Overview
Definition:
Leptospirosis is a systemic infection caused by pathogenic spirochetes of the genus Leptospira
In tropical exposures, it frequently presents with hepatic involvement leading to jaundice, a severe manifestation often termed Weil's disease.
Epidemiology:
Endemic in tropical and subtropical regions worldwide, particularly in areas with poor sanitation, heavy rainfall, and close contact with animal reservoirs (rodents, livestock)
Peak incidence often coincides with monsoon seasons
Pediatric cases are reported globally but are more common in agricultural and flood-prone communities.
Clinical Significance:
Leptospirosis is a significant cause of acute febrile illness and jaundice in children returning from or residing in endemic areas
Early recognition and prompt management are crucial to prevent severe complications like acute kidney injury, hepatic failure, and pulmonary hemorrhage, which can be life-threatening.
Clinical Presentation
Symptoms:
Sudden onset fever
Severe headache, often retro-orbital
Myalgia, particularly in the calves and lumbar region
Conjunctival suffusion without exudate
Nausea and vomiting
Abdominal pain
Progressive jaundice
Oliguria or anuria
Hemorrhagic manifestations like epistaxis, purpura, or hematemesis may occur.
Signs:
Fever >38.5°C
Tachycardia
Icteric sclera and skin
Hepatomegaly, often tender
Splenomegaly may be present
Signs of dehydration
Possible meningeal irritation
Evidence of acute kidney injury (reduced urine output, edema)
Pulmonary crackles or signs of respiratory distress in severe cases.
Diagnostic Criteria:
No single universally accepted pediatric diagnostic criteria for leptospirosis
diagnosis is based on a combination of epidemiological risk, clinical features, and laboratory confirmation
The criteria for Weil's disease (severe leptospirosis) typically include jaundice, renal impairment, and hemorrhage.
Diagnostic Approach
History Taking:
Detailed travel history to or residence in endemic areas
Exposure to contaminated water or soil (swimming, wading, farming, cleaning drains)
Contact with animal urine (rodents, dogs, cattle)
History of recent floods or heavy rainfall
Onset and progression of symptoms
Prodromal symptoms
Previous similar episodes.
Physical Examination:
Thorough systemic examination focusing on vital signs, hydration status, presence of jaundice, liver and spleen size, presence of edema, and signs of bleeding or respiratory distress
Neurological examination for meningeal signs or altered mental status.
Investigations:
Leptospira serology (MAT - microscopic agglutination test is gold standard, ELISA, IgM antibodies) - typically positive after 7-10 days
PCR on blood or urine during early illness
Complete blood count (CBC) with differential, platelet count
Liver function tests (LFTs) - elevated bilirubin (predominantly conjugated), elevated ALT/AST, elevated alkaline phosphatase
Renal function tests (RFTs) - elevated BUN/creatinine
Urinalysis - proteinuria, hematuria, casts
Coagulation profile if bleeding is present
Chest X-ray if pulmonary involvement suspected.
Differential Diagnosis:
Viral hepatitis (Hepatitis A, E)
Dengue fever
Malaria
Typhoid fever
Rickettsial infections
Hemolytic uremic syndrome (HUS)
Drug-induced liver injury
Sepsis with multi-organ dysfunction
Yellow fever
G6PD deficiency with hemolysis.
Management
Initial Management:
Supportive care is paramount
Fluid resuscitation for dehydration
Monitoring of vital signs, urine output, and electrolyte balance
Aggressive management of multi-organ failure.
Medical Management:
Antibiotics are indicated in suspected or confirmed cases, especially in severe illness, to reduce duration and severity
Penicillin G (IV) is the drug of choice for severe leptospirosis: 1-2 million units (or 25,000-50,000 U/kg/day) divided into 3-4 doses for 7-14 days
Alternatives for penicillin-allergic patients include doxycycline (oral, >8 years old) or azithromycin (oral/IV)
For milder cases, oral doxycycline or azithromycin may be used.
Surgical Management:
Rarely indicated
May be considered for complications like severe gastrointestinal bleeding requiring transfusion or, in extremely rare instances, hepatic transplantation if fulminant hepatic failure occurs.
Supportive Care:
Intensive monitoring in a hospital setting for severe cases
Management of electrolyte imbalances, acid-base disturbances
Nutritional support, often requiring nasogastric feeding or parenteral nutrition if oral intake is compromised
Management of renal failure with hemodialysis if indicated
Respiratory support with oxygen or mechanical ventilation if pulmonary involvement is significant.
Complications
Early Complications:
Acute kidney injury (AKI) - ranging from mild oliguria to anuria requiring dialysis
Hepatic dysfunction and jaundice - can be profound, leading to coagulopathy
Pulmonary hemorrhage and acute respiratory distress syndrome (ARDS)
Myocarditis
Meningitis/encephalitis
Rhabdomyolysis.
Late Complications:
Post-leptospirosis uveitis
Chronic meningitis
Hepatic granulomas
Renal scarring.
Prevention Strategies:
Avoidance of contact with contaminated water and soil, especially during monsoon season
Use of protective footwear in endemic areas
Rodent control measures
Public health education regarding risks and preventive behaviors
Prompt antibiotic treatment for exposed individuals in high-risk scenarios, though this is not standard practice for prophylaxis.
Prognosis
Factors Affecting Prognosis:
Age of the patient (younger children may have poorer outcomes), severity of initial illness, presence and severity of organ involvement (especially renal and pulmonary), promptness of diagnosis and initiation of treatment, presence of co-morbidities.
Outcomes:
With timely and appropriate management, many children recover fully
However, severe leptospirosis (Weil's disease) can have a mortality rate of 10-40% if untreated or inadequately managed
Survivors may have sequelae.
Follow Up:
Regular follow-up is essential for children who have had severe leptospirosis, particularly to monitor for renal function, liver enzyme levels, and any signs of ocular or neurological sequelae
Annual check-ups for a period of 1-2 years may be recommended.
Key Points
Exam Focus:
Leptospirosis is a zoonotic infection
Jaundice and renal failure are hallmarks of severe disease (Weil's disease)
Travel history to tropical/subtropical regions is a critical clue
Definitive diagnosis relies on serology (MAT) or PCR
Penicillin G is the drug of choice for severe illness.
Clinical Pearls:
Always consider leptospirosis in a febrile child with jaundice, especially with a history of potential exposure to contaminated water or animal urine in endemic areas
Conjunctival suffusion is a classic, albeit non-specific, sign
Early antibiotics can significantly alter the course of severe disease.
Common Mistakes:
Delayed diagnosis due to atypical presentation or lack of awareness
Inadequate antibiotic therapy (wrong drug, dose, or duration) in severe cases
Over-reliance on serology without considering the timing of sample collection
Failing to consider leptospirosis in the differential diagnosis of acute febrile jaundice in pediatric patients.