.6%) were classified as positive using the FBAT. In contrast, only eight (1.0%) were positive using the RBT. Of the 162 FBAT positives, one (0.62%) had an atypical agglutination in SAT and three (1.9%) showed low Coombs titres. Out of 148 FBAT positive individuals tested using the LFA, five (3.4%) were IgM positive and none were IgG positive. Poor or no correlation was observed between FBAT results and most established risk factors for Brucella infection. We observed substantial disagreement between the FBAT and a number of well-known serological tests, with the majority of reactive FBAT results appearing to be false positives. Poor FBAT specificity, combined with a lack of confirmatory testing, strongly suggests overdiagnosis of brucellosis is common in this low prevalence setting. This is expected to have important economic impacts on affected patients subjected to the long and likely unnecessary courses of multiple antibiotics required for treatment of the disease.

Brucellosis is a debilitating disease of people caused by infection with one of a number of different Brucella species. In almost all cases, people acquire the infection through exposure to infected animals or contaminated animal products. Human brucellosis is well known for its wide range of symptoms, and is often clinically indistinguishable from other infectious diseases, such as malaria or typhoid. Diagnosing the disease therefore typically relies on laboratory tests. A wide range of tests are available, but little is known about the accuracy of the principal test used in Government health facilities in Kenya, the febrile Brucella agglutination test (FBAT). In this study, we identified people with symptoms compatible with brucellosis attending health centres in Kenya. By comparing results from the FBAT performed on samples collected from these individuals with the results from a range of well-established diagnostic tests, we were able to show that the FBAT produces large numbers of false positive results. We expect that this leads to a high levels of overdiagnosis of brucellosis in some parts of Kenya. Treatment of the disease involves multiple weeks of multiple antibiotics, and these incorrect diagnoses may have important and unnecessary negative impacts on affected patients.

Detection of Anti-Leptospira IgM Antibody in Serum Samples of Suspected Patients Visiting National Public Health Laboratory, Teku, Kathmandu

Leptospirosis is a globally distributed zoonosis with varied clinical outcomes and multiorgan involvement in humans. In this study conducted from July 2011 to December 2011, 178 serum samples from patients suspected of leptospirosis were tested by Panbio IgM ELISA at National Public Health Laboratory, Kathmandu, out of which 51 (28.65%) were positive for anti-Leptospira IgM antibody. Leptospirosis was more common in people in their 2nd and 3rd decades of their life which together comprised 56.86% of the total positive cases. Most of those tested positive were farmers followed by students and housewives. Both animal contact and water contact seemed to play significant roles in disease transmission. Symptoms were vague with the most common being fever, headache, myalgia, abdominal pain, vomiting, jaundice, and diarrhoea. Life style heavily dominated by agronomical and farming activities in Nepal is conducive to leptospirosis transmission. Leptospirosis seems to be a significant public health problem in Nepal but is underestimated. In resource poor countries like Nepal where laboratories performing MAT or maintaining cultures are rarely available, serological test like ELISA could well depict the scenario of the disease prevalence.

Comparison of the Estimated Incidence of Acute Leptospirosis in the Kilimanjaro Region of Tanzania between 2007-08 and 2012-14

Background

The sole report of annual leptospirosis incidence in continental Africa of 75–102 cases per 100,000 population is from a study performed in August 2007 through September 2008 in the Kilimanjaro Region of Tanzania. To evaluate the stability of this estimate over time, we estimated the incidence of acute leptospirosis in Kilimanjaro Region, northern Tanzania for the time period 2012–2014.

Methodology and Principal Findings

Leptospirosis cases were identified among febrile patients at two sentinel hospitals in the Kilimanjaro Region. Leptospirosis was diagnosed by serum microscopic agglutination testing using a panel of 20 Leptospira serovars belonging to 17 separate serogroups. Serum was taken at enrolment and patients were asked to return 4–6 weeks later to provide convalescent serum. Confirmed cases required a 4-fold rise in titre and probable cases required a single titre of ≥800. Findings from a healthcare utilisation survey were used to estimate multipliers to adjust for cases not seen at sentinel hospitals. We identified 19 (1.7%) confirmed or probable cases among 1,115 patients who presented with a febrile illness. Of cases, the predominant reactive serogroups were Australis 8 (42.1%), Sejroe 3 (15.8%), Grippotyphosa 2 (10.5%), Icterohaemorrhagiae 2 (10.5%), Pyrogenes 2 (10.5%), Djasiman 1 (5.3%), Tarassovi 1 (5.3%). We estimated that the annual incidence of leptospirosis was 11–18 cases per 100,000 population. This was a significantly lower incidence than 2007–08 (p<0.001).

Conclusions

We estimated a much lower incidence of acute leptospirosis than previously, with a notable absence of cases due to the previously predominant serogroup Mini. Our findings indicate a dynamic epidemiology of leptospirosis in this area and highlight the value of multi-year surveillance to understand leptospirosis epidemiology.

Leptospirosis is an infectious disease that causes a fever. It can be severe or fatal. Understanding how many people get leptospirosis helps to determine priorities in allocating resources for disease diagnosis, treatment, and prevention. There are few data about leptospirosis incidence in sub-Saharan African countries. The only mainland estimate is from northern Tanzania for the years 2007–08. To see if leptospirosis incidence had changed since 2007–08, we measured leptospirosis incidence in the same location in 2012–2014. To do this, we systematically approached people at two hospitals in the Kilimanjaro Region and tested them for leptospirosis. We adjusted the number of identified cases of leptospirosis found at the hospitals to account for people with fever who did not come to hospital for testing and care. We also adjusted for imperfect testing methods. We found that the number of people who developed leptospirosis annually had dropped from 75–102 cases per 100,000 people during 2007–08 to 11–18 cases per 100,000 people during 2012–14. Also, the subtype of leptospirosis responsible for the most cases during 2007–08 was not present during 2012–14. The number of people developing leptospirosis was not stable, highlighting the value of measuring how commonly leptospirosis occurs over several years.

Risk factors for leptospirosis seropositivity in slaughterhouse workers in western Kenya

OBJECTIVES

Leptospirosis has been documented in slaughterhouse workers around the world. Risk factors include smoking and drinking at work, and performing tasks such as cleaning offal. This paper examined risk factors for leptospirosis seropositivity in slaughterhouse workers in western Kenya.

METHODS

The study was conducted between May 2011 and October 2012. Questionnaires were used to collect information from workers on demographic data, health and hygiene practices in the slaughterhouse. A commercial ELISA detected antibodies to Leptospira spp. in serum samples and multilevel logistic regression analysis identified factors associated with leptospirosis seropositivity.

RESULTS

A total of 737 workers from 142 slaughterhouses were recruited. The seroprevalence of antibodies to Leptospira spp. was 13.4% (95% CI 11.1% to 16.1%). Risk factors included: having wounds (OR 3.1; 95% CI 1.5 to 6.1); smoking (OR 1.8; 95% CI 1.1 to 2.9); eating at work (OR 2.1; 95% CI 1.2 to 3.6); cleaning the offal (OR 5.1; 95% CI 1.8 to 15.0); and having a borehole for personal water use (OR 2.3; 95% CI 1.1 to 4.7). At the slaughterhouse level, risk factors included having a roof (OR 2.6; 95% CI 1.2 to 5.6) and drawing water from a well (OR 2.2; 95% CI 1.2 to 4.0). Protective factors included working in slaughterhouses where antemortem inspection was conducted (OR 0.6; 95% CI 0.4 to 1.0) and where workers wore protective aprons (OR 0.4; 95% CI 0.2 to 0.7).

CONCLUSIONS

This is the first report of leptospirosis seropositivity in slaughterhouse workers in Kenya. Potential risk factors were identified and this information can be used to educate workers regarding their disease risks and ways to prevent or reduce transmission.

Polymerase Chain Reaction: An Important Tool for Early Diagnosis of Leptospirosis Cases

INTRODUCTION

Various diagnostic methods like Microscopic Agglutination Test (MAT), IgM ELISA, Isolation of Leptospira from the clinical specimen, Rapid leptocheck tests etc., are available for diagnosis of leptospirosis. Polymerase Chain Reaction (PCR) is used for diagnosis of various diseases of infectious origin including leptospirosis but there is paucity of data about comparison of PCR with other available method of diagnosis of leptospirosis.

AIM

The aim of the study was to detect the leptospiral DNA by PCR method and to compare the results of PCR with other available diagnostic methods used for diagnosis of suspected leptospirosis cases in acute phase of illness.

MATERIALS AND METHODS

A total of 207 blood samples were obtained from suspected patients of leptospirosis admitted in New Civil Hospital, a tertiary care hospital in South Gujarat, during the period of July 2008 to November 2008. These blood samples were subjected to Rapid leptocheck, IgM ELISA, MAT test to detect (IgG or IgM) antibody level, Leptospira culture and PCR.

RESULTS

In early phase of the disease, Rapid leptocheck test gave 44% detection, but along with PCR seropositivity reached upto 71%. Detection rate by IgM ELISA was 59% which increased to 80% with PCR. By MAT seropositivity was 57% but combined seropositivity of MAT with PCR was 78%. Sensitivity and specificity of PCR as compared to MAT (Gold standard) was 52% and 79% respectively. Leptospira was not growing in culture.

CONCLUSION

In present study, PCR picked up to 50% of cases which were negative by other serological tests so these finding suggest that PCR should be used routinely in acute phase of disease.

Two-Color Lateral Flow Assay for Multiplex Detection of Causative Agents Behind Acute Febrile Illnesses

Acute undifferentiated febrile illnesses (AFIs) represent a significant health burden worldwide. AFIs can be caused by infection with a number of different pathogens including dengue (DENV) and Chikungunya viruses (CHIKV), and their differential diagnosis is critical to the proper patient management. While rapid diagnostic tests (RDTs) for the detection of IgG/IgM against a single pathogen have played a significant role in enabling the rapid diagnosis in the point-of-care settings, the state-of-the-art assay scheme is incompatible with the multiplex detection of IgG/IgM to more than one pathogen. In this paper, we present a novel assay scheme that uses two-color latex labels for rapid multiplex detection of IgG/IgM. Adapting this assay scheme, we show that 4-plex detection of the IgG/IgM antibodies to DENV and CHIKV is possible in 10 min by using it to correctly identify 12 different diagnostic scenarios. We also show that blue, mixed, and red colorimetric signals corresponding to IgG, IgG/IgM, and IgM positive cases, respectively, can be associated with distinct ranges of hue intensities, which could be exploited by analyzer systems in the future for making accurate, automated diagnosis. This represents the first steps toward the development of a single RDT-based system for the differential diagnosis of numerous AFIs of interest.

An evaluation of dark field microscopy, culture and commercial serological kits in the diagnosis of leptospirosis

CONTEXT

This study was conducted to analyze the clinical utility of various leptospira diagnostic modalities.

AIMS

To evaluate the role of dark field microscopy (DFM), culture, immunochromatography (IgM Leptocheck), IgM enzyme-linked immunosorbent assay (IgM ELISA), macroscopic slide agglutination test (MSAT) and microscopic agglutination test (MAT) in diagnosing leptospirosis in febrile patients.

SETTINGS AND DESIGN

Descriptive study conducted in a tertiary care hospital from January 2011 to April 2012.

SUBJECTS AND METHODS

Blood, urine and paired sera from 100 patients with clinical suspicion of leptospirosis (study group) were collected and subjected to DFM, culture, IgM Leptocheck, IgM ELISA and MSAT. Fifty randomly selected sera from febrile patients tested positive for infections other than leptospirosis (control sera) were also subjected to the aforementioned serological assays. All the leptospira seropositive samples were subjected to MAT.

STATISTICAL ANALYSIS USED

Positive predictive values (PPV) and coefficient of agreement (kappa).

RESULTS

None of the clinical samples showed positivity by DFM. Leptospira inadai was isolated from a urine sample. The seropositivity of IgM Leptocheck, IgM ELISA and MSAT was 16%, 46% and 47%, respectively. The PPV of these assays was 14.3%, 8.7% and 6.5%, respectively. Poor agreement was obtained among these assays. Only four study group leptospira seropositive samples were confirmed by MAT with Australis being the predominant serovar. None of the leptospira-positive control sera were confirmed by MAT.

CONCLUSIONS

DFM and culture have limited utility in diagnosing leptospirosis with serology being the mainstay. The present study shows discordant results with the commercially available serological kits. Further studies should be done to evaluate the various diagnostic modalities.

Lipopolysaccharide Specific Immunochromatography Based Lateral Flow Assay for Serogroup Specific Diagnosis of Leptospirosis in India

BACKGROUND

Leptospirosis is a re-emerging infectious disease that is under-recognized due to low-sensitivity and cumbersome serological tests. MAT is the gold standard test and it is the only serogroup specific test used till date. Rapid reliable alternative serogroup specific tests are needed for surveillance studies to identify locally circulating serogroups in the study area.

METHODS/PRINCIPAL FINDINGS

In the present investigation the serological specificity of leptospiral lipopolysaccharides (LPS) was evaluated by enzyme linked immunosorbent assay (ELISA), dot blot assay and rapid immunochromatography based lateral flow assay (ICG-LFA). Sera samples from 120 MAT positive cases, 174 cases with febrile illness other than leptospirosis, and 121 seronegative healthy controls were evaluated for the diagnostic sensitivity and specificity of the developed assays. LPS was extracted from five locally predominant circulating serogroups including: Australis (27.5%), Autumnalis (11.7%), Ballum (25.8%), Grippotyphosa (12.5%), Pomona (10%) and were used as antigens in the diagnostics to detect IgM antibodies in patients' sera. The sensitivity observed by IgM ELISA and dot blot assay using various leptospiral LPS was >90% for homologous sera. Except for Ballum LPS, no other LPS showed cross-reactivity to heterologous sera. An attempt was made to develop LPS based ICG-LFA for rapid and sensitive serogroup specific diagnostics of leptospirosis. The developed ICG-LFA showed sensitivity in the range between 93 and 100% for homologous sera. The Wilcoxon analysis showed LPS based ICG-LFA did not differ significantly from the gold standard MAT (P>0.05).

CONCLUSION

The application of single array of LPS for serogroup specific diagnosis is first of its kind. The developed assay could potentially be evaluated and employed for as MAT alternative.

Estimation of the sensitivity and specificity of a Leptospira spp. in-house ELISA through Bayesian modelling

The microscopic agglutination test (MAT) is still considered the gold standard for the diagnosis of leptospirosis, although studies have shown that the test is an imperfect gold standard for clinical samples and unsuitable for epidemiological studies. Here, test characteristics of an in-house ELISA were identified for both subclinical and clinical populations by Bayesian latent class models. A conditional dependence model for two diagnostic tests and two populations was adapted to analyse a clinical and a subclinical scenario, respectively. These Bayesian models were used to estimate the sensitivity and specificity of the in-house ELISA and the MAT as well as the prevalences. The Bayesian estimates of the in-house ELISA were: clinical sensitivity=83.0%, clinical specificity=98.5%, subclinical sensitivity=85.7% and subclinical specificity=99.1%. In contrast, the estimates of the MAT were: clinical sensitivity=65.6%, clinical specificity=97.7%, subclinical sensitivity 54.9% and subclinical specificity=97.3%. The results show the suitability of the in-house ELISA for both clinical investigations and epidemiological studies in mildly endemic areas.

Evaluation of two immunodiagnostic tests for early rapid diagnosis of leptospirosis in Sri Lanka: a preliminary study

BACKGROUND

Leptospirosis is often treated based on clinical diagnosis. There is a need for rapid laboratory diagnosis for this condition. The aim of this study was to compare the diagnostic accuracy of two rapid IgM based immunodiagnostic assays with the microscopic agglutination test (MAT), in acute leptospirosis infection.

METHODS

MAT, IgM based immunochromatographic test (Leptocheck-WB) and IgM ELISA were performed using acute sera of patients clinically suspected to have leptospirosis (n = 83). Bayesian latent class modeling was used to compare the accuracy of these tests.

RESULTS

Percentage positivity for MAT, Leptocheck-WB, and IgM ELISA were 48.1, 55.3, and 45.7 % respectively. Bayesian latent class modeling showed a combined positivity rate of leptospirosis of 44.7 %. The sensitivity of MAT, Leptocheck-WB and IgM ELISA were 91.4, 95 and 81.1 %, and specificity were 86.7, 76.4 and 83.1 %, respectively.

CONCLUSIONS

Leptocheck-WB has high sensitivity, and, because it is quick and easy to perform, would be a good screening test for acute leptospirosis infection. IgM ELISA has good specificity, and is comparable with MAT; given that it is easier to perform and more widely available than MAT, it would be a more appropriate confirmatory test for use in hospitals with limited access to a specialized laboratory.

Diagnosis of Leptospirosis: Comparison between Microscopic Agglutination Test, IgM-ELISA and IgM Rapid Immunochromatography Test

BACKGROUND

Leptospirosis is diagnosed on clinical grounds, and confirmed by microscopic agglutination test (MAT). IgM-ELISA (Serion-Virion) and immunochromatography test (Leptocheck-WB) are two immunodiagnostic assays for leptospirosis. Their sensitivity, specificity and applicability in Sri Lanka have not been systematically evaluated.

METHODS

Clinically diagnosed leptospirosis patients (n = 919) were recruited from three hospitals in the Western Province of Sri Lanka, during June 2012 to December 2013. MAT, IgM-ELISA and Leptocheck-WB were performed on all patient sera. MAT titer of ≥ 400 in single sample, four-fold rise or seroconversion ≥ 100 in paired samples were considered as positive for MAT. For diagnostic confirmation, MAT was performed during both acute and convalescent phases. Anti-leptospiral IgM ≥ 20 IU/ml and appearance of a band in the test window were considered as positive for IgM-ELISA and Leptocheck-WB test respectively. Patients with an alternative diagnosis (n = 31) were excluded. Data analysis was performed using two methods, i) considering MAT as reference standard and ii) using Bayesian latent class model analysis (BLCM) which considers each test as imperfect.

RESULTS

MAT, IgM-ELISA and Leptocheck-WB positivity were 39.8%, 45.8% and 38.7% respectively during the acute phase. Acute-phase MAT had specificity and sensitivity of 95.7% and 55.3% respectively, when compared to overall MAT positivity. IgM-ELISA and Leptocheck-WB had similar diagnostic sensitivity when compared with acute-phase MAT as the gold standard, although IgM-ELISA showed higher specificity (84.5%) than Leptocheck-WB (73.3%). BLCM analysis showed that IgM-ELISA and Leptocheck-WB had similar sensitivities (86.0% and 87.4%), while acute-phase MAT had the lowest sensitivity (77.4%). However, acute-phase MAT had high specificity (97.6%), while IgM-ELISA and Leptocheck-WB showed similar but lower specificity (84.5% and 82.9%).

CONCLUSIONS

Both IgM-ELISA and Leptocheck-WB shows similar sensitivities and specificities. IgM-ELISA may be superior to MAT during the acute phase and suitable for early diagnosis of leptospirosis. Leptocheck-WB is suitable as a rapid immunodiagnostic screening test for resource limited settings.

Molecular Detection of Leptospira in Two Returned Travelers: Higher Bacterial Load in Cerebrospinal Fluid Versus Serum or Plasma

Leptospirosis is a potentially severe illness in returned travelers. Patients often present with fever, headache, and neck pain, which may lead to a workup for meningitis including the acquisition of cerebrospinal fluid (CSF). Although Leptospira DNA has been detected in CSF by polymerase chain reaction (PCR), little data exist regarding the utility of testing CSF in addition to serum or plasma obtained on presentation. In this report, we present two cases of leptospirosis in returned travelers presenting with fever and headache. Our first patient had neutrophilic meningitis, and Leptospira was detectable only in CSF obtained on admission. The second patient had a normal CSF profile, but Leptospira was detected in CSF at a bacterial load 5- to 10-fold higher than that in plasma. CSF is an important specimen for the diagnosis of Leptospira by molecular methods and may yield an actionable diagnosis in the absence of leptospiremia.

Neglected bacterial zoonoses

Bacterial zoonoses comprise a group of diseases in humans or animals acquired by direct contact with or by oral consumption of contaminated animal materials, or via arthropod vectors. Among neglected infections, bacterial zoonoses are among the most neglected given emerging data on incidence and prevalence as causes of acute febrile illness, even in areas where recognized neglected tropical diseases occur frequently. Although many other bacterial infections could also be considered in this neglected category, five distinct infections stand out because they are globally distributed, are acute febrile diseases, have high rates of morbidity and case fatality, and are reported as commonly as malaria, typhoid or dengue virus infections in carefully designed studies in which broad-spectrum diagnoses are actively sought. This review will focus attention on leptospirosis, relapsing fever borreliosis and rickettsioses, including scrub typhus, murine typhus and spotted fever group rickettsiosis. Of greatest interest is the lack of distinguishing clinical features among these infections when in humans, which confounds diagnosis where laboratory confirmation is lacking, and in regions where clinical diagnosis is often attributed to one of several perceived more common threats. As diseases such as malaria come under improved control, the real impact of these common and under-recognized infections will become evident, as will the requirement for the strategies and allocation of resources for their control.

Features of two new proteins with OmpA-like domains identified in the genome sequences of Leptospira interrogans

Leptospirosis is an acute febrile disease caused by pathogenic spirochetes of the genus Leptospira. It is considered an important re-emerging infectious disease that affects humans worldwide. The knowledge about the mechanisms by which pathogenic leptospires invade and colonize the host remains limited since very few virulence factors contributing to the pathogenesis of the disease have been identified. Here, we report the identification and characterization of two new leptospiral proteins with OmpA-like domains. The recombinant proteins, which exhibit extracellular matrix-binding properties, are called Lsa46 - LIC13479 and Lsa77 - LIC10050 (Leptospiral surface adhesins of 46 and 77 kDa, respectively). Attachment of Lsa46 and Lsa77 to laminin was specific, dose dependent and saturable, with KD values of 24.3 ± 17.0 and 53.0 ± 17.5 nM, respectively. Lsa46 and Lsa77 also bind plasma fibronectin, and both adhesins are plasminogen (PLG)-interacting proteins, capable of generating plasmin (PLA) and as such, increase the proteolytic ability of leptospires. The proteins corresponding to Lsa46 and Lsa77 are present in virulent L. interrogans L1-130 and in saprophyte L. biflexa Patoc 1 strains, as detected by immunofluorescence. The adhesins are recognized by human leptospirosis serum samples at the onset and convalescent phases of the disease, suggesting that they are expressed during infection. Taken together, our data could offer valuable information to the understanding of leptospiral pathogenesis.

Validation of a microsphere immunoassay for serological leptospirosis diagnosis in human serum by comparison to the current gold standard

A microsphere immunoassay (MIA) utilising Luminex xMap technology that is capable of determining leptospirosis IgG and IgM independently was developed. The MIA was validated using 200 human samples submitted for routine leptospirosis serology testing. The traditional microscopic agglutination (MAT) method (now 100 years old) suffers from a significant range of technical problems including a dependence on antisera which is difficult to source and produce, false positive reactions due to auto-agglutination and an inability to differentiate between IgG and IgM antibodies. A comparative validation method of the MIA against the MAT was performed and used to determine the ability of the MIA to detect leptospiral antibodies when compared with the MAT. The assay was able to determine samples in the reactive, equivocal and non-reactive ranges when compared to the MAT and was able to differentiate leptospiral IgG antibodies from leptospiral IgM antibodies. The MIA is more sensitive than the MAT and in true infections was able to detect low levels of antibody in the later stages of the acute phase as well as detect higher levels of IgM antibody earlier in the immune phase of the infection. The relatively low cost, high throughput platform and significantly reduced dependency on large volumes of rabbit antisera make this assay worthy of consideration for any microbiological assay that currently uses agglutination assays.

Leptospirosis is a zoonotic disease caused by spirochaetes of the genus Leptospira and affects millions of people, worldwide, each year. Laboratory diagnosis of leptospirosis currently relies on methods that are flawed in many areas. Current methods are outdated, time consuming and expensive. They rely on a continuous supply of animal products (rabbit anti-sera) and require specialist expertise and equipment. The current gold standard diagnostic assay for leptospirosis (MAT) cannot determine IgG from IgM antibodies and relies on live cultures, which presents problems in the way of maintenance and attenuation. Development of a new diagnostic assay for serological diagnosis of leptospirosis that is specific, sensitive and able to discriminate between IgG and IgM classes of antibodies—as well as being more cost effective—will significantly improve the capabilities for detecting leptospirosis infections. It will provide medical professionals with more valuable diagnostic information and public health professionals with improved epidemiological information.

To evaluate the different rapid screening tests for diagnosis of leptospirosis

INTRODUCTION

Leptospirosis is an acute febrile disease, in tropical and sub-tropical regions of world. It has been under-reported in India, due to presence of non-specific symptoms and unavailability of appropriate laboratory diagnostic facilities in most part of the country. The diagnosis of leptospirosis is usually based on demonstration of antibodies by different serological tests.

AIM

The present study aims to evaluate and compare commercially available rapid test.

DESIGN AND SETTINGS

Case control study.

MATERIALS AND METHODS

Three screening tests (Leptocheck WB, Latex agglutination test and SD leptospira) were compared by using 100 serum samples randomly obtained from clinical cases of Leptospirosis admitted in new civil hospital, Surat, Gujarat. All the patients with acute Leptospirosis were included in this 4-months pilot study from July 2011 to October 2011. All the results were compared with IgM ELISA and MAT for confirmation of diagnosis.

RESULTS

Leptocheck WB, Latex agglutination test and SD leptospira had sensitivities of 84.8%, 84.8% and 72.7% & specificities of 37.3%, 71.2% and 71.2% respectively as compared to MAT. Leptocheck WB, Latex agglutination test and SD leptospira had sensitivities of 90.7%, 89.7% and 53.7% & specificities of 93.4%, 90.9% and 60% respectively as compared to IgM ELISA.

CONCLUSION

Latex agglutination test kit and Leptocheck WB were found to be highly sensitive and specific. Neither of these tests require specialized equipment, and could be performed in peripheral laboratories with relatively little expertise.