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CONTEXT: To the best of our knowledge, there are no reports of serological evidence of human leptospirosis from Uttarakhand state in India. AIMS: The aim of this study was to screen for serological evidence of leptospirosis in patients with acute undifferentiated febrile illness at a tertiary care teaching hospital in Uttarakhand. SETTINGS AND DESIGN: A pilot study was conducted from March to November 2017. SUBJECTS AND METHODS: Fifty-three adult patients who presented in Medicine outpatient Department with a history of fever of ≥7 up to 14 days duration with or without other associated symptoms such as a headache, rashes, myalgia, arthralgia, and conjunctival suffusion were enrolled in the study using convenience sampling technique. Blood samples of these patients were collected and subjected to peripheral smear examination for malaria parasites, dengue immunoglobulin M (IgM) immunochromatographic card test, IgM Typhidot, Leptospira and Scrub typhus IgM ELISA, respectively. Aerobic blood culture was performed in 24 cases. Relevant clinico-epidemiological details were obtained as per the pro forma formulated in accordance with the modified Faine’s criteria. STATISTICAL ANALYSIS USED: Descriptive statistics. RESULTS: The study population consisted of 50.94% of males and 49.06% of females with a mean age ± standard deviation of 34.2 ± 15.2 years. Fifty febrile patients had additional symptoms of which myalgia was the most common (81.1%) followed by arthralgia (22.6%). Peripheral smears of all patients were negative for malaria parasites. Dengue and Typhidot IgM positivity was observed in two and eight patients, respectively. Six and five patients were tested positive by leptospira and scrub typhus IgM ELISA, respectively. Salmonella Typhi was isolated from blood sample of only one patient. Serum samples of two patients showed dual positivity. All six leptospira seropositive patients satisfied modified Faine’s criteria. CONCLUSIONS: Leptospirosis is a seemingly unexplored infection in Uttarakhand and should be considered as a differential diagnosis in patients with acute undifferentiated febrile illness.

Leptospirosis is a rodent-borne acute febrile illness, classically seen after heavy rainfall and floods. This study aimed to describe the clinical profile, management strategies and outcome of patients with leptospirosis amidst the Coronavirus disease-2019 outbreak. A prospective study of adult patients with undifferentiated fever (5-15 days) was conducted in South India between October 2020 and February 2021. The demographic, clinical details, laboratory details, treatment and outcome of leptospirosis positive (based on serology) and negative patients were compared. A chisquare test was used for qualitative variables, while an independent t-test or Mann Whitney U test was used for continuous variables. Of the 206 patients with suspected acute febrile illness, a total of 63 patients were diagnosed with leptospirosis based on serology results. The median sequential organ failure assessment score was higher in those with leptospirosis (p

Co-infections are common in tropical countries and can be present with the overlapping of clinical features. The diagnosis of co-infection poses a challenge to the treating physician. We report a varicella child who was presented with persisting fever even after the formation of scabs along with conjunctival suffusion. Her platelets were persistently less than 50000/mm3 for 3 days and her serology was positive for the dengue infection.

Zusammenfassung. Wir berichten über einen 52-jährigen Patienten, der sich mit Fieber, starken Muskelschmerzen, Ikterus, akuter Niereninsuffizienz, Anämie und Thrombozytopenie vorstellte. Aufgrund der Anamnese sowie der typischen Klinik konnte eine Leptospirose klinisch vermutet und mittels PCR diagnostiziert werden.

Leptospirosis is a common condition in Wallis and Futuna, and the definitive diagnosis needs to be established urgently at the first patient consultation, which is usually one to two days after the onset of clinical signs. As a diagnostic aid, a composite index was established based on data from 338 patients seen by the Wallis and Futuna admissions services between 2008 and 2015. The data taken into account include: age and sex of the patient, their home island, the consultation period and the results of leukocytes, platelets, CRP, creatinine and GGT tests combined with 2 major clinical signs, headache and conjunctival suffusion. Then 5 threshold limits were defined for this index, which indicates from very low risk to almost certain biologically confirmed leptospirosis. Other febrile diseases responsible for thrombocytopenia are not found in Wallis and Futuna, which probably explains the good statistical qualities of this index with a value of area under the curve equal to 0.821.

Leptospirosis is a disease condition of infected wild or domestic animals. Humans get this infection when they come in touch with the contaminated soil or water in the infected animal’s urine/excreta of animal reservoirs directly or indirectly. Water logging during rainy session, traditional cultivation with animals and water flow to the rivers are common in Assam. Those events may increase the risk of infection and that is why Lakhimpur and Dhemaji districts were choose for our study area as both districts are neighboring of hilly area (Arunachal Pradesh) and found maximum water logging. Blood samples were collected from the acute febrile patients reported to the laboratory for different tests like typhoid, japanese encephalitis (JE), dengue, malaria etc. Serums were obtained from the whole blood and selected only the JE, dengue, malaria, typhoid negative samples for our studys, Original Research Article Malakar et al.; IJTDH, 15(3): 1-5, 2016; Article no.IJTDH.25132 2 after the consent from the patients or attendance of the patients. The test results showed that 2.13% (16/750) patients were positive for leptospirosis. Where 12.5% (2/16) positive patients were from Dhemaji district and races were from Lakhimpur. Clinical finding represented fever 100% (16/16), headache 68.75% (11/16), myalgia 50% (8/16), conjunctival suffusion 6.25% (1/16), jaundice 12.5% (2/16), cardiac arrhythmia 12.5%(2/16), skin rash 6.25% (1/16), haemorrhage 6.25% (1/16), unconsciousness/semiconciousness 12.5% (2/16), nausea/vomiting 6.25% (1/16), and abdominal pain 6.25% (1/16) in the positive patients. This proves the prevalence of leptospirosis in the study districts of Assam. An awareness of disease transmission could minimize the disease risk.

Rationale: Bleeding in the anterior pituitary lobe leading to tissue necrosis occurs in the acute stage of severe clinical forms of hemorrhagic fever with renal syndrome (HFRS), while atrophy of the anterior pituitary lobe with diminution of the gland function occurs after the recovery stage. The relationship between Hantaan virus infection and empty Sella syndrome (ESS) has rarely been reported. Patient concerns: This patient was a 54-year-old previously healthy Chinese male. He presented with fever, headache, and backache with dizziness and oliguria. Physical examination was notable for hypotension and the signs of conjunctival suffusion. His platelets decreased, and his urine protein was positive. Hantaan virus IgM and virus RNA were positive. Diagnosis: He was diagnosed as having HFRS. In his diuretic phase, his 24-hour urine volume was maintained at 10,000 mL, and his blood pressure was higher for a week. Then, he was diagnosed as having ESS after a series of examinations. Interventions: Hormone replacement therapy was given to this patient after the diagnosis “ESS” was made. Outcomes: The patient's symptoms improved, and he was discharged from the hospital soon after hormone replacement therapy. Lessons: Pituitary function examination and brain magnetic resonance imaging (MRI) need to be considered to scan for ESS and panhypopituitarism in the patients with HFRS accompanied by diabetes insipidus.

Introduction: Measles is a highly contagious viral disease, which affects mostly children and rarely adults, which results in a more severe presentation. After a prodromal phase (malaise, anorexia, and the classic triad of conjunctivitis, cough, and coryza and a high fever), enanthem (Koplik spot) appears at buccal mucosa and then, typical erythematous maculopapular rash happens. There are several reports of atypical measles in the adults who have been immunized by killed type vaccine, therefore, prior history of vaccination with the original killed - virus among individuals who present with maculopapular rash and fever do not rule out measles. Case Presentation: Here we report a 44 - year - old woman with fever, chills, myalgia, odynophagia, exudative pharyngitis, bilateral parotitis, anterior cervical lymphadenopathy, tender splenomegaly, conjunctival suffusion and disseminated pruritic erythematous maculopapular, as well as a petechial rash all over her body. She was evaluated mainly for infectious mononucleosis, acute human immunodeficiency virus infection, and acute viral hepatitis, when all investigations were negative for possible diagnoses, although she mentioned immunization against measles, evaluations for measles were done and she had positive IgM antibody with high titer and also positive measles virus RT - PCR. Conclusions: The aim of this report is to emphasize that physicians should be aware of the atypical measles syndrome and entertain the diagnosis of measles in adults with a febrile illness and rash in order to make the most accurate diagnosis and prevent complications.

Leptospirosis is considered underdiagnosed because of its nonspecific presentation and lack of proper understanding of its epidemiology. Early diagnosis and treatment are crucial. However, few data are available on confirmed leptospirosis cases in children in industrialized countries. We therefore aimed to describe epidemiologic and clinical characteristics of laboratory-confirmed childhood leptospirosis in Okinawa, Japan. We reviewed the national surveillance data of pediatric leptospirosis in Okinawa, Japan from January 2003 through December 2015. The database included all of laboratory-confirmed leptospirosis diagnosed at the only central laboratory for leptospirosis in the region. There were 44 children (0–20 years of age) with laboratory-confirmed leptospirosis. Of these, 90% were male, 91% were 10–20 years of age, and 96% of cases occurred in August and September. The number of laboratory-confirmed patients ranged from 0 to 11 per year (mean: 3.3 per year), and the estimated annual rate was 1.0 per 100,000 pediatric populations. In all cases, the presumed infection route was recreational exposure to river water. Commonly observed manifestations include fever (95%), myalgia (52%), and conjunctival suffusion (52%). Childhood leptospirosis in Okinawa, Japan occurred predominantly in teenage boys after freshwater exposure in summer, and most patients had characteristic conjunctival suffusion. Cohort studies would be helpful to better understand more detailed clinical manifestations in association with prognosis., Author summary Leptospirosis is a bacterial disease that affects humans and animals. It is caused by Leptospira. Leptospira is a spiral-shaped Gram-negative spirochete with internal flagella, which enters the host through mucosa and broken skin. Leptospirosis is a worldwide zoonosis, but it is considered underdiagnosed because of its nonspecific presentation and lack of proper understanding of its epidemiology, especially in children. In human, it can cause a wide range of symptoms in acute phase include fever, chills, headache, muscle aches, vomiting, and diarrhea. Some of these symptoms can be observed in other febrile diseases such as typhoid fever, rickettsiosis, Kawasaki disease, and adenovirus infections. Although Leptospirosis can be deadly in severe, untreated cases, few data are available on leptospirosis in children, industrialized countries, and confirmed cases. This study conducted a population-based study to describe epidemiologic and clinical characteristics of childhood leptospirosis in a leptospirosis-endemic area in an industrialized country, Okinawa, Japan. This new knowledge may contribute to a better overall understanding of the Leptospirosis in children.

We present a case of Weil's disease complicated by a Jarisch-Herxheimer reaction (JHR) after initiation of antibiotics while in the emergency department requiring invasive monitoring and vasopressor support. The case is followed by a brief review of the JHR which is rarely observed with treatment of leptospirosis. A healthy 28-year-old female who recently returned from the Caribbean presented to the emergency department with flu-like symptoms. The patient appeared jaundiced with conjunctival suffusion and was ultimately treated with the appropriate antibiotics for leptospirosis in the ED. She decompensated subsequently, requiring supplemental oxygen, central and arterial line placement, and vasopressor support with norepinephrine. Although rarely encountered and not well reported throughout the literature, initiation of antibiotics can cause a JHR reaction given that Leptospira interrogans is a spirochete. This JHR may be self-limited and of short duration, or it can be prolonged and severe, requiring invasive therapies such as central line placement for vasopressor support and intubation. It is suggested that patients started on antibiotics for leptospirosis/Weil's disease should be monitored in the emergency department for a short duration prior to discharge or transfer to a regular medical floor for observation given the possibility for decompensation.

Leptospirosis, an infectious zoonosis, is common to tropical areas. The clinical presentation varies from flu-like symptoms to a serious presentation called Weil’s syndrome. Fever and conjunctival suffusion are present in the majority of patients. This case report describes a resident of New York City who presented initially with gastroenteritis symptoms without fever or conjunctival suffusion to develop septic shock before being diagnosed with leptospirosis. Keywords: Urban leptospirosis, Unusual presentation, Weil’s syndrome, Sepsis

Leptospira spp. are delicate bacteria that cannot be studied by usual microbiological methods. They cause leptospirosis, a zoonotic disease transmitted to humans through infected urine of wild or domestic animals. We studied the incidence of this disease in the Uruguayan population, its epidemiologic and clinical features, and compared diagnostic techniques. After examining 6,778 suspect cases, we estimated that about 15 infections/100,000 inhabitants occurred yearly, affecting mainly young male rural workers. Awareness about leptospirosis has grown among health professionals, and its lethality has consequently decreased. Bovine infections were probably the principal source of human disease. Rainfall volumes and floods were major factors of varying incidence. Most patients had fever, asthenia, myalgias or cephalalgia, with at least one additional abnormal clinical feature. 30-40% of confirmed cases presented abdominal signs and symptoms, conjunctival suffusion and altered renal or urinary function. Jaundice was more frequent in patients aged >; 40 years. Clinical infections followed an acute pattern and their usual outcome was complete recovery. Laboratory diagnosis was based on indirect micro-agglutination standard technique (MAT). Second serum samples were difficult to obtain, often impairing completion of diagnosis. Immunofluorescence was useful as a screening test and for early detection of probable infections. El género Leptospira comprende bacterias delicadas, que requieren métodos de estudio especiales. Causan una zoonosis transmitida a los seres humanos por la orina de animales domésticos o silvestres. Estudiamos la incidencia de la leptospirosis en la población humana de Uruguay, sus características epidemiológicas y clínicas, y comparamos técnicas diagnósticas. Tras examinar 6778 casos sospechosos, estimamos que anualmente ocurren unas 15 infecciones/100.000 habitantes, principalmente en trabajadores rurales jóvenes de sexo masculino. El nivel de alerta sobre la leptospirosis ha avanzado en el personal sanitario, y su letalidad ha descendido. La enfermedad humana se asocia principalmente con las infecciones bovinas. Lluvias e inundaciones influyen sobre su incidencia. La mayoría de los pacientes experimentaron fiebre, astenia, mialgias o cefaleas, con al menos un síntoma o signo adicional. 30 a 40% presentaban sintomatología abdominal, hiperemia conjuntival o alteraciones nefro-urológicas. La ictericia era más frecuente en mayores de 40 años. La enfermedad era habitualmente aguda y la recuperación completa. El diagnóstico de laboratorio se basó en la técnica de microaglutinación (MAT), con cepas vivas de distintos serovares. Se requieren segundas muestras de suero, de difícil obtención. El test de inmunofluorescencia se reveló útil para screening y detección precoz de la infección.

In the autumn two patients with general malaise were consecutively admitted to the department of internal medicine of our hospital in the northern region of Nagasaki Prefecture. Since both patients were engaged in rice farm work and showed conjunctival suffusion and pain of the gastrocnemius muscle, leptospirosis was suspected. The first patient required temporary hemodialysis for renal dysfunction, whereas liver dysfunction developed in the second patient. The disease was remitted by antimicrobial agents. A diagnosis of leptospiro sis was made serologically in both patients. Leptospirosis should be considered as a differential diagnosis when a patient engaged in farm work in the autumn has typical symptoms, and an early initiation of treatment after onset is important., Internal Medicine, 49(12), pp.1143-1147; 2010

A 19-year-old man presented with a 5-day history of vomiting and passing dark urine. He gave a 6-month history of arthralgias and joint swelling, particularly affecting larger joints. He had recurrent epistaxis and recent episcleritis. He was noted to be thin and pale, with conjunctival suffusion and deformity of his nasal bridge. He was normotensive (115/60 mm Hg) and apyrexic (35.5°C). Blood parameters revealed normocytic normochromic anemia and acute renal failure. Renal biopsy showed extensive crescent formation with segmental necrotizing inflammation and fibrin deposition of the glomeruli. cANCA was strongly positive (titer 1280; ELISA PR3+) and he was diagnosed with Wegener granulomatosis. He commenced hemodialysis, steroids, and oral cyclophosphamide, and he was discharged home. One month later, he presented with acute onset of throbbing headaches associated with nausea and photophobia, as well as recurrent generalized seizures necessitating sedation and intensive care unit admission. He was pyrexic (38°C) and hypertensive (165/95 mm Hg). Renal indices were abnormal (urea 29.1mmol/L; creatinine 755 μmol/L; potassium 5.4 mmol/L). Clinical examination revealed no focal neurologic deficits. Initial noncontrast brain CT was normal. Brain MRI with gadolinium showed small, ill-defined, nonenhancing high signal areas measuring 5–20 mm in several locations (figure, A). Figure Brain MRIs (A) Axial fluid-attenuated inversion recovery (FLAIR) brain MRI showing small, ill-defined, nonenhancing high signal areas measuring 5–20 mm in several locations. (B) Axial FLAIR brain MRI showing progression in radiologic changes over a further 1-month interval. Bright confluent lesions are seen in both parieto-occipital regions. (C) Axial FLAIR brain MRI showing marked progression …

There is scarce data on the burden of leptospirosis and its epidemiological characteristics in Argentina. This study aimed to evaluate distribution of leptospirosis cases and identify risk factors for the disease during national laboratory-based surveillance. From January 1999 to December 2005, 812 suspected cases were referred to the national reference laboratory, of which 182 and 463 had respectively, laboratory confirmed and unconfirmed diagnosis of leptospirosis. The diagnosis of leptospirosis was discarded in 167 cases. The most prevalent presumptive infecting serogroup was Icterohaemorrhagie followed by Pomona, Ballum and Canicola. The majority of cases occurred during the worm and rainy months. Confirmed cases were predominantly adults and males, who presented with fever, headache and myalgias. Severe clinical manifestations included jaundice and acute renal insufficiency. Conjunctival suffusion, a hallmark clinical sign of leptospirosis, was found in 55% of confirmed cases, and 43% of the cases with discarded diagnosis (p=0.036). After multivariate analyses, age >30 years (OR=2.16; 1.05-4.41), occupation in a rural setting (OR=3.41; 1.45-8.06), contact with contaminated surface water (OR=2.17; 1.01-4.68), and contact with floods (OR=4.49; 1.17-17.25) were significantly associated with leptospirosis. In conclusion, although activities associated with rural occupations remain important risk factors in Argentina, exposures occurring during flooding events have emerged to be the major risk factor for leptospirosis.

Leptospirosis is a worldwide zoonotic disease difficult to diagnose both to the clinic and the laboratory. Many risk factors have been involved, such as planting, hunting, harvesting and butchering or sports, such as rafting. We reported our experience through a period of 20 months and we tried to investigate prognostic factors predicting clinical outcomes. Five male patients were admitted to our Department with a median age of 40 years. Overall, three out of five patients presented to other hospital and were transferred to ours with a wrong or delayed diagnosis. In terms of clinical signs and symptoms, all presented with fever, myalgia, headache and jaundice, whereas conjunctival suffusion was present in 80% of them. Acute renal injury and liver deficiency were diagnosed in all subjects. Acute renal failure management required dialysis in 3/5 patients, whereas renal recovery was achieved soon after clinical improvement. However, clinical awareness and serology are the most important tools for accurate and quick diagnosis in order to administer the appropriate therapy.

Summary Albania is an attractive tourism destination with an increasing volume of travel. As a Mediterranean country some tropical infectious diseases are present in certain areas of Albania, including leptospirosis, which is a zoonotic infectious disease prevalent around the world. The goal of this retrospective study is to describe the ocular and cutaneous manifestations of leptospirosis in Albanian patients and raise awareness to travelers travelling in and out of the country. Methods We retrospectively studied 107 cases of leptospirosis, treated at “Mother Teresa” University Hospital Center, in Tirana, Albania between January 2009 and December 2014. All cases included in the analysis had a clinical and epidemiological presentation suggestive of leptospirosis, confirmed with ELISA (enzyme linked immunoassay) positive for IgM antibodies against Leptospira. Results There were 89.7% males (n = 96) and 10.2% females (n = 11). Mean age at the time of diagnoses was 43.7 ± 17.8 years old (range 17–78). All patients were native and residents of Albania. Conjunctival suffusion was present in 81.3% of the cases, whereas subconjunctival hemorrhage was seen in 12 patients (11.2%). Uveitis was seen in 38.3% of the cases and all patients with uveitis presented a severe systemic disease. A cutaneous rash was present in 58.8% of patients. Other cutaneous manifestations include jaundice in 62.6% and intense pruritus in 5.6% of cases. Conclusions Ocular and cutaneous involvement happens more frequently in patients with Leptospirosis, than it was thought to be. Therefore the clinician should be more careful in his systemic evaluation of the disease.

Leptospirosis is a disease with a large geographical spreading. The clinical picture varies from undiagnosed, flulike syndrome to multiorgan involvement forms. Involvement of pericardium during leptospirosis is a rare event but not unknown. Objective: Our aim is to describe a severe case of leptospirosis (Weil's diseases) with prominent liver involvement, complicated with exudative pericarditis. Materials and Methods: A male patient, working as a mechanic, presents with fever, conjunctival suffusion, jaundice, pronounced myalgia and anuria for more than two days. Based on the clinical evidence, laboratory results showing multiorgan involvement and the epidemiological data, the patient was suspected for leptospirosis. Results: Referring to the above mentioned data, the patient was serologically tested with ELISA for leptospirosis, which resulted positive for IgM and IgG in two blood samples. Conclusion: Severe clinical presentations of leptospirosis are not rare and cardiac involvements are not to, but remain underreported in most of the cases. Through this case report, we want to share our experience with our colleague and at the same time we want to bring into attention the rare complications of leptospirosis, such as pericarditis in our case.

This prospective study was undertaken to investigate the possibility of a concurrent outbreak of leptospirosis and dengue and to describe the clinical illnesses. From 20 June to 14 November 2002, children who presented to our hospital with a suspected diagnosis of leptospirosis or dengue were admitted. In every child with suspected leptospirosis, a screening latex agglutination test was carried out to detect aati-Leptospira antibodies. The diagnosis of leptospirosis was confirmed by a positive enzyme-linked immunosorbent assay (ELISA) test or microagglutination test. The diagnosis of dengue was confirmed by a positive IgM antibody capture ELISA test. Clinical features in the leptospirosis and leptospirosis-negative groups, and dengue and dengue-negative groups were analysed. Of 90 children screened, 15 (16.7 per cent) had leptospirosis. Two children with Weil's disease died and the remaining 13 responded well to intravenous penicillin. Five clinical features were significantly associated with leptospirosis, namely conjunctival suffusion (p = 0.007), haemorrhage (p = 0.020), abdominal pain (p = 0.011), hepatosplenomegaly (p = 0.044), and ocdema (p = 0.007). As the number of these five features concomitantly present increased, the chances of the child having leptospirosis also increased significantly (p < 0.0001). Of 90 children screened, 16 (17.8 percent) had dengue. All responded well to the treatment and went home. Two clinical features were significantly associated with dengue, namely arthralgia (p = 0.020) and thrombocytopenia (p = 0.001). If both these features were present, the chances of the child having dengue increased significantly (p = 0.001). Our study shows that a concurrent outbreak of leptospirosis and dengue had occurred in the slums of Mumbai city.

We report a patient with leptospirosis caused by Leptospira borgpetersenii serovar Sejroe infection on Bali Island, Indonesia. This 33-year-old Japanese man had stayed at a resort hotel on the island from July 8 to July 13 2004. At the hotel, he swam in the pool, walked barefoot, and lied down in the grass. He developed a high fever and headache 7 days after completing his trip, and was admitted to our hospital on July 23. On admission he showed conjunctival suffusion and complained of myalgias. Laboratory findings included granulocytosis and elevated CRP. Plasmodium spp. were not found in blood smears, and no pathogenic bacteria were isolated from blood or fecal cultures. We diagnosed the patient as leptospirosis upon detection of slender coiled organisms with characteristic morphology by darkfield examination of blood sample. Minocycline 100 mg i.v.b.i.d. showed excellent efficacy. A microscopic agglutination test (MAT) during the convalescent stage demonstrated a significant increase in antibodies against L. borgpetersenii serovar Sejroe, confirming the diagnosis of leptospirosis. Despite occurrence of a pandemic of leptospirosis in certain Southeast Asian countries including Indonesia, information concerning pandemic disease is limited. In addition serovars of "imported" cases representing infection in pandemic areas differ widely from those in domestic cases. Adequate laboratory support therefore is crucial for accurate diagnosis of leptospirosis.

Background: Leptospirosis is relatively uncommon in children. Following torrential rains and flooding an outbreak of leptospirosis was suspected in Mumbai. Aims: To investigate the possibility of an outbreak of leptospirosis and describe the clinical illness. Methods: From 24 July to 14 September 2000, children with a history of abrupt onset of high fever (>39°C), who presented to our hospital, were admitted and tested serologically for anti-Leptospira antibodies by a quantitative enzyme linked immunosorbent assay (ELISA) test. An IgM titre of more than 20U/ml confirmed the diagnosis of leptospirosis. Clinical features in the confirmed leptospirosis and leptospirosis negative groups were analysed. Results: Of 53 children screened, 18 (34%) had leptospirosis. In all 18, the disease was anicteric and responded well to intravenous penicillin. Four clinical features present at the time of admission were significantly associated with leptospirosis: a history of contact with flood water (18/18 v 16/35), conjunctival suffusion (5/18 v 1/35), abdominal pain (9/18 v 5/35), and skin rash (5/18 v 1/35). As the number of these four features concomitantly present increased, the chances of the child having leptospirosis also increased significantly. A history of contact with flood water had a sensitivity of 100%, and the presence of conjunctival suffusion, abdominal pain, and skin rash had a specificity of 97%, 86%, and 97%, respectively, for identifying children with leptospirosis. Conclusion: Leptospirosis should be suspected in febrile children with contact with flood water.

We present a case of imported dengue fever in a 52-year-old man acquired during a recent trip to Ecuador. Fever in a returning traveler from tropical areas often presents a diagnostic problem for clinicians. Our patient presented with severe arthralgias and myalgias and had a camelback/saddleback fever pattern accompanied by relative bradycardia, which was a clue to the diagnosis. He had conjunctival suffusion and the truncal rash, but adenopathy was not present. He also had a generalized headache and abdominal pain. Nonspecific laboratory abnormalities included leukopenia, lymphopenia, atypical lymphocytes, thrombocytopenia, and mildly increased serum transaminases. Clinicians should consider dengue fever in the differential diagnosis in travelers returning from dengue fever endemic areas of Southeast Asia, Latin America, and Africa. Although early findings are nonspecific, a truncal rash accompanied by leukopenia and thrombocytopenia, if followed by biphasic fever pattern (ie, camelback/saddleback fever curve with relative bradycardia), suggest dengue fever as the primary diagnostic consideration.

We present a case of severe adenoviral pneumonia in a 20-year-old immunocompetent host with persistently high fevers. The patient was needlessly given multiple empiric antibiotics for non-existent bacterial co-infection. This case has important antibiotic stewardship lessons for practitioners in approaching fevers in the ICU.

To the Editor: Severe pulmonary hemorrhagic syndrome (SPHS) is a serious complication of Leptospira infection, a globally widespread bacterial zoonosis that is increasing in incidence in tropical and subtropical regions. Despite decreasing endemicity of leptospirosis in industrialized regions, the disease is reemerging in travelers and recreationalists. Leptospirosis is an appreciable attributable cause of travel-related infections (typically associated with waterborne activities), and the incidence of travel-related leptospirosis is proportionally higher than that for endemic leptospirosis. Disease risk epidemiology has shifted concomitantly from occupational to recreational in industrialized countries (1–3). Risk factors include urbanization, climatic changes, and agricultural practices (1–3). Clinical features of leptospirosis range from asymptomatic infections and undifferentiated febrile syndromes to multiorgan dysfunction and death. Weil syndrome (i.e., severe leptospirosis) is characterized by renal and hepatic dysfunction, hyperbilirubinemia (disproportionate to transaminase elevation), and hemorrhage (pulmonary, gastrointestinal, or intracranial). Pulmonary involvement predicts poor clinical outcome: the case-fatality rate for persons with SPHS is >50% (4–6). Most US leptospirosis cases are reported from Hawaii, where the annual incidence is 1.63 cases/100,000 person-years (1). Leptospirosis is endemic to Hawaii; however, SPHS is uncommonly reported (7). We treated a 21-year-old active-duty Navy sailor for SPHS after he had a 5-day port visit in Hawaii, during which he went cliff-diving in Maunawili Falls. Afterwards, he returned to California and 2 days later sought medical attention in an outpatient clinic. Pharyngitis was diagnosed and azithromycin prescribed. Two days later, he was hospitalized with fever, chills, pharyngitis, dyspnea, nonproductive cough, headache, myalgias, hemoptysis, epistaxis, diarrhea, nausea, emesis, meningismus, and a lower-extremity rash. Vital signs included temperature 38.3°C, pulse 132 beats/min, blood pressure 128/72 mm Hg, and oxygen saturation 98% on room air. Physical examination noted conjunctival suffusion, epistaxis, posterior cervical and inguinal lymphadenopathy, bilaterally diminished breath sounds, rhonchi and crackles, bloody cough, tachycardia, hepatosplenomegaly, and a macular rash over the lower extremities. Laboratory studies were noteworthy for reference range leukocyte count, hemoglobin (11.8 g/dL), platelets (102 × 103/mm3), creatine phosphokinase (1,719 IU/L), sodium (128 mmol/L), bicarbonate (23 mmol/L), blood urea nitrogen (29 mg/dL), creatinine (2.2 mg/dL), aspartate aminotransferase (171 U/L), alanine aminotransferase (147 U/L), bilirubin (1.9 mg/dL), and urinalysis (7 erythrocytes and 9 leukocytes/high-power field). Chest radiography showed multilobar bilateral opacities, and cerebrospinal fluid (CSF) showed mild pleocytosis. The patient received intravenous acyclovir, ceftriaxone, and vancomycin and continued azithromycin. At hospital admission, the patient experienced respiratory decompensation requiring endotracheal intubation and mechanical ventilation. Results of blood, urine, and CSF cultures and CFS PCR (herpes simplex virus and enterovirus) remained negative at 48 hours, prompting discontinuation of vancomycin and acyclovir. Serologic test results for HIV, dengue fever virus, mycoplasma, and Chlamydophila and Rickettsia species were negative. Nasopharyngeal influenza PCR, Streptococcus pneumoniae and Legionella spp. urinary antigen test results and hepatitis panel results were negative. Leptospira spp. test results by culture, PCR, and serologic testing (ELISA and microscopic agglutination testing) were negative. Given an elevated suspicion for leptospirosis, ceftriaxone and azithromycin were continued through hospital day 7. The patient rapidly improved, was extubated after 48 hours, and was discharged on hospital day 7 with a 7-day course of oral doxycycline. A convalescent-phase serum sample had a titer of 1,600 against L. interrogans serovar Copenhageni, as determined by microscopic agglutination testing. SPHS is associated with infection with L. interrogans serovars Copenhageni and Icterohaemorrhagiae (8), and the syndrome has been identified in diverse settings, including the Andaman Islands. Recent outbreaks have occurred in Nicaragua and Brazil (4,5). SPHS pathogenesis remains poorly understood. In animal models and human autopsy studies, immunoglobulin and complement are deposited along alveolar septa without a clear cause-and-effect relationship (9). Bacterial virulence factors are postulated but unproven. Leptospires induce endothelial activation and pulmonary endothelial and epithelial injury (possibly by immune-complex deposition and/or autoimmune mechanisms) (9). Pulmonary histopathology demonstrates a paucity of leptospires, and antigen levels do not correlate with injury severity (9). Steroids, intravenous immunoglobulin, and plasma exchange are of unproven benefit but have been reported to be useful (9). Genetically determined responses include associations with human leukocyte antigen–DQ6 and hyperactive Toll-like receptor 4–dependent immunity. Diagnosis of leptospirosis may have been delayed for this patient because of early empiric azithromycin administration. Azithromycin is increasingly recognized as a potentially effective treatment that is comparable or superior to doxycycline (10) and thus warrants testing in human trials. Given the paucity of SPHS in leptospirosis case reports from Hawaii, potential sentinel cases may be harbingers of more virulent disease expression. A potential parallel is the emergence of SPHS in Salvador, Brazil, in 2003. No cases were identified before 2003, but 47 cases and a 75% case-fatality rate were identified during 2003–2005 (4,5). The entrenched active surveillance and physician awareness of SPHS in neighboring Brazilian cities suggests it is unlikely that this observation stemmed from prior underrecognition of disease; instead, it suggests de novo emergence. Clinicians should consider leptospirosis (SPHS) in patients with acute fever accompanied by hemoptysis after travel to Hawaii, and leptospirosis should be suspected in any traveler with undifferentiated febrile illness, especially those reporting water exposures (2). Vigilant national surveillance is needed to determine further emergence of SPHS in Hawaii.

Leptospirosis is frequently misdiagnosed as a result of its protean and nonspecific presentation. Leptospirosis, a zoonosis with global distribution, commonly occurs in tropical and subtropical regions; most reported cases in the United States occur in Hawaii. All laboratory-confirmed leptospirosis cases in the State of Hawaii from 1974 through 1998 (n=353) were clinically evaluated. The most common presentation involved nonspecific signs or symptoms, including fever, myalgia, and headache. Jaundice occurred in 39% of cases; conjunctival suffusion was described in 28% of these cases. Initiation of antibiotics before the seventh day of symptoms was associated with a significantly shortened duration of illness. Because early recognition and initiation of antibiotic therapy are important, clinicians should familiarize themselves with the clinical presentation of leptospirosis, and when evaluating a patient with a febrile illness, they should obtain exposure and travel histories and entertain the possibility of leptospirosis in the differential diagnosis.

Nine hundred and forty two serum samples from clinically suspected cases of leptospirosis admitted in Lokmanya Tilak Municipal General Hospital, Mumbai during July-September 2005 were tested by LeptoTek Dri-dot/Leptocheck. One hundred and sixty five positive sera by these tests were sent to I.R.R., Mumbai, for detection of leptospira IgM antibodies by ELISA (PanBio). Eighty seven positive sera were also sent to B.J. Medical College, Pune, for microscopic agglutination test (MAT) for serovar identification. Seropositivity with LeptoTek Dri-dot/Leptocheck was 34.3%. Adults and males predominated. All patients were febrile. The commonest presentation in adults was jaundice (81.4%), followed by oliguria (37.6%). In children, myalgia was commonest (75.6%), followed by conjunctival suffusion (54.7%). IgM ELISA positivity was 69.1% and MAT positivity was 29.9%. Commonest serovar detected in this geographical area was Leptospira icterohaemorrhagiae (42.9%), followed by L. bataviae, L. tarassovi, and L. pomona . Considering at least two of the above three serological tests positive, 127 cases could be diagnosed and only 89.8% of them could be diagnosed by ELISA and rapid test. Therefore, along with rapid serological tests, IgM ELISA should be routinely done for laboratory diagnosis of leptospirosis.

Dear Editor, I read with interest the report of Drs. Hakim and Tleyjah on severe adenovirus pneumonia in your journal [1]. Their literature review reminds us of the reemergence of adenoviral community-acquired pneumonia (CAP) and that it may mimic other causes of CAP, particularly the atypical pneumonias, e.g., Legionnaire’s disease [2, 3]. As the authors correctly state, adenovirus is the only viral cause of CAP that may resemble bacterial pneumonia with focal/ lobar infiltrates or consolidation. However, as with other viral causes of pneumonia, early the chest X-ray in adenoviral CAP may be normal, even when the patient is short of breath and hypoxemic. The two most likely radiologic presentations of adenovirus is a completely normal chest X-ray with hypoxemia and symptoms of pneumonia or with lobar infiltrate/consolidation. Unlike influenza, routinely associated with leukopenia, adenoviral CAP is associated with a normal or elevated white blood cell (WBC) count, excluding viral influenza. An important clue noted by the authors, which has been our experience as well is the presence of conjunctival suffusion when present. Another important point is that viral pneumonias are ordinarily not accompanied by loose stools/diarrhea [4]. Adenovirus is most likely to be confused in this respect with Mycoplasma pneumoniae or Legionnaire’s disease, which is a common feature of both. Adenoviral CAP in patients with lobar infiltrates mimic Legionnaire’s disease, which may be differentiated from Legionella by the absence of hyponatremia, hypophosphatemia, and highly elevated serum levels [5]. As with conjunctival suffusion, an important clue to adenoviral pneumonia is wheezing, more common in children that, if present, should suggest adenovirus [1]. Recently, we have had a case of adenoviral CAP in a normal host different to that reported by the authors. The patient was a 36-year-old immunocompetent male who presented with severe CAP with a prominent dry cough and headache. On physical examination, he had a questionable faint truncal rash and conjunctival suffusion. Auscultation of the chest revealed no rales. His WBC count was 7.3 K/ mm with monocytosis. Relative lymphopenia was not present. His platelet count was 280,000 K/mm. Because of his headache and possible rash, the question of aseptic meningitis was raised and a lumbar puncture was performed. His cerebrospinal fluid (CSF) showed 8 WBCs/hpf with a normal glucose, protein, and lactic acid level. Head magnetic resonance imaging (MRI) was negative. He was hypoxemic on room air. Both his erythrocyte sedimentation rate (ESR) and liver function tests (LFTs) were unelevated and cold agglutinin titers were negative. His creatine phosphokinase (CPK) was unelevated. Titers for Legionella, M. pneumoniae, and Chlamydia pneumoniae were negative. His Legionella urinary antigen test was negative. His adenovirus titer was elevated 1:128 (normal

A 45- year-old male farmer presented with a history of fever since 1 week associated with dyspnoea and dry cough since 5 days, followed by bodyache, jaundice and redness in both eyes since 2 days. There was no history of similar complaints, or any history of hypertension, diabetes, tuberculosis, etc. For his current symptoms he consulted a local health worker but was referred to us for further management when he did not improve. On admission, the patient was conscious and oriented. He was febrile with a temperature of 100 F, pulse 102/min and blood pressure of 116/86 mm Hg. He was tachypnoeic with a respiratory rate of 26/min and hypoxic with an oxygen saturation of 80% at room air. He had conjunctival suffusion and there was no pallor, cyanosis, lymphadenopathy, pedal oedema or …

Answer: Measles. Although the patient had received his childhood immunizations, he had been potentially exposed to an adult with measles 2 weeks prior to admission while visiting a friend. Measles IgM and IgG titers were ordered, but the results were not immediately available. Because of the potential measles exposure and findings compatible with measles, i.e., conjunctival suffusion and maculopapular rash, he was placed on airborne precautions until the diagnosis of measles could be established or ruled out. Consistent with measles were thrombocytopenia, atypical lymphocytes, mildly decreased serum sodium, and an elevated serum transaminase level (2–4). Against the diagnosis of measles were his previous immunization history and the profuse and prolonged watery diarrhea as a major manifestation of measles.

In October 2011, a case of leptospirosis was identified in a Dutch traveller returning from the Dominican Republic to the Netherlands. The 51-year-old man had aspired muddy water in the Chavon river on 29 September. Twenty days later he presented with fever, nausea, vomiting, diarrhoea, arthralgia, headache, conjunctival suffusion and icterus. Leptospira serovar Icterohaemorrhagiae or Australis infection was confirmed ten days later by laboratory testing.

Following prolonged water logging due to heavy rainfall in Mumbai during July 2000, a total of 102 patients clinically suspected of leptospirosis were admitted in our hospital. Blood samples were examined for the presence of leptospires by dark ground microscopy (DGM) and IgM antibodies were detected by ELISA. Out of 102 blood samples, 37 were positive by ELISA giving a positivity rate of 36.27%. Of these, only 24 were positive by DGM. Out of the positive cases, 37.83% had respiratory symptoms, 32.43% each had jaundice and conjunctival suffusion and 16.21% had renal involvement. Mortality amongst the positive cases was 10.81%. Apart from hepatic and renal involvement, respiratory symptoms due to leptospirosis are on the rise.

Background Leptospirosis has a varied clinical presentation with complications like myocarditis and acute renal failure. There are many predictors of severity and mortality including clinical and laboratory parameters. Early detection and treatment can reduce complications. Therefore recognizing the early predictors of the complications of leptospirosis is important in patient management. This study was aimed at determining the clinical and laboratory predictors of myocarditis or acute renal failure. Methods This was a prospective descriptive study carried out in the Teaching Hospital, Kandy, from 1st July 2007 to 31st July 2008. Patients with clinical features compatible with leptospirosis case definition were confirmed using the Microscopic Agglutination Test (MAT). Clinical features and laboratory measures done on admission were recorded. Patients were observed for the development of acute renal failure or myocarditis. Chi-square statistics, Fisher's exact test and Mann-Whitney U test were used to compare patients with and without complications. A logistic regression model was used to select final predictor variables. Results Sixty two confirmed leptospirosis patients were included in the study. Seven patients (11.3%) developed acute renal failure and five (8.1%) developed myocarditis while three (4.8%) had both acute renal failure and myocarditis. Conjunctival suffusion - 40 (64.5%), muscle tenderness - 28 (45.1%), oliguria - 20 (32.2%), jaundice - 12 (19.3%), hepatomegaly - 10 (16.1%), arrhythmias (irregular radial pulse) - 8 (12.9%), chest pain - 6 (9.7%), bleeding - 5 (8.1%), and shortness of breath (SOB) 4 (6.4%) were the common clinical features present among the patients. Out of these, only oliguria {odds ratio (OR) = 4.14 and 95% confidence interval (CI) 1.003-17.261}, jaundice (OR = 5.13 and 95% CI 1.149-28.003), and arrhythmias (OR = 5.774 and 95% CI 1.001-34.692), were predictors of myocarditis or acute renal failure and none of the laboratory measures could predict the two complications. Conclusions This study shows that out of clinical and laboratory variables, only oliguria, jaundice and arrhythmia are strong predictors of development of acute renal failure or myocarditis in patients with leptospirosis presented to Teaching Hospital of Kandy, Sri Lanka.

We report a case of severe leptospirosis infection (Weil's disease) in Tokyo. A 54-year-old man admitted on September 14, 2006, for a 5-day inability to walk due to severe progressive bilateral leg pain, shoulder pain, and fever exhibited jaundice, conjunctival suffusion, hypoxia, and grasping pain in the bilateral leg muscles. Laboratory findings showed severe liver damage, renal failure, leukocytosis, anemia, thrombocytopenia, elevated CRP, hyponatremia, and hypokalemia. Chest X-ray imaging showed interstitial infiltrates in the bilateral lung fields. After cefepime was initiated, he developed chills, fever, and hypotension due to Jarisch-Herxheimer reaction, necessitating respiratory support. Pulmonary hemorrhaging was also found. On hospital day 2, a urine polymerase chain reaction test for leptospira proved positive for the same base sequence as part of the leptospira gene. A microscopic agglutination test showed elevated antibody titers against Leptospira interrogans. Based on a diagnosis of leptospirosis, the man was treated with 2g per day of ceftriaxione for 2 weeks and recovered fully. The leptospira strain was isolated from rodents captured at his home, and we identified the same base sequence as from his urine sample. Reports shows, leptospirosis in Japan have decreased recently, but, as this case can still be seen even in Tokyo, and diagnosticians should maintain an awareness of possible significance in patients with typical findings for this disease.

Leptospirosis is a globally prevalent disease that affects humans, causing systemic illness that may lead to multi-organ involvement. Clinical signs include sudden fever, general malaise, muscular pain, conjunctival suffusion, and jaundice. Disease is caused by pathogenic bacteria including over 200 serologic variants. Most serologic variants have primary reservoirs in wild mammals, which continually infect and colonize domesticated animals. The organism has been recovered from rats, swine, dogs, cattle, and other animals, notably bats. Most studies have focused on domestic animals as reservoir hosts; however, because of their abundance, spatial distribution, and interrelationship with domestic animals, bats are becoming an epidemiologically significant source of leptospires. We present a case of serologically confirmed leptospirosis after bat exposure to add to the growing literature of bats as a possible source of transmission. Recognition of the common presentation of leptospirosis and Weil’s disease, and identification of animal vectors, including bats, allows for the selection of appropriate antibiotic management to aid in resolution of symptomotology.

Kawasaki's disease is a disease of unknown cause. The characteristic clinical features of Kawasaki's disease are feveror =102 degrees F foror =5 days accompanied by a bilateral bulbar conjunctivitis/conjunctival suffusion, erythematous rash, cervical adenopathy, pharyngeal erythema, and swelling of the dorsum of the hands/feet. Kawasaki's disease primarily affects children and is rare in adults. In children, Kawasaki's disease is more likely to be associated with aseptic meningitis, coronary artery aneurysms, and thrombocytosis. In adult Kawasaki's disease, unilateral cervical adenopathy, arthritis, conjunctival suffusion/conjunctivitis, and elevated serum transaminases (serum glutamic oxaloacetic transaminase [SGOT]/serum glutamate pyruvate transaminase [SGPT]) are more likely. Kawasaki's disease in adults may be mimicked by other acute infections with fever and rash, that is, group A streptococcal scarlet fever, toxic shock syndrome (TSS), and Rocky Mountain Spotted Fever (RMSF). Because there are no specific tests for Kawasaki's disease, diagnosis is based on clinical criteria and the syndromic approach. In addition to rash and fever, scarlet fever is characterized by circumoral pallor, oropharyngeal edema, Pastia's lines, and peripheral eosinophilia, but not conjunctival suffusion, splenomegaly, swelling of the dorsum of the hands/feet, thrombocytosis, or an elevated SGOT/SGPT. In TSS, in addition to rash and fever, there is conjunctival suffusion, oropharyngeal erythema, and edema of the dorsum of the hands/feet, an elevated SGOT/SGPT, and thrombocytopenia. Patients with TSS do not have cervical adenopathy or splenomegaly. RMSF presents with fever and a maculopapular rash that becomes petechial, first appearing on the wrists/ankles after 3 to 5 days. RMSF is accompanied by a prominent headache, periorbital edema, conjunctival suffusion, splenomegaly, thrombocytopenia, an elevated SGOT/SGPT, swelling of the dorsum of the hands/feet, but not oropharyngeal erythema. We present a case of adult Kawasaki's disease with myocarditis and splenomegaly. The patient's myocarditis rapidly resolved, and he did not develop coronary artery aneurysms. In addition to splenomegaly, this case of adult Kawasaki's disease is remarkable because the patient had highly elevated serum ferritin levels of 944-1303 ng/mL; (normal189 ng/mL). To the best of our knowledge, this is the first report of adult Kawasaki's disease with highly elevated serum ferritin levels. This is also the first report of splenomegaly in adult Kawasaki's disease. We conclude that Kawasaki's disease should be considered in the differential diagnosis in adult patients with rash/fever foror =5 days with conjunctival suffusion, cervical adenopathy, swelling of the dorsum of the hands/feet, thrombocytosis and otherwise unexplained highly elevated ferritin levels.

We report three children with tubulointerstitial renal failure following leptospirosis. All had acute nonoliguric renal failure with mild hypocalemia and mild metabolic acidosis. Maximum blood urea nitrogen (BUN) and creatinine were 217 and 7.1 mg/dl, respectively, on the 6th day of disease, and no patient required dialysis. They presented with acute febrile illness and dehydration, and required intravenous fluid supplements. Myalgia, vomiting, and bleeding were found in two children. Abdominal pain, arthralgia, diarrhea, and conjunctival suffusion were found in one child. Only one child, who had an underlying disease of beta-thalassemia/Hb E, had jaundice, hepatosplenomegaly, anemia, and thrombocytopenia. Penicillin treatment was given in one case. All recovered, with normal renal function. The leptospirosis complement fixation test was used to confirm diagnosis. L. batavia was considered the etiologic agent in two of the children.

To the Editor: Leptospirosis is a zoonotic disease that has now been identified as an emerging infectious disease (1,2). It is caused by pathogenic spirochetes of the genus Leptospira. The natural hosts for Leptospira spp. come from a variety of species (2–4), of which the rodent is the most important reservoir (4,5). The incubation period range for leptospirosis is usually 5–14 days, with a range of 2–30 days (4). Leptospirosis is a disease of humid tropical and subtropical countries. According to the World Health Organization (4), probable leptospirosis incidence ranges from ≈0.1–1 case/100,000 population/year in temperate climates to 10–100 cases/100,000 population/year in humid tropical climates. Leptospirosis epidemics are often related to heavy rainfall and flooding (1,6,7). Because of its climate, Taiwan may be at high risk for leptospirosis. We therefore investigated human leptospirosis in Taiwan and the relationship between leptospirosis incidence and rainfall pattern. Taiwan is a medium-sized archipelago in East Asia; the Tropic of Cancer runs through its center. The northern part of Taiwan is subtropical; the southern part is tropical. Taiwan lies in the path of many tropical storms and typhoons that bring extremely heavy rainfall usually during July–September. The annual “plum rain” season in May and June also brings a lot of precipitation. Because of its tropical and subtropical marine climate, Taiwan enjoys rich agricultural productivity throughout the year, which is favorable for rodent infestations (8,9). In Taiwan, reported cases of leptospirosis have been investigated by the Centers for Disease Control since 2001. Leptospirosis should be suspected in patients who have fever; headache; myalgia; abdominal pain; prostration; conjunctival suffusion; meningeal irritation and aseptic meningitis; anuria, oliguria, or proteinuria; jaundice; acute renal insufficiency; or gastrointestinal or lung hemorrhage. Patients with suspected leptospirosis are reported by physicians to Taiwan’s Centers for Disease Control through the Notifiable Disease Surveillance System, after which local health bureaus collect urine and blood samples for confirmation by serologic testing. Urine and blood samples from patients with clinically suspected leptospirosis are inoculated into Ellinghausen-McCullough-Johnson-Harris culture medium plus 5-fluorouracil and incubated at 30°C for 8–12 weeks. Cultures are examined by dark-field microscopy every week. Alternatively, latex agglutination assay may be used for rapid serologic diagnosis of serum from patients with clinically suspected leptospirosis (10). Samples with positive latex agglutination assay results should be confirmed by microscopic agglutination test (MAT). An antibody titer >100 as determined by MAT is regarded as a probable case of leptospirosis. The local health bureau again collects patients’ serum during the convalescent phase of illness for confirmation by MAT. A laboratory-confirmed case is defined as the isolation of leptospires from urine and blood or a 4-fold increase in antibody titer between acute- and convalescent-phase samples. During 2001–2006, of 7,733 suspected human cases of leptospirosis, 291 cases were confirmed. The major serotype identified was L. santarosai serovar Shermani. The mean annual incidence was 0.21 cases/100,000 population. The laboratory-confirmed cases were observed in Taiwan, mostly in male patients (83.5%) (Figure, panel A). Cases occurred in all age groups but were more common (90%) in those 25–74 years of age. Age-specific incidence was highest for persons 55–64 years of age; mean annual incidence was 0.57/100,000 population. Figure Leptospirosis cases (N = 291) in Taiwan, 2001–2006. A) Distribution by age and sex. B) Relationship between rainfall and leptospirosis incidence. Data represent averages for each month during the 6 years. Rainfall data from the Central Weather Bureau of the Republic of China showed typically high rainfall (252–433 mm/month) in Taiwan during May–September. Heavy rains were followed by an increase in laboratory-confirmed cases of leptospirosis (Figure, panel B); June–October accounted for 60% of cases, with a higher incidence of 0.022–0.028 cases/100,000 population. In October–December, monthly rainfall was below average (201.1 mm/month), but leptospirosis incidence was above average (0.018/100,000). Specifically, 25 (74%) of leptospirosis cases in October, 10 (42%) in November, and 4 (19%) in December were likely associated with several days of heavy rainfall from typhoons. Therefore, the typhoons may be the reason for high incidence in October–December. The annual incidence of leptospirosis in Taiwan is relatively lower than that in other countries with tropical or subtropical climates. Our study does not conclusively document the reason for lower incidence, although it does suggest an association between amount of rainfall and incidence. An understanding of the relationship between leptospirosis incidence and rainfall is indispensable for implementing appropriate preventive measures.

International audience; BackgroundBecause early recognition and initiation of antibiotic therapy are important, clinicians should familiarize themselves with the clinical presentation of leptospirosis, and determine prognostic factors. Patients and methods This study included all patients treated at Angers University Hospital between January 1995 and December 2005 for leptospirosis – both probable (cases combining epidemiologically suggestive features with compatible clinical, laboratory, and radiographic findings, with no other diagnosis envisioned) and confirmed (by finding microorganism on direct examination or culture of blood, urine or CSF, or by seroconversion or by a significant increase in the antibody titer between two samples). Severe leptospirosis was defined by hospitalization in the critical care department or need for renal dialysis. The statistical analysis used SPSS software version 12. Results Of 97 records reviewed, we retained 62 cases that met the criteria above, including 35 confirmed cases, 27 probable and 15 severe. The sex ratio was nine men for every woman. The patients' mean age was 45 ± 18 years [12–77]. The principal clinical signs observed were: fever (n = 59) with shivering (n = 42), diffuse myalgia (n = 41), headaches (n = 38), jaundice (n = 24), conjunctival suffusion (n = 10), rash (n = 11), herpes eruption (n = 7), renal damage (n = 33) that was sometimes severe (>500 μmol/L) (n = 7), meningitis (n = 12), meningoencephalitis (n = 2), myocarditis or pericarditis (n = 6), and atypical radiographic lung disease (n = 16), sometimes with ARDS (n = 6). Blood tests showed thrombocytopenia (platelets < 140 G/L) in 65.5% of patients (n = 40). Logistic regression modeling showed that two criteria remained independently predictive of development toward severe leptospirosis: clinical jaundice (p = 0.005) and cardiac damage seen either clinically or on ECG (p < 0.02). These factors can be identified easily at the first clinical examination and during evolution, and should help to reduce mortality by allowing earlier management of patients with suspected leptospirosis.