Leptospirosis in Indonesia: diagnostic challenges associated with atypical clinical manifestations and limited laboratory capacity

Unraveling Sociocultural Influences on Leptospirosis Incidence and Prevalence: A Qualitative Study in Sri Lanka

This study aimed to explore sociocultural determinants that might contribute to the increased prevalence and incidence of leptospirosis, and how those determinants can also hinder health promotion interventions, particularly in rural areas of Sri Lanka. Even though several epidemiological studies have been conducted on leptospirosis in the Asia-Pacific region, the sociocultural background of this disease has not received sufficient attention. Therefore, through a qualitative study involving nine public health officials and 25 infected patients in five selected health administrative divisions, we demonstrate that a set of certain sociocultural determinants influence leptospirosis incidence and its prevalence. The thematic analysis generated six themes: a lack of knowledge of the causes and consequences of leptospirosis, false illness interpretations, a lack of readiness for the disease, poor economic conditions, social capital failure, and issues within the health system at the community level. Overall, results suggest that awareness programs aimed at demystifying false interpretations of leptospirosis lie at the center of any health promotion interventions at the community level.

Feline leptospirosis prevalence worldwide: A systematic review and meta-analysis of diagnostic approaches

Background and Aim

Leptospirosis in felids (domestic and wild cats) presents an ongoing challenge in our understanding. Numerous studies have reported the detection of Leptospira spp. in these feline populations, highlighting their potential as zoonotic carriers. This systematic review and meta-analysis aimed to provide insight into the global prevalence of leptospirosis in domestic and wild cats.

Materials and Methods

We conducted extensive searches across five databases (PubMed, Scopus, Web of Science, Science Direct, and Google Scholar) following the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols guidelines. Random-effect meta-analyses were performed using R software version 4.3.0 to estimate pooled prevalence rates. Subgroup meta-analyses were conducted based on continents, diagnostic methods, sample types, and wildcat genera.

Results

A total of 71 articles on leptospirosis in domestic cats and 23 articles on leptospirosis in wild cats met the eligibility criteria. Our findings indicated a significantly higher pooled seroprevalence of leptospirosis in domestic cats compared with infection prevalence (9.95% [95% confidence interval (CI), 7.60%-12.54%] vs. 4.62% [95% CI, 2.10%-7.83%], p = 0.01). In contrast, no significant difference was observed in pooled seroprevalence and infection prevalence among wild cats (13.38% [95% CI, 6.25%-21.93%] vs. 2.9% [95% CI, 0.00%-18.91%], p = 0.21). A subgroup meta-analysis of domestic cats revealed significant differences in seroprevalence across continents, sample types, and diagnostic methods. On the contrary, wild cats had no significant differences in any of the subgroups.

Conclusion

Leptospira spp. have evidently been exposed to both domestic and wild cats, highlighting their potential roles as reservoir hosts for leptospirosis. These findings highlight the importance of considering felids as a possible public health threat.

Severe mononeuritis multiplex as a rare case of neuro leptospirosis: A case report

Leptospirosis is a zoonotic bacterial disease caused by infection of spirochetes of the genus Leptospira. While typically self-limiting and non-fatal, severe manifestations can arise, including various neurological complications that are often overlooked. This case study presents a 59-year-old man with serologically positive Leptospirosis, who subsequently developed asymmetrical progressive leg weakness, severe back pain, and overflow incontinence suggestive of mononeuritis multiplex. Doxycycline treatment was started and intended to last for seven days. The patient had ongoing paraparesis, but all other problems were disappeared. The present case emphasizes the significance of identifying and treating neurological problems brought on by leptospirosis. To improve suitable treatment plans and patient outcomes, more research on these problems is necessary.

An investigation of geographical clusters of leptospirosis during the outbreak in Pangandaran, West Java, Indonesia

Leptospirosis is neglected in many tropical developing countries, including Indonesia. Our research on this zoonotic disease aimed to investigate epidemiological features and spatial clustering of recent leptospirosis outbreaks in Pangandaran, West Java. The study analysed data on leptospirosis notifications between September 2022 and May 2023. Global Moran I and local indicator for spatial association (LISA) were applied. Comparative analysis was performed to characterise the identified hotspots of leptospirosis relative to its neighbourhoods. A total of 172 reported leptospirosis in 40 villages from 9 sub-districts in Pangandaran District were analysed. Of these, 132 cases (76.7%) were male. The median age was 49 years (interquartile range [IQR]: 34-59 years). Severe outcomes including renal failure, lung failure, and hepatic necrosis were reported in up to 5% of the cases. A total of 30 patients died, resulting in the case fatality rate (CFR) of 17.4%. Moran's I analysis showed significant spatial autocorrelation (I=0.293; p=0.002) and LISA results identified 7 High-High clusters (hotspots) in the Southwest, with the total population at risk at 26,184 people. The hotspots had more cases among older individuals (median age: 51, IQR: 36-61 years; p<0.001), more farmers (79%, p=0.001) and more evidence of the presence of rats (p=0.02). A comprehensive One Health intervention should be targeted towards these high-risk areas to control the transmission of leptospirosis. More empirical evidence is needed to understand the role of climate, animals and sociodemographic characteristics on the transmission of leptospirosis in the area studied.

Global, regional, and country-level cost of leptospirosis due to loss of productivity in humans

BACKGROUND

Leptospirosis, a prevalent zoonotic disease with One Health priority and a disease of poverty, lacks global economic burden estimates. This study aims to determine the global, regional, and country-level cost of leptospirosis due to loss of productivity.

METHODOLOGY/PRINCIPAL FINDINGS

The cost of leptospirosis due to loss of productivity (referred to as productivity cost hereafter) was estimated by converting the disability-adjusted life years (DALYs) lost due to leptospirosis to a monetary value using the per capita gross domestic product (GDP). The country-specific DALYs lost were obtained from the global burden of leptospirosis study published previously. Non-health GDP per capita (GDP- per capita health expenditure) was used for the cost conversion of DALYs. Country-specific GDP and health expenditure data were obtained from the World Bank data repositories. Estimates were done using both nominal and international dollars. The estimated global productivity cost of leptospirosis in 2019 was Int$ 29.3 billion, with low and high estimates ranging from Int$ 11.6 billion to 52.3 billion. China (Int$ 4.8 billion), India (Int$ 4.6 billion), Indonesia (Int$ 2.8 billion), Sri Lanka (Int$ 2.1 billion), and the United States (Int$ 1.3 billion) had the highest productivity cost due to leptospirosis. Eight out of 10 countries with the highest burden were in the Asia-Pacific region. In addition, lower-middle-income countries had an annual productivity cost of Int$ 13.8 billion, indicating that the disease is poverty-related.

CONCLUSION

Although significant, the cost estimate due to loss of productivity is merely a fraction of the overall economic burden of this disease, which also includes other direct, indirect, and intangible costs. The existing partial estimates of the different components of economic cost suggest a profound economic burden that demands the inclusion of leptospirosis in the global health agenda for comprehensive disease control and prevention efforts, including vaccine development.

Development and evaluation of polyclonal antibody-based antigen detection ELISA and dot blot assays as a less costly diagnostic alternative for pathogenic Leptospira infection

Leptospirosis is an infectious, zoonotic disease of worldwide distribution, the cause of which is infection by pathogenic Leptospira. In Chile, dairy cattle are recognized a significant source in the maintenance and transmission of this infection, which causes economic losses and represents an infection threat to workers in the dairy industry. The infection is underestimated in cattle, due to the lack of clinical, pathognomonic signs, as well as the low efficiency of current diagnostic techniques. In this study, we developed antigen ELISA and dot blot assays, based on polyclonal antibodies, to detect pathogenic Leptospira in the urine samples of dairy cattle. The proposed tests showed an acceptable diagnostic accuracy, based on an analytical sensitivity of 1·10⁴ Leptospira per mL for ELISA, and 3.2·10³ for dot blot. These results corresponded with those obtained by qPCR, and the use of urine samples allowed us to propose new diagnostic alternatives for pathogenic Leptospira infection at a low cost, which can provide information on active infection status, which is a key element in control programs both at individual and herd level.

Cerebral infarct induced by severe leptospirosis-a case report and literature review

BACKGROUND

Although most leptospirosis is mild, the severe form can cause multiple complications, with a fatality rate of over 50% even with ICU support. The clinical manifestations of leptospirosis vary depending on organs and tissues involved. Both cerebral artery and coronary artery can be damaged by leptospirosis. Although cerebral arteritis induced by leptospirosis has been reported, cerebral infarction caused by leptospirosis is rarely reported.

CASE PRESENTATION

We report the case of a 79-year-old man admitted to intensive care unit (ICU) because of 3 days duration of fever, bloody sputum and dyspnea. Five days before he was admitted to hospital, he had harvested rice in flooded fields. After admission, leptospira interrogans DNA sequence was identified in bronchoalveolar lavage fluid (BALF) by next-generation sequencing (NGS). Microscopic agglutination test (MAT) showed the serum antibody of Mini serovars was 1,600 and Hebdomadis serovars was 800. On the eighth day of admission, the patient noted left hemiplegia. Cranial CT scan revealed low-density shadow in the right basal ganglia, so cerebral infarction was diagnosed. The patient's condition rapidly deteriorated and he died on the eleventh day of admission despite penicillin treatment, invasive mechanical ventilation and continuous renal replacement support.

CONCLUSION

Neurologic leptospirosis manifested as cerebral occlusion, although rare, might be deadly and should not be ignored.

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

Background

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

Design

Cress-sectional retrospective study.

Settings

Tertiary care teaching hospitals in Kelantan, Peninsular Malaysia.

Participants

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

Results

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

Conclusions

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

Comparative genomic analysis of Leptospira spp. isolated from Rattus norvegicus in Indonesia

Leptospirosis is one of the most prevalent zoonotic diseases caused by pathogenic spirochetes of Leptospira spp. The disease has become a public health concern in urban localities in the tropics, where rats serve as significant reservoir animals for leptospirosis transmission. In Indonesia, the occurrence of leptospirosis is underestimated, and information on the causative Leptospira genotypes and serotypes is limited. This study reports the isolation of Leptospira spp. from rats captured in urban areas of Bogor, Indonesia. Serogroups and genotypes, sequence types (STs), or multiple-locus variable-number tandem repeat analysis (MLVA) types using 11 loci, were determined for the isolates. Furthermore, whole genome sequencing (WGS) was performed on 11 Indonesian isolates and 24 isolates from other Asian countries. Ninety small mammals, including 80 Rattus norvegicus and ten Suncus murinus, were captured and, 25 Leptospira spp. were isolated solely from R. norvegicus (31.3%). The isolates were identified as Leptospira borgpetersenii serogroup Javanica with ST 143 (four strains) and Leptospira interrogans serogroup Bataviae with the same MLVA type as isolates from other Asian countries (19); the serogroup of the two L. interrogans with ST252 could not be identified. The core genome SNP-based phylogenetic tree revealed that Indonesian isolates were genetically related to L. borgpetersenii serogroup Javanica strains widely distributed in Asian countries but formed a different cluster from other strains. The phylogenetic tree of L. interrogans serogroup Bataviae isolates from Indonesia, the Philippines, Taiwan, and Vietnam revealed that isolates were grouped into five clusters based on their geographic locations. This study discovered a high carriage rate of Leptospira spp. among R. norvegicus in Bogor, Indonesia, indicating a potential risk of rat-borne leptospirosis in the area. Besides L. borgpetersenii serogroup Javanica, WGS on L. interrogans serogroup Bataviae illustrated the geographical structuring of genetic diversity in Leptospira spp.

Going Micro in Leptospirosis Kidney Disease

Leptospirosis is a zoonotic and waterborne disease worldwide. It is a neglected infectious disease caused by Leptospira spp., as well as a reemerging disease and global public health problem with respect to morbidity and mortality both in humans and animals. Leptospirosis emerges as a leading cause of acute febrile illness along with hepatorenal injury in many countries, including Thailand. While most affected persons are symptomatic in acute disease, which is always difficult to differentiate from other tropical diseases, there is growing evidence of subtle manifestations that cause unrecognized chronic symptoms. The kidney is one of the common organs affected by Leptospires. Although acute kidney injury in the spectrum of interstitial nephritis is a well-described characteristic in severe leptospirosis, chronic kidney disease from leptospirosis is widely discussed. Early recognition of severe leptospirosis leads to reduce morbidity and mortality. Thus, in this review, we highlight the spectrum of characteristics involved in leptospirosis kidney disease and the use of serologic and molecular methods, as well as the treatments of severe leptospirosis.

Leptospirosis with pulmonary haemorrhage and multiple organ failure: a case report and literature review

Pulmonary haemorrhage is an important complication of leptospirosis. We herein report an uncommon case of severe pulmonary haemorrhage and multiple organ failure caused by leptospirosis in a 49-year-old man who was previously healthy. He was a farm worker who was admitted to the hospital because of haemoptysis. He had worked in a paddy field 4 days prior to admission. Chest computed tomography revealed pulmonary haemorrhage, which rapidly deteriorated into haemorrhagic shock and multiple organ failure. Based on the patient’s possible history of contact with contaminated water and the DNA sequence of Leptospira detected in his bronchoalveolar lavage fluid, the patient was diagnosed with pulmonary haemorrhagic leptospirosis. Despite the administration of a fluid bolus, norepinephrine, broad-spectrum antibiotics, and haemostatics, and even with administration of a blood transfusion and extracorporeal life support, the pulmonary haemorrhage could not be controlled effectively. The patient eventually died of haemorrhagic shock. Leptospirosis can be a life-threatening disease despite aggressive treatment, even with extracorporeal life support. Next-generation sequencing can provide important diagnostic clues for patients with atypical leptospirotic symptoms.

Leptospirosis in Ruminants in Yogyakarta, Indonesia: A Serological Survey with Mixed Methods to Identify Risk Factors

Leptospirosis is a zoonotic disease occurring worldwide with reproductive symptoms and production losses in livestock, while humans can suffer fatal renal failure. In Yogyakarta Special Province, Indonesia, there have been several outbreaks with high case fatality, demonstrating the public health importance, but there is limited understanding of the epidemiology. This study used an EcoHealth approach to ensure transdisciplinarity and community participation. Seroprevalence of Leptospira in animals was studied between October 2011 and May 2013 in 15 villages. Serum samples from 1404 cattle and 60 small ruminants were screened by a Microscopic Agglutination Test (MAT), first in pools, and then the individual positive samples were identified. Focus group discussions including farmers, village officials, and official stakeholders were used to explore knowledge and behavior of zoonotic diseases, particularly leptospirosis. Two small ruminants were seropositive for Leptospira icterohemorrhagiae. From the cattle, 3.7% were seropositive, and the most common serovars were Leptospira hardjo, followed by L. icterohemorrhagiae. Out of all farms, 5.6% had at least one positive cattle. Risk factor analyses showed that the risk of the farm being seropositive increased if the farmer used water from an open source, or if farming was not the main occupation. This study showed the presence of Leptospira spp. in ruminants in Yogyakarta and identified use of open water as a risk factor for the livestock. We also observed that the knowledge related to leptospirosis was low, and risky farm management practices were commonly employed.

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.