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Here, we report a case of a 64-year-old man with severe leptospirosis infected in an area in Japan that is non-endemic to leptospirosis. Initially, findings of high-grade fever, mild generalised arthralgia, rashes on the trunk, mild thrombocytopenia, elevated liver enzymes and renal dysfunction led to the suspicion of rickettsiosis, which was an endemic infectious disease in the area. Subsequently, leptospirosis was also considered after carefully reviewing patient history, which revealed that he may have been exposed to mice urine. Finally, leptospirosis was diagnosed after the serum indicated a positive PCR for leptospirosis. Furthermore, due to serum antibody positivity for Rickettsia japonica , false-positivity or coinfection of spotted fever rickettsiosis was suspected. Despite the delayed diagnosis, the patient recovered with antibiotic treatment. Thus, to prevent diagnostic errors, leptospirosis should be potentially considered with high suspicion in patients with acute undifferentiated fever, even in non-endemic areas of leptospirosis., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Leptospirosis is one of the most common travel-related infections. We report 5 cases of travel-related leptospirosis who presented at our clinic between January 2008 and December 2013. Patients were included in the study if they presented with a clinical profile that was compatible with the disease within 21 days of their return from traveling, which were laboratory-diagnosed as leptospirosis by blood culture, rise in antibody titers in paired sera using the microscopic agglutination test (MAT), and/or DNA detection using flaB-nested PCR. Five leptospirosis cases were evaluated, all of which contracted the disease after exposure to fresh water in Southeast Asian countries. All of the cases had fevers, headaches, conjunctival injections, and relative bradycardia. The pertinent laboratory findings included elevated C-reactive protein levels, elevated creatinine levels, and sterile pyuria. All 5 cases had serum MAT titers that increased by ≥ 4 times in the interval between specimens taken during the acute phase and those taken during the convalescence phase, and leptospiral DNA was detected in plasma and/or urine specimens in 4 cases. Leptospira interrogans was isolated from one patient's blood sample. Patients were treated with penicillin G, minocycline, or doxycycline. One case was cured without antibiotics. A diagnosis of leptospirosis should be considered for febrile travelers who return from Southeast Asian countries to Japan after being exposed to freshwater while traveling., (Copyright © 2014 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Leptospirosis is not a major disease in urban areas of Japan. We describe a 49-year-old man with leptospirosis, who lived in an urban area and had no history of living in endemic area of leptospirosis. As he worked at a fish market infested with rats, he was suspected of having contracted leptospirosis and received antimicrobial agent treatment. Serum and urinary tests confirmed the diagnosis of leptospirosis. Although it took six days from the onset until treatment initiation, the patient improved in response to receiving ceftriaxone for seven days. Analyzing past reports of Japanese patients with leptospirosis who had no history of overseas travel, we identified 90 patients with courses similar to that of our patient, and the period from onset to treatment initiation was about six days on average (described in 46 cases). Health care providers as well as patients need to recognize that even people with no history of being in an endemic area of leptospirosis may still be at risk of developing this disease depending on occupations and activities., (Copyright © 2013 Japanese Society of Chemotherapy and the Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

We diagnosed leptospirosis in 2 patients exposed to southern flying squirrels imported from the United States to Japan. Patients worked with exotic animals in their company. Leptospira isolates from 1 patient and 5 of 10 squirrels at the company were genetically and serologically identical and were identified as Leptospira kirschneri.