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Objective: Analysis of risk factors associated with severity in patients with confirmed leptospirosis., Design and Setting: Retrospective study in 147 leptospirosis-confirmed patients at two tertiary nonteaching hospital in Reunion Island., Patients: 138 men and 9 women, aged 36+/-14 years, 80 in the ICU and 67 in medical wards., Measurements and Results: We collected demographic, clinical, biological, and radiographic data and performed univariate and multivariate analysis to examine risk factors associated with admission in ICU and mortality. Pulmonary forms were more frequent (85%) than in previous reports, with 85 cases (65.3%) on abnormal chest radiography. Among the 38 patients who underwent bronchoalveolar lavage at admission 31 (81.5%) had alveolar hemorrhage. Independent factors related to ICU admission were: age over 46[Symbol: see text]years (OR 3.02), creatinine higher than 200[Symbol: see text]mumol/l (6.69), shock (13.87), and acute respiratory failure (20.69). Mortality was 12.9%. The only factor independently related to mortality was need for mechanical ventilation (OR 20.94). Icterohemorrhagiae serogroup was found in 62 cases (42.8%) but was not related to death., Conclusions: Pulmonary involvement is a major feature in leptospirosis disease but is not associated with poor outcome. Identification of clinical and laboratory findings on admission may help to better characterize severe cases.