PROFILE OF HUMAN LEPTOSPIROSIS _updated_ - CiteSeerX

ARTICLE 1

LEPTOSPIROSIS IN CHENNAI – CHANGING CLINICAL PROFIL E

In a recent article, M. Jayakumar et al from Chennai have stated that

acute renal failure (ARF) due to Leptospirosis in Chennai has significantly

declined from 31% in 1987 – 91 to 7.5% in 1995 – 20041. Of the 120 cases of

leptospiral ARF during the period 1987 –91, the highest numbers of 45 cases were

reported in 19902. Since 1992, there has been a decline in leptospiral ARF cases

and during a 10 years period from 1995 – 2004, only 84 cases were reported.

Our experience also suggests that though severe Leptospirosis has

declined, mild Leptospirosis has increased. In a study of 57 cases in 1990 – 91,

Jaundice occurred in 84% and renal failure occurred in 72%. Serogroup

Automnalis was the most common serogroup encountered. 26 patients were

dialysed and two patients died3. In a recent study of 106 cases of Leptospirosis

from North Chennai, Jaundice occurred in 17.8% and renal failure occurred in

10.3% showing a decline in complications. Fever, headache and Myalgia were the

common presentations. Only 2 patients were dialysed and there were no deaths.

Contaminated environment (95%) and rainfall (50%) were the important

epidemiological risk factors. Icterohemorrhagiae was the most common serogroup

and Autumnalis was not detected.

The reasons for decline of severe Leptospirosis suggested were greater

awareness of the disease, availability of better diagnostic facilities and widespread

use of antibiotics. In addition, serogroup Autumnalis, a virulent serogroup causing

severe Leptospirosis has also declined since 1995. The seropositive prevalence

rate in Chennai was 32.9% in1993. The increase in mild Leptospirosis suggests

that the environmental risk factors (Infected rodents and domestic animals,

contaminated environment and rainfall) play an important role in the

JAPI · VOL. 54 · DECEMBER 2006 964 – 965

Profile of Human Leptospirosis

2

persistence and spread of the disease. Intensive surveillance for early detection of

mild Leptospirosis with appropriate therapy would definitely play an important

role in reducing the incidence of severe Leptospirosis. Since diagnostic tests

become positive only after 5 days, it would be appropriate to start empiric therapy

in suspect cases of Leptospirosis with Doxycycline or other appropriate

antibiotics.

S.Shivakumar Professor of Medicine, Department of Medicine, Stanley Medical College and Hospital, Chennai.

REFERENCES:

1. Jayakumar M, Ram Prabakar H, Edwin Fernando M, et al. Epidemiologic

trend changes in acute renal failure – A tertiary center experience from

south India. Renal Failure 2006; 28: 405-10.

2. Muthusethupathi MA, Shivakumar S, Jayakumar M, et al. Renal

involvement in Leptospirosis – our experience in Madras City J. Postgrad

Med 1994;40:127-31

3. Muthusethupathi MA, Shivakumar S, Jayakumar M, et al. Leptospirosis in

Madras – A clinical and serological study. J. Assoc phys India

1995;43:456-8.

JAPI · VOL. 54 · DECEMBER 2006 964 – 965

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ARTICLE 2

LEPTOSPIROSIS – EVALUATION OF CLINICAL CRITERIA

I read the article “Evaluation of Clinical Criteria for the Diagnosis of

Leptospirosis” with interest1. I would like to make the following comments.

1. Leptospirosis can be diagnosed only by serological tests, as the clinical

features are non-specific. By this criteria, only 22 of 118 (18%) patients had

Leptospirosis. By Faine’s criteria, 44 out of 118 patients were diagnosed to have

Leptospirosis. The positive predictive value of this test is 40.9%. This value can

be increased by modification of Faine’s criteria (Part B). History of animal

contact (Part B) is not essential for diagnosis of Leptospirosis in developing

countries. The more important epidemiological factors in our country are 1. Rain

fall 2. Contact with contaminated environment. During rainfall, those who come

into contact with water contaminated with infected rodents (or other animals)

urine are prone to develop Leptospirosis which is facilitated by environmental

factors.2 It is impossible to trace the source of infection and any person can be

infected, irrespective of direct contact with animals.

The following factors have to be introduced in Part B of Faine’s criteria

(which is more relevant to India).

1. Rainfall

2. Outdoor activities leading to contact with contaminated environment.

These factors should be given appropriate scores.

JAPI · VOL. 51 · MARCH 2003 329 – 330


4

One hundred and eighteen patients with PUO in this study were seen

during a one-year period (Jan – Dec 1998). It would be interesting to note whether

the 22 Leptospirosis cases occurred during monsoon months (monthly breakup of

these cases would be useful). What was the diagnosis in those cases in whom

Faine’s criteria was positive, but MAT was negative? The group constituted

nearly 59% of the cases.

2. Leptospirosis was diagnosed by Micro Agglutination Test (MAT).

MAT is considered the gold standard test for serodiagnosis of Leptospirosis. This

is a complicated test and can be done only in specialized laboratories. Therefore,

ELISA IgM and Slide Agglutination Test (SAT) are considered to be more

sensitive, simpler and adequate for diagnosis of current leptospiral infection.2-4 In

fact they can replace MAT for diagnosis of current infection. But all these tests

become positive only after five days.

Thus, in the early stages of infection (5 days), clinical features are very

important to suspect Leptospirosis utilizing Faine’s criteria (Part A). But the

diagnosis should always be confirmed by ELISA (or) SAT.

I recommend that Leptospirosis diagnosis can be done by making the

following modification of Faine’s criteria.

Faine’s Criteria PART A No modification PART B (Include the following) SCORE

1. Rainfall – 5 2. Outdoor contact with

Contaminated environment – 4

3. Animal contact – 1

(The score of 10 in Part B has been split)

PART C (> 5 days)

a) Positive ELISA/SAT b) MAT – Rising titres/High titres

JAPI · VOL. 51 · MARCH 2003 329 – 330

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It should be realized that clinical data on milder (Anicteric) forms of

Leptospirosis are inadequate in our country and this can be made available only if

simpler tests are done in small laboratories.

S. Shivakumar Additional Professor of Medicine, Government Stanley Medical College and Hospital, Chennai

REFERENCES:

1. Bal AM, Kakrani AL, Bharadwaj RS, Kagal AS, Joshi SA, Wadkar VP,

Evaluation of clinical criteria for diagnosis of Leptospirosis. J Assoc

Physicians India 2002;50:394-6.

2. Muthusethupathi MA, Shivakumar S, Suguna R, Jayakumar M,

Vijayakumar R, Everard COR, Carrington DG. Leptospirosis in Madras –

A clinical and serology study. J Assoc Physicians India 1995;43:456-8.

3. Chinari KS, Sumathi G, Vimala Ranga Rao A, Shiva Kumar S.

Leptospirosis laboratory, Chennai Medical College – A three year

experience in Serodiagnosis (1995-1997). Indian J Med Microbiol

1999;717:50-7.

4. Sumathi G, Chinari KS, Shiva Kumar S, MSAT-A Screening test for

Leptospirosis. Indian J Med Microbiol 1997;15:84.

JAPI · VOL. 51 · MARCH 2003 329 – 330


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ARTICLE 3

DIAGNOSIS OF LEPTOSPIROSIS UTILIZING MODIFIED

FAINE’s CRITERIA

In a letter published in JAPI 2003, I had stated that certain modification to

be made on Faine’s criteria (WHO guidelines) to diagnose current leptospiral

infection in Indian institutions.1 A prospective study done in patients with

Leptospirosis is presented by us utilizing the modified Faine’s criteria. Faine had

evolved a criteria for diagnosis of Leptospirosis on the basis of clinical,

epidemiological and laboratory data (A+B+C).2 The modifications in the Faine’s

criteria has been made by us in the epidemiological and laboratory criteria

(Table1). No modifications have been made in the clinical aspects of Leptospirosis

(Part A). A score of 26 or more when using PART A, PART A+B or 25 or more

using PART A+B+C can be considered as current Leptospirosis.

The reasons for the modifications are:

(1) Most of the cases of Leptospirosis are reported in the monsoon and post

Monsoon seasons. Therefore, factors such as rainfall and contact with

contaminated environment have been incorporated with appropriate

scores (Part B).

(2) Laboratory tests are very essential for diagnosis of Leptospirosis. ELISA

IgM and Slide agglutination tests (SAT) are simple, sensitive tests and

can be used to diagnose current Leptospirosis. They have been included

with appropriate scores (Part C). Microscopic agglutination tests (MAT)

is the Gold standard test, but it is complicated and less sensitive

compared to ELISA and SAT.

JAPI · VOL. 52 · AUGUST 2004 678 – 679

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The difficulties in utilizing MAT are due to the following factors:

a) The antibody titers rise and peak only in 2nd or 3rd week, making it a less

sensitive test.

b) The high titers of past infection persist for a long time (1-5years) and therefore

interfere with the diagnosis of current leptospirosis. A Positive titer may

represent a rising titer of current infection or declining titer of past infection.

c) The cut off titer for diagnosis of current infection depends in whether the area

is endemic or non-endemic, for example the cut off titer varies from 1/80 to

1/400. Therefore a second sample is usually required (to demonstrate 4 fold

rise in titer) to diagnose current infection. Sero-epidemiological studies are

required for determining the cutoff value.

d) The test is complicated requiring dark field microscopy and cultures of various

live serovars, which may not be available in small laboratories.

As Elisa and SAT measures IgM antibodies become positive by 5th day, they

are the tests of choice for diagnosis of current infection and more over a single

sample is adequate. A repeat sample is necessary, if the first sample is negative.

High titers and rising titers of MAT have been given appropriate scores (Part C).

This study has been undertaken to compare the standard and modified

Faine’s criteria. The original Faiane’s criteria (WHO guidelines) have been

designated as Standard Faine’s criteria in this study. One hundred and fifty patients

admitted with fever were taken up for the study from April 2002 to March 2003.

Leptospirosis was diagnosed by positive macroscopic slide agglutination test

(confirmed by MAT). Malaria, enteric fever, UTI, pneumonia and TB was excluded

by appropriate tests. Thirty-one of 150 patients (20.7%) were diagnosed to have

Leptospirosis. All these patients had both standard and modified Faine’s criteria

positive (A+B+C > 25). It is observed that 38% (22/57) of the patients with fever

had Leptospirosis during monsoon when compared to 9% in the non-monsoon season

(9/93).

JAPI · VOL. 52 · AUGUST 2004 678 – 679


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Table 1

Faine’s Criteria Modified Faine’s Criteria

Part A : Clinical Data Part A : Clinical Data

Question Score Question Score

Headache 2 Headache 2

Fever 2 Fever 2

Temp > 39ºC 2 Temp > 39ºC 2

Conjunctival suffusion 4 Conjunctival suffusion 4

Meningism 4 Meningism 4

Muscle pain 4 Muscle pain 4

Conjunctival suffusion

+ Meningism

+ Muscle pain

10

Conjunctival suffusion

+ Meningism

+ Muscle pain

10

Jaundice 1 Jaundice 1

Albuminuria/Nitrogen Retention

2 Albuminuria/Nitrogen Retention

2

Total score Total score

Part B: Epidemiological factors

Part B: Epidemiological Factors

Contact with animals or Contact with known Contaminated water

Total

10

Rainfall

Contact with contaminated Environment

Animal contact

Total

5

4 1

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Part C: Bacteriological and Lab

Findings


Findings

Isolation of leptospira in culture – Diagnosis certain


Positive Serology (MAT) Leptospirosis Endemic

Positive Serology

Single positive – Low titre Single positive – High titre Leptospirosis Non Endemic Single positive – Low titre Single positive – High titre Rising titre (Paired sera) Total Score

2 10 5 15 25

ELISA IgM Positive * SAT – Positive MAT – Single High titre * Rising titre (Paired sera) Total Score

15 15 15 25

* Any one of the tests only should be scored

Table 2

(PART A+B) Seropositive Seronegative

Standard Faine’s Criteria

Faine’s positive

Faiane’s negative

Modified Faine’s Criteria

Faine’s positive

Faine’s negative

13

18

31

18

13

31

18

101

119

3

116

119

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Table 3

(PART A+B) Sensitivity Specificity PPV NPV Standard Faine’s criteria Modified Faine’s criteria Statistical significance

41.9%

58%

NS

84.9

97.4

p value <0.001

41.9%

85.7%

p value <0.001

84.9%

89.9%

NS

As Leptospirosis tests become positive only after the fifth day, the

diagnosis of Leptospirosis has to be done only by clinical and epidemiological

criteria during this period. Hence the clinical and epidemiological criteria (A+B)

only have been compared between standard and modified Faine’s criteria

(Table 2). The standard Faine’s criteria had a sensitivity of 41.9%, specificity of

84.9% and a positive predictive value of 41.9%. It was observed that the positive

features (A+B>26) were more in seronegative leptospirosis compared to

seropositive Leptospirosis. In contrast, modified Faine’s criteria had a sensitivity

of 58%, Specificity of 97.4% and positive predictive value (PPV) of 85.7%. By

modifying the epidemiological factors a significantly better PPV and specificity

was obtained in the modified Faine’s criteria. (Table 3). A study conducted by

AM Bal et al utilizing Faine’s criteria had observed that the sensitivity and PPV to

be 81.8% and 40.9% respectively3. In our study the PPV was much higher

utilizing modified Faine’s criteria though the sensitivity was low. An important

observation in the study has been the importance of laboratory tests. If clinical

and epidemiological criteria (A+B) along were utilized, only 18 cases were

diagnosed by modified Faine’s criteria (sensitivity – 58%), but if lab criteria was

incorporated 31 cases were diagnosed (A+B+C). This is because if A+B alone

JAPI · VOL. 52 · AUGUST 2004 678 – 679

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were utilized, the score should be > 26, but if C is available, A+B can be just 11

(A+B=11+C=15 TOTAL=26). If lab criteria are included, the score in PART A

(Clinical features) can be just 2, PART B (epidemiological factors) 9 and PART C

(Laboratory test) 15 (TOTAL=26). Thus milder cases can be diagnosed if

laboratory tests are available. In addition, the modified Faine’s criteria makes it

more difficult to diagnose Leptospirosis in the non monsoon months as the

epidemiological factors would be minimal (PART A=10, PART B=0, PART

C=15).4

We would like to emphasize that the study has been done in symptomatic

patients only (A+B+C) to diagnose current Leptospirosis. It can be argued that a

score of 25 or more can be obtained from B+C along in asymptomatic patients.

This would be relevant only for epidemiological studies to evaluate the prevalence

rates of Leptospirosis in high-risk group and general population. This study has

been done to evaluate a simple method to diagnose current leptospiral infection,

with necessary modification of Faine’s criteria. Though other criteria are utilized,

this criteria is most useful because it utilizes clinical, epidemiological and lab

features.

To conclude, modified Faine’s criteria is a more a practical methods to

diagnose current Leptospirosis. Availability of simple diagnostic tests (ELISA –

IgM or SAT) should help in diagnosis of milder forms (Anicteric) of

Leptospirosis, which is more common (90%) than severe Leptospirosis (10%).

S. Shivakumar*, PS Shareek** *Professor; ** Post Graduate; Department of Medicine, Government Stanley Medical College and Hospital, Chennai

JAPI · VOL. 52 · AUGUST 2004 678 – 679


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REFERENCES:

1. Shivakumar S. Leptospirosis evaluation. J Assoc Phys India 2003;51:

329-30

2. Faine.S. Guidelines for the control of Leptospirosis. WHO offset

publication 1982:67.

3. Bal AM, Kalkarni AL, Bharadwaj RS, Kagal AS, Joshi SA, Wadkov VP.

Evaluation of clinical criteria for diagnosis of Leptospirosis. J Assoc Phys

India 2002;50:394-6

4. Shivakumar S. Approach to Leptospirosis in India. Bhattacharya PK(Ed);

Medicine Update – APICON, Assam, 2003;7:699 – 703.

JAPI · VOL. 52 · AUGUST 2004 678 – 679

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ARTICLE 4

DIAGNOSIS OF LEPTOSPIROSIS – ROLE OF MAT

We read the article by Dutta et al on “Leptospirosis – An Overview” with

interest.1 The problem in utilizing Microscopic Agglutination Test (MAT) has

been highlighted and we shall discuss briefly the current status of MAT.

MAT is considered the gold standard test for diagnosis of Leptospirosis.

It has unsurpassed specificity, but its sensitivity is low compared to ELISA/SAT

(Slide agglutination test). Angelo P Brendo et al from Brazil in their study of 108

cases of Leptospirosis have stated that 65% of first sample where positive by SAT

compared to 44% by MAT.2

A four-fold rise in titer or seroconversion is the most definitive criteria

for diagnosis of Leptospirosis. Therefore, a second sample is mandatory, which is

difficult to obtain. In such circumstances, a single high titer in MAT can be taken

as diagnostic criteria. As MAT titers peak and persist for a long time (5 – 10 yrs),

they would interfere with current diagnosis. Therefore, many workers use

different criteria.3 A titer of 1:100 is taken as significant criteria, but there is

controversy on the single diagnostic titer as they depend on endemicity (Table 1).

In endemic areas, a titer of 1/100 or 1/200 is considered low; while high titer is

usually > 1/400 (some consider 1/800 or 1/1600 as diagnostic criteria). In non-

endemic areas, 1/100 titer is taken as diagnostic criteria. It is preferable to do

SAT/ELISA along with single high titers. Positive SAT/ELISA with high titers

suggest current infection, while negative SAT/ELISA is probably due to past

infection (Table 2). Therefore in the modified Faine’s criteria, a four-fold rise in

MAT has been given 25 points, while single high titer has been given 15 points

JAPI · VOL. 54 · APRIL 2006 338 – 339


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along with SAT/ELISA.4 In addition, low titers based on endemicity in the

original Faine’s criteria has been excluded as they complicate diagnosis.

Serosurvey in the asymptomatic high risk group should be done with MAT only

and titer of > 1/50 can be taken as cut off titer.

Table 1 : Endemicity and titer

Table 2 : Interpretation of Tests

ELISA/SAT MAT Interpretation +ve

+ve

-ve

±

Single high titer

-ve

Single high titer

Seroconversion/ 4 fold rise in titer

Current infection

Current infection

Past infection

Current infection

JAPI · VOL. 54 · APRIL 2006 338 – 339

MAT (single titer)

Asymptomatic (Serosurvey)

Symptomatic

High-risk group

General Population

≥ 1:50

Low Titer

High Titer

1:100 1:200

1:400 1:800 1:1600

15

Table 3 : Approach to diagnosis of Leptospirosis

Confirm (If available)

JAPI · VOL. 54 · APRIL 2006 338 – 339

Clinical features suggestive of current Leptospirosis

Leptospiremic phase < 7days Immune phase > 7 days

Negative MAT Positive

Positive Negative

Repeat (if low titer)

Rising titer

Repeat (> 3 days)

Blood culture

PCR ELISA / MSAT

Repeat

Seroconversion High titer


16

During an epidemic, the microbiology laboratories would be burdened

with large number of samples (about 25 or more). It would be impossible to do

MAT as it is complicated test. In addition the laboratories need to have all the 24

serogroups; otherwise, a negative MAT does not exclude current Leptospirosis if

the considered serogroup is not available. Therefore, ELISA/SAT are adequate

for current diagnosis. If facilities for MAT are available, then the test should be

done to confirm the diagnosis and identify serovars (Table 3).

To conclude there is an urgent need to study the prevalence and incidence

of Leptospirosis in India. This can be done by

1. Sero-survey of asymptomatic high risk groups utilizing MAT.

2. Diagnosis of current infection utilizing ELISA/SAT.

3. Evaluating the cut off titers of single high titer and determine the

serogroups utilizing MAT in samples with positive ELISA/SAT.

S Shivakumar*, B Krishnakumar** * Professor of Medicine; **Postgraduate in General Medicine; Department of Medicine, Stanley Medical College, Chennai REFERENCES:

1. Dutta TK, Christopher M. Leptospirosis – An overview. Assoc Physicians

India 2005;53:545-51.

2. Brendo AP, Camargo ED, De Silva ED et al. Macroscopic agglutination

test for rapid diagnosis of Heman Leptospirosis. J Clin Microbiol

1998;36:3138-42.

3. Katz AR, Ansell VE, Effler PV, et al. Assessment of the clinical

presentation and treatment of 353 cases of laboratory confirmed

Leptospirosis in Hawaii, 1974-1998. Clini Infect Dis 2001;33:1834-41.

4. Shivakumar S, Shareek PS. Diagnosis of Leptospirosis – Utilizing

modified Faine;s criteria. J Assoc Physicians India 2004;52:678-9.

JAPI · VOL. 54 · APRIL 2006 338 – 339

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ARTICLE 5

LEPTOSPIROSIS IN MADRAS –

A CLINICAL AND SEROLOGICAL STUDY

(1990 – 91)

MA MUTHUSETHUPATHI*, S SHIVAKUMAR*, R SUGUNA*,

M JAYAKUMAR*, R VIJAYAKUMAR*, COR EVERARD +,

DG CARRINGTON +

ABSTRACT

Leptospirosis was confirmed by Microscopic Agglutination Test (MAT) and/or ELISA in 57 patients admitted to the Government General Hospital, Madras, India, during November and December of 1990 and 1991 with symptomatology suggestive of the disease. Fifty (88%) of the 57 cases were males; the mean age of all the cases was 39.6 years (range 17 – 72). The main clinical features were: fever 100%, Jaundice 84%, Myalgia 82%, Acute Renal Failure 72% and Conjunctival Suffusion 58%. Non azotemic jaundice occurred in 19% of cases. Renal failure was non-oliguric in 24% of cases. 3.5% of patients died. 23 patients underwent peritoneal and/or hemodialysis. ELISA IgM titres ranged from1:80 to 1:10240 (geometric mean tire 911). MAT titres > 1:1600 and > 1:800 occurred in 39 of 54 and 51 of 54 cases respectively. Autumnalis was the serogroup most commonly recorded serologically, and Leptospira interrogans serovar autumnalis was isolated from one patient. This study shows that Leptospirosis is a significant health problem in Madras, though normally grossly underestimated due to the absence of routine laboratory diagnostic facilities for the disease. Gross under-reporting is also likely in other high rainfall third world areas.

* Department of Nephrology, Madras Medical College, Madras, India + Formerly of the Leptospira, Bridgetown, Barbados

JAPI · 1995, VOL. 43 · NO.7 456 – 458


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INTRODUCTION

Leptospirosis had long been considered a rare zoonotic disease in India,

with only sporadic cases being recorded. Recently, however, the disease was

reported from Madras during the monsoon months in mini-epidemic proportions.1-3

Leptospiral infection is now recognized as a common cause of acute renal failure

in Madras.4

Leptospirosis has been under-diagnosed and under-reported from India

due to a lack of awareness of the disease, a lack of appropriate laboratory

diagnostic facilities in most parts of the country, and a reliance on indigenous

remedies to treat jaundice. Combining clinical expertise and awareness with

confirmatory laboratory backup dramatically increases the recognition of patients

with Leptospirosis.

PATIENTS AND METHODS

Single, paired or triple serum samples were obtained from patients with

clinical symptoms of Leptospirosis admitted o the Government General Hospital,

Madaras, during November-December of 1990 and 1991. The sera were

lyophilized and sent with ice packs to the Leptospira Laboratory, Bridgetown,

Barbados, where they were examined by the Microscopic Agglutination Test

(MAT)and/or the Enzyme-linked Immunosorbent Assay (ELISA). The ELISA

was undertaken using Leptospira biflexa, serovar patoc as an antigen to detect

specific IgM and IgG anatibodies.5 A patient was considered to have current

Leptospirosis if he had an ELISA IgtM titre of > 1:80 coupled with confirmatory

MAT serology and vice versa. The MAT was performed with 22 live culture

antigens using standard microtitre methodology6,7. The sera were initially

screened at dilutions of 1:50 and 1:100 and those that were positive were titrated

further to the end-point. The serogroup reacting at the highest titre was presumed

to be the infecting one. Where two or more serogroups reacted at the same

JAPI · 1995, VOL. 43 · NO.7 456 – 458

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(highest) titre the result was recorded a “mixed equal”. Using EMJH medium

according to the standard methodology of Sulzer & Jones. Attempts were made to

culture leptospires from the blood of a few of these patients7.

The following data were noted for patients considered to have current

Leptospirosis: age, gender, occupation, residence, and clinical features including

fever, myalgia, jaundice, conjunctival suffusion, oliguria, volume depletion,

bleeding diathesis, gastrointestinal and neurologicval symptoms. The relevant

hematological and biochemical tests (liver and renal function) were also done.

Patients were started on a conservative treatment including maintenance of fluid

and electrolyte balance and administration of one million units i.v. of Benzyl

Penicillin four times a day. Peritoneal dialysis (PD) was instituted if patients had

severe renal failure (plasma Creatinine > 440uMol/L), acute pulmonary oedema,

severe metabolic acidosis or hyperkalemia. Hemodialysis (HD) was undertaken if

there was a contraindication to PD, or if the patient was in hypercatabolic renal

failure.

RESULTS

Current Leptospirosis was confirmed in 57 of the 70 patients whose sera

were examined by the MAT and ELISA. 31 patients provided single serum

samples, and 26 provided repeat samples. On average, the first, second and third

serum samples were taken 12.3 days (all 57 cases), 20.9 days (26 cases), and 28.5

days (7 cases) following onset of illness. The mean age of the 57 cases was 39.6

years (range 17-72); 50 (88%) were males. Occupation varied though not

surprisingly 28 (49%) cases were outdoor manual workers (Table 1). The

pataients came from various parts of the city, and no geographical clustering of

cases was evident.

JAPI · 1995, VOL. 43 · NO.7 456 – 458


20

The important clinical features and abnormal biochemical reports of those

57 patients are shown in Tables 2 and 3. All patients had fever. 48 of the 57

(84%) patients were icteric (serum bilirubin 17 uMol/L); the mean serum bilirubin

was 231.5 ± 159 uMol/L, with the highest value being 646 uMol/L. Jaundice

without renal failure occurred in 11 patients. The transminase levels were only

moderately elevated (4-fold). Renal failure occurred in 41 patients (Per >180

uMol/L), and was severe in 12 cases. 31 (76%) of renal failure patients were

oliguric. Anicteric renal failure occurred in four (9.7%) patients. Myalgia (82%),

conjunctival suffusion (58%) and volume depletion (39%) were the other major

clinical features noted. Thrombocytopenia occurred in 13 patients. Of the 23

patients who needed dialytic support, 18 (78%) were managed by peritoneal

dialysis. 4 patients were switched from peritoneal dialysis to haemodialysis and

only one patient needed haemodialysis from the beginning. Two patients died

(3.5%).

Of the 57 cases, only two had ELISA IgM titres of 1:80, four had 1:160,

and 51 had > 1:320. The highest value was 1:10240, and the geometric mean titre

(GMT) was 911. The IgG values ranged from 1:80 to 1:20480 (GMT 922). MAT

titres were not available for three patients; three patients had MAT titres in the

range 1:100 – 1:400; while the remaining 51 cases all had MAT titres > 1:800 (39

patients had titres > 1:1600). Of the 31 patients who provided single samples,

only one had an IgM value < 1:160 and another had a MAT valaue < 1:800.

considering the 26 repeat samples, nine showed rising titres, nine had stable titres

and eight had declining titres, particularly with regard to IgM but also to the IgG

and MAT values.

Serogroup Automnalis predominated in 40 of the 54 patients for whom

MAT results were available, with titres ranging from 1:100 to 1:51200 (GMT

2557). 38 of the 40 patients had titres > 1:800. In the “mixed equal” group, eight

JAPI · 1995, VOL. 43 · NO.7 456 – 458

21

patients had titres in the range 1:800 – 1:3200 to Autumnalis and Australis (GMT

1234). The presumptive infecting serogroups in the remaining 6 cases were

Icterohaemorrhagiae (2), Cynopteri (2), Australis (1) and Canicola (1). A single

isolate obtained was identified by the Leptospira reference Laboratory in

Amsterdam as Leptospira interrogans serovar autumnalis.

Table 1: Occupations of 57 cases of Leptospirosis in Madras City

Work Category No. %

Outdoor manual workers Indoor/outdoor artisans Outdoor non/manual workers Indoor non manual workers Housewives Unemployed Retired Unknown

28 7 5 6 7 1 1 2

49.0 12.3 8.8 10.5 12.3 1.8 1.8 3.5

Table 2 : Clinical features (n = 57)

N % Fever Jaundice Myalgia Oliguria Conjunctival Suffusion Vomiting Altered Sensorium Volume Depletion Gastrointestinal Bleed Diarrhoea Headache Abdominal Pain Hemoptysis Meningitis Epistaxis

57 48 47 41 33 33 24 22 15 15 15 10 5 4 2

100 84 82 72 58 58 42 39 26 26 26 18 9 7 3

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22

Table 3 : Abnormal biochemical reports

PARAMETER n MEAN ± S.D RANGE

Plasma Urea (mmol/L)

Plasma Creatinine (uMol/L)

Plasma Bilirubin (uMol/L)

AAST (IU/L)

ALT (IU/L)

Platelets (105/c.mm)

41

41

48

25

27

13

23.5 ± 9.1

362.56 ± 119.9

231.46 ± 159

58.4 ± 24.4

70.4 ± 20.4

0.84 ± 0.2

15.0 – 49.0

204 – 661

20 – 646

20 – 125

24 – 132

0.2 – 0.98

DISCUSSION

Everard and Everard point out that where leptospires are widespread in

the environment, and where the disease is endemic, infection will be related to a

way of life as well as to specific occupations8. Thus, where there are large

numbers of rodents, stray dogs and wild animals, where people drink or bathe in

untreated water, where sewerage and drainage are inadequate, and where open

shoes or none at all are worn, leptospiral infection can be common. In such places

occupational risk factors are so inextricably linked with lifestyle risk factors that

investigations of sources of infection in individuals are inappropriate. In Madras

the general truth applies – that maleness, high rainfall and outdoor manual

occupation encourage higher incidence rates of Leptospirosis and that more

specific sources cannot be pinpointed with certainty.

Leptospira can survive outside the hosts vertebrate body more easily

under conditions of warmth and adequate rainfall (or in riverine areas) and if

looked for can be readily detected in man and other mammals (domestic,

peridomestic or wild) throughout the tropical belt. Long term environmental

JAPI · 1995, VOL. 43 · NO.7 456 – 458

23

changes are usually not sudden and dramatic and the increase in hospital

admissions with Leptospirosis from 9 cases in the 6 year period 1979 – 1984 to

159 cases in the 5 years 1987 – 1991 can be attributed to improved clinical

expertise and laboratory confirmation.

A simple, rapid diagnostic laboratory test is needed to confirm suspected

mild and severe cases, and as importantly, to eliminate non-cases. At this time,

ELISA should be the test of choice for the diagnosis of current illness. ELISA

(IgM) is more sensitive than the MAT and simpler to perform in a routine hospital

diagnostic laboratory, but it cannot determine the infecting serogroup. The

detection of specific IgM, which usually develops a few days after the onset of

fever, helps in the fairly rapid diagnosis of current infection. A high IgM titre in a

single blood sample can be diagnostic, though taking repeat samples should be

made mandatory to compare changes in titre. In the 31 single sample results, IgM

alone was just about adequate to diagnose nearly all the current infections. If a

MAT titre of 1:1600 is taken as diagnostic, they only 20 of 29 (two cases not

tested by MAT) would have been confirmed. At a MAT diagnostic level of 1:800,

the number of confirmed cases would have been 28. However, particularly in

endemic areas, evidence of previous infection, whether mild or severe, can be

common, and an elevated MAT from a single sample would inevitably result in a

false positive. (In some individuals MAT titres of 1:1600 have been known to

persist for a few years). Thus for single samples, ELISA IgM and MAT must be

combined. Because of the delay in antibody development (7 – 10 days after onset

of first symptoms) single early blood samples may not have any detectable

antibody and the negative result could be equally misleading. Thus at least two

serum samples taken at least 3 to 4 days apart should be examined before a

negative result can be confirmed.

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24

Although the MAT is the test for choice for serological surveys, it is

complicated, has to be permanently established, and uses numerous serovars

which must be maintained aseptically in stock culture. Normally it is used daily or

weekly. Its main advantage is that it gives a good indication of infecting

serogroup, especially late in illness or in surveys, since it detects serovar specific

antibodies which tend to peak later. Repeat samples (ideally demonstrating a four

fold rise in titre) are usually necessary to confirm or disprove current illness.

MAT titres may take several years to decline. This of considerable value in

epidemiological studies, but it complicates the diagnosis of current illness,

particularly where recent asymptomatic or mild reexposure had resulted in

misleading anamnestic rise in titre.

Of the 57 Leptospirosis cases studied, 48 had jaundice and 41 renal

failure. By comparison, about 97% of all hospital cases of Leptospirosis on

Barbados were icteric. The jaundice was cholestatic in type as characterized by

high bilirubin levels with moderately elevated transaminases. Non azotemic

hepatitis occurred in 19% of patients. Renal failure was severe in 21% and was

non-oliguric in 24%. All patients received intravenous benzyl penicillin, though

its effectiveness in late Leptospirosis is controversial.9,10 Peritoneal disalysis was

adequate for most patients. Only two patients (3.5%) died.

A serosurvey recently undertaken by Ratnam et al, among conservancy

workers in Madras (using MAT) revealed a seropositive prevalence rate of 32.9%

(range 17.8% to 40.5%).11 The predominating serogroup was Autumnalis.

Autumnalis was also the most commonly recorded serogroup (serologically and

bacterilogically) in the present study.

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25

ACKNOWLEDGEMENTS

The authors are indebted to the UK Medical Research Council, British

Council and Overseas Development Administration for their support and

assistance. We are also most grateful to the staff of the Barbados Leptospira

(particularly Carol Whitington) and staff of the Department of Nephrology,

Madras Medical College, for their help; and to Hans Korver of the WHO

Leptospirosis Reference Laboratory at the N.H. Swellengrebel Labaoratory for

Tropical Hygiene, Royal Tropical Institute, Amsterdam, for identifying our

isolate.

REFERENCES:

1. Krishnamurthi MV, Madanagopalan N, Hussain AT. Leptospirosis in

Madras. J Assoc Phys India 1965; 13: 737-740.

2. Muthusethupathi MA, Shivakumar S. Acute renal failure due to

Leptospirosis. J Assoc Phys India 1987;35: 631-633.

3. Muthusethupathi MA, Shivakumar S, Suguna Rajendran, Vijayakumar R,

Jayakumar M. Leptospiral renal failure in Madras City. Ind J. Neph. (New

Series). 1991; 1: 151-17.

4. Muthusethupathi MA, Shivakumar S, Jayakuamar M, Rajenderan S. Acute

renal failure in Madras City – Changing Profile. Ind J. Neph. (New

Series).1993; 3: 66 – 70.

5. Terpstra WJ, Lingthart TS, Schooner GJ. ELISA for the detection of

specific IgM and IgG in human Leptospirosis. Journal of General

Microbiology 1985; 131: 377-385.

6. Cole JR, Sulzer CR, Pursell AR. Improved Microtechnique for the

leptospiral microscopic agglutination test. Applied Microbiology 1973; 25:

976.

JAPI · 1995, VOL. 43 · NO.7 456 - 458


26

7. Sulzer CR & Jones WL. (1978) Leptospirosis; methods in laboratory

diagnosis. (Revised edition – reprinted.) US Department of Health,

Education and Welfare, Public Health Service, Centers for Disease Control,

Atlanta, Georgia, HEW Publication No.(CDC) 79 – 8275.

8. Everard JD, Everard COR. Leptospirosis in the Caribbean. Reviews in

Medical Microbiology 1993; 4: 114-122.

9. Watt G, Tuazom MA, Santiago LE. Placebo controlled trial of intravenous

penicillin for severe and late Leptospirosis. Lancet 1988; 1: 433-435.

10. Edwards CN, Nicholson GD, Hassell TA, Everard COR. & Calendar J.

Penicillin therapy in Icteric Leptospirosis. Am J Trop Med Hyg. 1988; 39

(4): 388-390.

11. Ratnam S, Everard COR, Alex JC, Suresh B, Thangaraju P.Prevalence of

leptospiral agglutinins among conservancy workers in Madras City, India.

Journal of Tropical Medicine and Hygiene 1993; 96: 41-45.

JAPI · 1995, VOL. 43 · NO.7 456 - 458

27

ARTICLE 6

RENAL INVOLVEMENT IN LEPTOSPIROSIS –

OUR EXPERIENCE IN MADRAS CITY

(1987 – 93)

MA MUTHUSETHUPATHI, S SHIVAKUMAR, R VIJAYAKUMAR,

M JAYAKUMAR

INTRODUCTION

Leptospirosis is now recognized as one of the important causes of Acute

Renal Failure (ARF) in Madras city.1-3 It has been under diagnosed in other parts

of the country probably due to lack of diagnostic facilities. In Thailand and

Singapore, it is the leading cause of ARF.4 In this article, we shall discuss the

various aspects of Leptospirosis and give our experience over the past few years.

EPIDEMIOLOGY Leptospirosis is an infectious disease caused by leptospira interrogans

complex which has over 20 sero groups and more than 200 serovars. The major

vectors to humans are rodents, though other animals such as cattle, dogs and pigs

can also transmit the illness.

These organisms are excreted in the urine of the animals and they affect

man when he comes into contact with the urine of infected animals directly or

indirectly when he is exposed to an environment contaminated by the urine of the

infected animals such as soil or surface water following monsoon rains.

Therefore, this illness commonly occurs during the monsoon. These organisms

survive for 6 hours in dry soil and for 6 months in flooded conditions. They enter

the host through abrasions of the skin (of the feet when they come into contact

with infected water) or intact mucus membranes of the eye, throat and gut, when

From: Department of Nephrology, Government General Hospital, Madras

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28

contaminated food is ingested. In urban areas of developing countries, a

contaminated environment due to various factors such as – overcrowded slums,

inadequate drainage and sanitation facilities for both man and animals, presence of

stray dogs, cattle, pigs and domestic rats and bandicoots, poor condition of

slaughter houses and people walking barefooted, contributes to the spread of this

illness.5,6

In rural areas, high-risk groups are workers in rice fields, can fields and

other agricultural crops and animals husbandry staff. In addition, workers in

sewers, mines and military operations are also at risk. Though Leptospirosis is

considered an occupational disease, a contaminated environment makes any

person vulnerable to infection. In Madras City, we have noted a dramatic increase

in Leptospirosis during the past few years. Between 1979-84, there were only 10

cases of renal failure due to Leptospirosis, but between 1987-91, there were 120

cases.1 In the last 2 years (1992-93), there were only 15 cases of leptospiral ARF.

The reasons for the decline are not clear. The annual incidence is shown in

Table 1.

Most of these patients were males and were seen during the monsoon

months. The infection is probably transmitted to people when they wade through

stagnant rainwater contaminated by infected urine of animals. There was no

relationship to any specific occupation though most of them were outdoor manual

J POSTGRAD MED 1994; 40(3) : 127 - 31

Table-1 : Annual Incidence of Leptospirosis : Nephrology Department, Government General Hospital, Madras

1987 1988 1989 1990 1991 1992 1993 Leptospirosis 4 21 26 60 48 8 9

Leptospiral ARF 4 20 21 45 30 8 7

29

laborers. These patients were seen from various parts of the city and there was no

geographical clustering. This emphasizes the epidemiological important of a

contaminated environment in the spread of Leptospirosis. A sero survey

conducted among conservancy workers in Madras City has revealed a prevalence

rate of about 33%.7

The common reservoirs appear to be rodents such as bandicoots, though it

has been reported in domestic animals such as dogs, cattle, goat, sheep and

buffaloes.8,9 Studies have revealed that the common serogroup is L. autumnalis

though other groups such as L. icterohaemorrhagia, L. canicola and L. Pomona

have been reported.1,2

CLINICAL FEATURES

The clinical features vary from a mild anicteric illness characterized by

fever, Myalgia and Conjunctival suffusion, to a severe illness in which jaundice,

renal failure, bleeding diathesis, meningitis and Myocarditis (Weil’s syndrome or

Icteric Leptospirosis) occur. The incubation period is 7 – 14 days but ranges from

2 to 21 days. Ninety percent or more of all cases of Leptospirosis are anicteric.11

Most patients noted by us presented with fever, Myalgia, conjunctival

suffusion, jaundice and renal failure. The comparisons of various clinical studies

are shown in Table 2.

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30

Although, the clinical course of leptospiral infection may vary in

individual cases, in general, it is predictable in that both anicteric and icteric cases

follow a biphasic course. The initial or “septicemic phase” is characterized by

development of fever, Myalgia, conjunctival suffusion, headache and vomiting.

Termination of this phase occurs after 4 to 7 days, with defervescence of fever and

symptomatic improvement coincident with the disappearance of leptospires from

the blood, cerebrospinal fluid and all other tissues with the exception of the

aqueous humor and renal parenchyma.

Circulating antibody titres leptospires develop rapidly and this immune

response ushers in the second or “Immune stage” of the illness, which varies in

duration from 4 to 30 days or longer. The “Immune stage” is characterized by

manifestations of the immune response of the host to the infecting

J POSTGRAD MED 1994; 40(3) : 127 - 31

Table – 2: Clinical features – comparison of various studies Barbados United States Korea India (Edwards) (Heath) (Park) (Muthusethupathi) Reference (12) (13) (14) (1987-91) Patient No. 88 345 93 159 Fever 85 100 97 100 Renal Failure 49 26 15 75 Jaundice 95 43 16 85 Conjunctival 54 33 58 42 Suffusion Myalgia 49 68 88 80 Bleeding 2 4 40 2 Diathesis CNS 2 21 6 43 Manifestations

(Figures represent %)

31

microorganisms. Leptospires are found only in renal and ocular tissue during this

phase. Leptospiruria, a hallmark of this stage, generally continues for 1 to 3

weeks, but rarely longer than 1 month, and is unaffected by antimicrobial therapy.

Meningitis and Uveitis become apparent and reach ‘peak’ intensity during this

stage of the disease.

The demarcation between the first and second stages is rarely as distinct

in patients with severe icteric illness as it is in anicteric cases. In the former, the

biphasic course of disease often is obscured. Although many authors have

regarded the onset of jaundice as the beginning of immune phase, it is not always a

reliable index because some investigators have been able to isolate organisms

from the blood of patients who have been icteric for 24 to 48 hours.11 It is

considered that jaundice, renal failure and other features of Weil’s syndrome are

“first stage” features and are due to leptospiremia, rather than to immune

mechanisms.

Data on anicteric illness have not been adequately reported from our

country probably due to lack of awareness. Available data only reveal a high

incidence of severe Leptospirosis with jaundice and renal failure.

Renal involvement is the most serious complication and is the commonest

cause of death. Renal manifestations range from urinary sediment changes

(pyuria, hematuria and granular casts) to renal failure. Renal manifestations are

observed commonly in all forms of Leptospirosis regardless of severity of disease

or of the infecting serogroup. In anicteric patients, proteinuria, microscopic

hematuria and azotemia have been noted. Proteinuria is mild and is due to the

febrile state. Hematuria may be due to hemorrhagic diathesis rather than

glomerular injury.

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32

Azotemia has been divided into two groups.15,16 The first is characterized

by decreased renal perfusion with diagnostic indices suggestive of pre renal

azotemia, with a good response to fluid administration. The second is

characterized by features consistent with tubular necrosis with no respose to fluid

challenge. It has been emphasized that hemodynamic alterations (Hypotension,

volume depletion) responsible for the former, may result in acute tubular necrosis

if uncorrected. In addition, acute interstitial nephritis may account for renal failure

regardless of the hemodynamic state. Renal failure occurs in the second week but

it can occur as early as the fourth day. It may be short lived or prolonged for upto

two weeks.

The pathogenesis of renal failure in Leptospirosis is multifactorial and

may include a) Hypoxia secondary to hypovolemia/Hypotension b) direct

nephrotoxicity due to toxic by products of leptospires. The possible causes of

hypovolemia and Hypotension must be considered. Body fluid loss due to

vomiting, increased insensible water losses, and diminished intake of fluid are

responsible for hypovolemia and Hypotension in some cases. Decreased

intravascular volume secondary to a shift in fluid from the intra – to extra vascular

space as a result of severe endothelial injury has been suggested, which result in

Hypotension and shock. Massive gastrointestinal hemorrhage is an important

cause of hypovolemia. Adrenal insufficiency secondary to adrenal hemorrhage is

a rare cause of Hypotension.

Hypo perfusion may also be the result of cardiac dysfunction. Cytotoxic

factors may be responsible for toxic tubular injury though nosuch toxin has been

isolated so far. In the kidney, leptospires initially cause glomerular injury and by

hematogenous spread, the organisms reach peritubular capillaries and migrate to

the interstitium, renal tubules and tubular lumen causing interstitial nephritis and

tubular necrosis.17

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33

The kidneys are greatly swollen with pale cortex and congested medulla.

Glomerular changes are mesangial proliferation with polymorphonuclear

infiltration. On immunofluorescence staining, nonspecific C3 uptake is reported

in the mesangial area and occasionally in the affected arterioles. C1q and IgM

deposition may be noted occasionally in the mesangial area. On electron

microscopy, occasional dense deposits are seen in the mesangial, paramesangial

and intramembranous location. Vascular changes in the kidney consist of

endothelial swelling and necrosis with platelet aggregation, especially in the

cortico- medullary region. Interstitial nephritis is the basic renal lesion

characterized by mononuclear cells infiltration.17

Renal failure in Leptospirosis is primarily the result of tubular damage.

Though some investigators have emphasized that interstitial nephritis is the

fundamental renal lesion of Leptospirosis others have found that it occurs only

inpatients who have survived until inflammation has had an opportunity to

develop.17,18 Evidence of interstitial nephritis frequently is absent in patients

whose disease is characterized by a rapid, fulminant course. Sequential

observations of histologic, enzymatic and functional renal changes in both animal

and human Leptospirosis suggest that the initial and most prominent renal lesion

is tubular and that in many cases it is unaccompanied by interstitial inflammatory

infiltrates. These tubular lesions are similar to acute tubular necrosis of other

causes.18

We did not do biopsy in most of our patients as serology was adequate for

diagnosis and there are no pathognomonic changes in Leptospirosis. In addition,

as bleeding diathesis is an important component of this illness we did not take the

risk of renal biopsy. In an earlier study, we did biopsy in a few patients and they

revealed acute interstitial nephritis.

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34

Most patients with renal failure also have significant hepatic involvement.

Jaundice occurs between the fourth and sixth day but may occur as early as the

second day or as late as the 9th day. Jaundice is partly due to hepatocellular

damage. However, hepatocellular necrosis is usually mild and additional factors

include intrahepatic cholestasis and increased billirubin load from absorption of

blood from tissue haemorrhage. Death is rarely due to hepatic failure. In our

patients, marked elevation of serum billirubin with near normal or mildly elevated

SGOT and SGPT levels were characteristic.

DIAGANOSIS

Laboratory diagnosis involves the isolation of leptospira in culture of

blood and urine and serological tests.

ISOLATION PROCEDURES

Isolation of leptospires from blood or cerebrospinal fluid generally can be

achieved only during the first 10 days of clinical illness. Leptospires usually

appear in the urine during the 2nd week of disease and may persist for 30 days or

longer. In general, other than blood, urine or cerebrospinal fluid, only tissue

sections obtained by biopsy or at necropsy serve as sources from which organisms

can be isolated. Fletcher’s semisolid medium or EMJH semisolid mediums are the

media often used.

SEROLOGICAL TESTS

a) Microscopic agglutination test (MAT) – MAT is considered the comer

stone of serodiagnosis.19 Rising titres or initial high titres are diagnostic of

leptospiral infection. The main advantage of MAT is that the serovars can be

identified which is of epidemiological importance. The main disadvantage is that

the titres rise late and peak about the third or fourth week. The high titres of MAT

take a much longer time to decline, which is of value for epidemiological studies,

but the presence of high titres from previous infection complicate the diagnosis of

current infection.6

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35

b) ELISA – The ELISA is now the test of choice for the diagnosis of current

infection. It detects specific IgM and IgG antibodies. Detection of specific IgM

antibodies helps in the rapid diagnosis of current infection.6,20 This test detects

genus specific antibodies which tend to become positive early in the disease and

also revert early. It is a relatively simple test as the antigen used is genus specific.

This test cannot determine the infecting serogroup. A high titre in a single sample

can be diagnostic though repeat samples may be necessary if initial titres are low.

Recently, a collaborative study done with Leptospira laboratory

Barbados, using ELISA for estimating elevated specific IgM titres has confirmed

the diagnosis of current leptospiral infection in Madras city.10 In addition, MAT

study revealed L. autumnalis tobe the commonest serogroup. L. auatumnaalis was

isolated from the blood of one of our patients at the Royal Tropical Institute,

Amsterdam.

MANAGEMENT

The conservative treatment of Leptospirosis consists of giving antibiotics

(Penicillin, Doxycycline) and adequate hydration. The efficacy of antibiotics in

the treatment of Leptospirosis remains controversial because of conflicting

data.22,23 It is generally believed that antibiotics are effective only if given early in

the course of disease and their efficacy in unknown in late or severe disease. Watt

et al22 conducted a placebo controlled trial of intravenous penicillin for severe

(S.Cr > 177 micromoles/L) and late (symptoms > 4 days) Leptospirosis in 42

patients and included that antibiotic therapy was definitely useful in these patients.

Fever lasted more in the placebo group compared to the treated group (11.6 vs 4.7

days) Creatinine rises persisted more than thrice as long in the patients receiving

only placebo (8.3 vs 2.7 days) Penicillin also shortened the hospital stay and

prevented leptospiruria.22 However, Edwards et al in a prospective controlled

study in 70 patients concluded that penicillin therapy has no effect in severe

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36

Leptospirosis. In animal studies, fewer deaths and less severe course of the

disease among penicillin treated, jaundiced puppies compared to untreated

controls were noted by Yoder et al.24 Hamsters severely ill with Leptospirosis

survived when given penicillin 1 – 2 days before the expected time of death.22

The overall impression thus seems to be that antibiotics are useful even in severe

or late Leptospirosis. It has been our policy to treat all patients with intravenous

crystalline penicillin. Of primary importance is the meticulous attention, which

must be paid, to fluid and electrolyte balance. Hypovolemia and Hypotension

needs prompt and specific treatment with intravenous fluids. In patients with

oliguria, if prerenal azotemia is suspected, prompt diuresis should be attempted

with fluid therapy. In patients who have no response to such therapy, they should

be managed as for ARF.

Peritoneal dialysis has been found to be a safe, simple and effective

procedure in the management of leptospiral ARF. Peritoneal dialysis was

adequate for most of our patients who needed dialysis (Table 3).

The overall mortality was 20.8% in our experience.

J POSTGRAD MED 1994; 40(3) : 127 – 31

Table – 3 : Dialysis and mortality data of leptospiral ARF (1987 – 91)

No. : 120 Mean age (Yrs) : 40.1 Males : 108 Peritoneal dialysis : 56 Haemodialysis : 14 Mortality No. : 25 % : 20.8 ----- Total No. of Leptospirosis : 159 -----

37

REFERENCES:

1. Muthusethupathi MA, Shivakumar S, Jayakumar M, Rajendran S. Acute

Renal failure in Madras City – Changing profile. Ind J Nephrol (New

series) 1993 ; 3 : 66-70.

2. Muthusethupathi MA, Shivakumar S, Suguna Rajenderan, Vijayakumar R,

Jayakumar M. Leptospiral Renal Failure in Madras City. Ind J Nephrol

1991; 1 : 15 – 7.

3. Muthusethupathi MA, Shivakumar S. Acute Renal Failure due to

Leptospirosis. J Assoc Phys India. 1987 ; 35 : 631 – 3.

4. Rastegar A, Sitprija V, Rocha R. Tropical Nephrology. In:Schrier RW,

Gottschalk CW (Es.,) Diseases of the Kidney – Fourth Edition. Boston.

Little. Brown and Company 1988; 2583 – 613.

5. Faine S. Guidelines for the control of Leptospirosis. WHO offset

Publications 1982; 67 : 151 – 3.

6. Everard JD, Everard COR Leptospirosis in the Caribbean. Reviews in

Medical Microbiology 1993; 4 : 114-22

7. Ratnam S, Everard COR, Alex JC, Suresh B, Thangaraju P. Prevalence of

Leptospiral agglutinins among conservancy workers in Madras City, India.

J Trop Med and Hygiene 1993; 96 : 41 – 5.

8. Ratnam S, Sundararaj T, Subramaniam S : Role of bandicoots in human

Leptospirosis in Madras City – An epidemiological approach. Ind J Pub

Health 1986; 30 : 167-8

9. Ratnam S, Subramaniam S, Sundararaj T : Evidence of Leptospiral

antibodies among domestic animals in Madras City. Cherion 1983; 12 :

176 – 9.

J POSTGRAD MED 1994; 40(3) : 127 - 31


38

10. Shivakumar S, Muthusethupathi MA, Everard COR et al. Leptospirosis in

Madras City – A collaborative study (abstract). V Asian Pacific Congress

of Nephrology 1992; 44.

11. Folgin RD, Anderson DC. Human Leptospirosis. CRC Crit Rev Clin Lab

Sci 19175; 5 : 413 – 67.

12. Edwards CN, Nicholson GD, Hassell TA, Everard COR Callender J.

Leptospirosis in Barbados – A clinical study. W I Med J 1990; 39 : 27 –

34.

13. Heath CW, Alexander AD, Galton MM. Leptospirosis in the United

States. N Engl J Med 1965; 273 : 857.

14. Park YK, Park SK, Rhee YK, Kang SK. Leptospirosis in the Chonbuk

province of Korea in 1987. Korean J Intern Med 1990; 5 : 34 – 43.

15. Sitprija V. Renal Involvement in human Leptospirosis. Br Med J 1968; 2

: 656 – 8

16. Nicholson GD, Edwards CN, Hassell TA, Everard COR, Callender J.

Urinary Diagnostic Indices in the Management of Leptospirosis –

Selection of patients for Dialysis Therapy. W I Med J 1989; 38 : 33 – 8.

17. Sitprija V, Pipalangul V, Metrowidjoji K. Pathogenesis of Renal disease

in Leptospirosis – Clinical and experimental studies. Kidney Int 1980;

17 : 827 – 36.

18. Arean VM. The pathologic anatomy and pathogenesis of fatal human

Leptospirosis (Wells disease). Am J Pathol 1962; 40 : 393 – 6.

19. Cole JR, Sulzer CR, Pursell AR. Improved micro technique for the

leptospiral microscopic agglutination test. Applied Microbiology 1973;

25 : 976.

J POSTGRAD MED 1994; 40(3) : 127 - 31

39

20. Terpstra W.J. Ligthart GS, Schooner GJ. ELISA for the detection of

specific IgM and IgG inhuman Leptospirosis. Journal of General

Microbiology 1985; 131 : 377 – 85.

21. Alexander AD, Rule PI. Penicillin, Cephalosporins and Tetracyclines in

treatment of hamsters with fetal Leptospirosis. Antimicrob Ag Chemother

1986; 30 : 835-39

22. Watt G, Tuazom MA, Santiago LE. Placebo Controlled trial of

intravenous penicillin for severe and late Leptospirosis. Lancet 1988;1 :

433 – 5

23. Edward CN, Nicholson GD, Hassell TA, Everard COR, Callendar J.

Penicillin therapy in icteric Leptospirosis. Am J Trop Med Hyg 1988;

39(4) : 388-90

24. Yoder HW, Bergman HN, Glener CA. Experimental Canine Leptospirosis

IV. Evaluation of selection antibiotics in the therapy of acute experimental

leptospira icterohaemorrhagic infections in immature dogs. J Infect Dis

1957; 100 : 257 – 67

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40

ARTICLE 7

LEPTOSPIROSIS – NEED FOR URGENT ACTION

Leptospirosis is an important cause of acute renal failure (ARF) in

Madras City, especially during and after the monsoon rains, when it assumes

near epidemic proportions1. In 1988, like in previous years, many cases of

leptospiral renal failure were treated at several large hospitals in Madras City;

in the Government General Hospital alone 21 cases of leptospiral renal failure

were encountered.

Leptospirosis is a public health problem of great importance since (a)

it has a predilection for people following certain occupations (e.g. workers in

rice or cane fields, veterinarians, sewage workers) causing loss of considerable

man-hours in a vital section of our economy (b) it affects domestic and farm

animals causing abortion and (c) it can be prevented by taking appropriate

public health measures. In view of these facts, the World Health Organization

(WHO) has done considerable work in this field and has laid down excellent

guidelines for the diagnosis and control of Leptospirosis2.

We have been interested in and are working on this problem since

1985. In the light of our experience, we would like to point out some

important facts and problems pertaining to diagnosis, management and

prevention of this condition in our country.

JAPI 1989, VOL. 37, NO.7 477

41

1. Diagnosis: Leptospirosis has a variety of clinicala manifestations;

once suspected, it can be confirmed by (a) isolation of pathogenic leptospira

from urine or blood (b) demonstrating a rising titre of leptospiral antibodies by

agglutination tests or (c) demonstration of leptospira in blood or urine by dark

field microscopy. Of these, (c) is the least reliable, since artifacts can easily be

mistaken for the organism; (a) is the most specific but needs a special

laboratory and trained personnel; it is not a sensitive test and several cases may

be missed, (b) comprises macroscopic agglutination test as a screening

procedure and microscopic agglutination test to determine the serogroup.

Overall, the best screening test is the macroscopic agglutination test, which can

be easily performed and is inexpensive.

The problem is that even this test is not readily available in

microbiology laboratories in our country. From the reports of our colleagues,

we are convinced that Leptospirosis occurs in many places in Tamil Nadu,

Kerala and elsewhere. Physicians are unable to get the diagnosis confirmed

due to lack of laboratory facilities. We have been helped in all our studies by

the Department of Veterinary Preventive Medicine, Madras, but for the

majority of our colleagues, no such help is available.

2. Epidemiology: Before control measures are started, it is essential

that we have relevant data on the problem. Since it is not transmitted by

humans and is initially confined to the animal reservoir, a thorough study

should involve animals in the locality also.

JAPI 1989, VOL. 37, NO.7 477


42

The principles of epidemiological investigations are (i) Identification

of cases (human and animals) (ii) Search for the source of individual

infections, and of epidemic and epizootic waves. (iii) Establishment of a level

of endemic and enzootic infection. (iv) Advice on implementation of a control

programme.

These data are useful to clinicians, veterinarians, microbiologists,

epidemiologists and public health staff. None of these groups can operate

independently to control Leptospirosis and they have to act as a team.

It is clear from the above that four steps should be immediately taken

if we are to study and control this infection (1) facilities for macroscopic

agglutination test should be made available in all medical college microbiology

laboratories. (2) A central Leptospirosis reference laboratory should be set up

(3) Leptospirosis should be made a ‘notifiable’ disease and (4) public health

officials should be actively associated in detection/control programmes.

MA Muthusethupathi Shivakumar S Department of Nephrology, Madras Medical College & Government General Hospital, Madras 600 003

REFERENCES

1. Muthusethupathi MA, Shivakumar S, Acute renal failure due to

Leptospirosis. J Assoc Phys India 1987 : 35 : 631 – 3.

2. Faine S, Guidelines for the control of Leptospirosis. WHO offset

Publication 1982 : 67 : 151 – 3.

JAPI 1989, VOL. 37, NO.7 477

43

ARTICLE 8

MSAT – A SCREENING TEST FOR LEPTOSPIROSIS

Microscopic agglutination test (MAT) and IgM ELISA are the important

tests used for serodiagnosis of Leptospirosis. But these tests can be done only in

specialized microbiological laboratories. Therefore, there is a need for a simple

screening test for diagnosis of current infection. We have evaluated the

Macroscopic Slide Agglutination Test (MSAT) as a screening test and shall

discuss out experience with it.

At the Institute of Microbiology, Chennai Medical College, serum

samples obtained from patients with clinical features suggestive of Leptospirosis

during the period Jan – Dec. 1995 were tested by a) Macroscopic slide

Agglutination Test (MSAT) using Patoc, Icterohaemorrhagiae and Autumnalis

antigens, b) IgM ELISA and c) Microscopic Agglutination Test (MAT). The

diagnosis of current leptospiral infection was made by a titre of > 40 by IgM

ELISA. MSAT was compared with IgM ELISA and MAT.

MAT and IgM ELISA were done by standard procedures as reported by

us earlier.1 MSAT was done using a dense suspension of killed Leptospirosis was

mixed with a drop of serum on a slide and rotated on a rotator (120 rpm) for 4

min. It was then examined by naked eye for presence of agglutination. A 4+

agglutination titre was considered significant.2-4

Of the 592 samples received, 317 were positive by IgM ELISA. Among

these, MSAT was positive in 310. (Sensitivity 97.8%). 303 samples had MAT

titres of > 80. In all these patients, the MSAT was positive. 14 samples, which

INDIAN JOURNAL OF MEDICAL MICROBIOLOGY, 15(2)(1997):84


44

had MAT titres of 40, were positive by IgM ELISA. Of these, the MSAT was

positive in seven. Autumnalis was the most common serogroup (59.9%) followed

by Icterohaemorrhagiae (15.5%). 275 samples, which were negative by IgM

ELISA, were also negative by MSAT. The MSAT has shown good correlation

with both IgM ELISA and MAT.

Test Positive Patients (n = 568) Samples (n = 592)

IgM ELISA

MSAT

MAT (> 1: 80)

293

286

279

317

310

303

Rapid slide agglutination tests for Leptospirosis are well established and

have been used satisfactorily. Galton et al used 9 cultures and divided them into 3

groups (pooled 3 antigens in each group) and found MSAT to be a sensitive as

MAT.2 The Patoc Slide Agglutination test of Mazzonelli et al modified by

Coghlan utilizing Patoc as a single antigen, is also a sensitive test.3,4 These tests

are valuable in the diagnosis of current infection. The main advantage of these

slide agglutination tests is that they are simple to perform and do not need-

sophisticated instruments.

To conclude, MSAT is a valuable and simple screening test. The

sensitivity of this test was enhanced by adding the locally prevalent serovars. This

was an important modification done by us over the PSAT (Patoc Slide

Agglutination Test).1 As this test does not require sophisticated equipments,

conjugates and substrates, it would be an ideal test for screening current

leptospiral infection.

* G.SUMATHI * K.S. CHINARI PRADEEP **S. SHIVAKU MAR *Institute of Microbiology and **Institute of Inter nal Medicine Madras Medical College, Chennai 600 003


45

REFERENCES:

1. Sumathi G, Subudhi CPK, Manuel HPS, shivakumar KS, Rajendran S and

Muthusethupathi MA. Serodiagnosis of Leptospirosis. Indian J of Med.

Microbiol (1995) 13(4): 192-195.

2. Galton MM, Powers DK, Hall AD and Cornell RG. A rapid macroscopic

slide screening test for the serodiaganosis of Leptospirosis. Am J Vet Res

(1958) 19:505-512.

3. Mazzonelli J, Dorta de Mazzonelli G and Mailloux M. Possibilite de de

diagnostic serologique macroscopique des leptospires a Paide d;un

antigene unique. Medecine et Maladies Infectieuses (1974) 4:252-254.

4. Coghlan JD, Leptospira, Borrelia, Mackie and McCartney. Practical

Medical Microbiology, Thirteenth Edition (Churchill Livingstone,

London) (1989) 671.



46

ARTICLE 9

LEPTOSPIROSIS LABORATORY, CHENNAI MEDICAL COLLEGE

– A THREE YEAR EXPERIENCE IN SERODIAGNOSIS (1995 – 1997)

The Leptospirosis laboratory was established in July 1994 at the Institute

of Microbiology, Chennai Medical College. We present our experience on

serodiagnosis of Leptospirosis during the period 1995 – 1997.

Blood samples were received from both public and private institutions for

the diagnosis of current Leptospirosis. The following tests were done:

Microscopic agglutination test (MAT), IgM ELISA and Macroscopic slide

agglutination test (MSAT) utilizing preparations of Patoc, Autumnalis and

Icterohaemorrhagiae serogroups. The diagnosis of Leptospirosis was made by the

standard criteria.1,2

A total number of 5614 samples were received of which 1764 (31.4%)

were positive for current infection (Table 1). The number of samples showed a

dramatic increase during the three-year period probably due to increased

awareness of the illness. Mostly single samples were received. The declining

percentage of positive cases is probably due to the fact that samples were sent

early (5 days of illness) and second samples were not available.

Table 1. Annual data of total and positive blood samples

Year Total samples Positive (%) 1995 592 317 (53.5) 1996 1461 581 (39.7) 1997 3561 866 (24.3) Total 5614 1764 (31.4)

INDIAN JOURNAL OF MEDICAL MICROBIOLOGY, (1999)17(1):50-51

47

During 1995, IgM ELISA, MSAT and MAT were done for serodiagnosis.

IgM ELISA was positive in 317 out of 592 samples. Among these MSAT was

positive in 310 (Sensitivity 97.8%). Three hundred and three samples had MAT

titres of > 1:80. During 1996, MSAT and MAT were done for serodiagnosis, the

IgM ELISA could not be done due to non-availability of reagents, the results are

shown in Table-2. As MSAT had shown good correlation with MAT and IgM

ELISA earlier in 1995, this was utilized as the screening test for current leptospiral

infection. One thousand four hundred and sixty one samples were received during

1996, of which 581 were positive by MSAT and 509 were positive by MAT.

MAT revealed the predominant serovars to be Autumnalis (48.3%) and

Icterohaemorrhagiae (31.1%) during 1995 and 19963. Since these two serovars

were incorporated along with Patoc in the MSAT, the sensitivity of this test was

enhanced. During 1997, MSAT along was used for serodiagnosis. Of the 3561

samples received during 1997, 866 were positive.

Table 2. The findings with three different leptospiral serological tests

No. Test Positive (%) Year

No.

Samples IgM ELISA MSAT MAT 1995 592 317(53.5) 310 (52.4) 303 (51.2) 1996 1461 -- 581 (39.8) 509 (34.8) 1997 3561 -- 866 (24.3) --

The microscopic agglutination test (MAT) is considered to be the gold

standard test for diagnosis of Leptospirosis. MAT was valuable in identifying the

serogroup. A tire of > 1:80 was used for diagnosis and it correlated with IgM

ELISA.1,3 The observation of a significant titre in a single sample does not

necessarily indicate current disease as it may be attributed to persistent antibodies



48

of past infection. We recommend genus specific test in addition (MSAT or IgM

ELISA) to confirm the diagnosis of current infection. For performing the MAT,

stock cultures of various antigens have to be maintained. In addition, poor growth

and subsequent loss of Leptospirosis used for antigens in the MAT, contamination

of culture medium are also other important problems encountered. Unless,

international Leptospira reference laboratories supply stock cultures to National

Laboratories, it would be impossible to perform the test. There is an urgent need

to establish a National reference laboratory to help the regional laboratories to

identify the predominant local serogroups which could not be utilized for the test.

As there is inter observer variation in cut off titres, standardization of this test

between various workers is essential. Therefore, MAT is a complicated test and

can be performed only in established Microbiology laboratories with trained

personnel.

The IgM ELISA test is a very sensitive test for the diagnosis of current

infection when appropriately developed in the laboratory. It is an expensive test,

kits are becoming commercially available but their sensitivity has to be evaluated

before use.

The MSAT is a simple, rapid and sensitive diagnostic test for current

Leptospirosis.2 The improved sensitivity was due to addition of locally prevalent

serovars. This test has become the test of choice in our laboratory for diagnosis of

current infection.

INDIAN JOURNAL OF MEDICAL MICROBIOLOGY, (1999) 17(1):50-51

49

To conclude, there is an urgent need to establish a National reference

laboratory in collaboration with international reference laboratories. This

laboratory should collate the information from various regional laboratories in our

country and also help them with supply of antigens and materials for diagnostic

purposes. We recommend that MSAT be made as the screening test of choice for

diagnosis of current leptospiral infection till other reliable tests become available.

CHINARI PRADEEP KS* SUMATHI G* VIMALA RANGA RAO G* SHIVAKUMAR S** *Institute of Microbiology *Institute of Internal Medicine Madras Medical College, Chennai 600 003

REFERENCES:

1. Sumathi G, Pradeep Kumar Subudhi Ch, Helen PS, Manuel, Kalpana,

Shiva Kumar S, Suguna Rajendran and Muthusethupathi MA,

Serodiagnosis of Leptospirosis – A Madras Study, Indian J Med Microbiol

(1995) 13 : 192 – 195.

2. Sumathi G, Chinari Pradeep KS and Shiva Kumar S. MSAT – A screening

test for Leptospirosis. Indian J Med Microbiol (1997) – 15 : 84.

3. Chinari Pradeep KS. A two year study on serodiagnosis of Leptospirosis.

M.D. (Thesis). The Tamil Nadu Dr. M.G.R. Medical University, March

1998.



50

ARTICLE 10

ACUTE RENAL FAILURE DUE TO LEPTOSPIROSIS

(1984 – 85)

*MA MUTHUSETHUPATHI, **S SHIVAKUMAR

SUMMARY

Nineteen patients with acute renal failure due to Leptospirosis were

encountered during a two year period, from January 1984 to December 1985. All

had positive agglutination tests for Leptospirosis. In seven patients, leptospira

were demonstrated in blood. Kidney biopsy in two patients showed acute tubulo-

interstitial nephritis. Marked seasonal and geographical “clustering” were evident.

Penicillin and conservative measures were the cornerstone of therapy,

supplemented by peritoneal or haemodialysis. Fifteen patients recovered. Severe

haemorrhage and uraemia resulted in four deaths. Leptospirosis thus appears to be

an important cause of acute renal failure in Madras.

INTRODUCTION

Leptospirosis is an infectious disease caused by the various serovars of

leptospira interrogans and is characterized by fever, conjunctival suffusion and

Myalgia; in severe cases, jaundice, renal failure and central nervous system

involvement may occur. In our country this condition was first reported from

Calcutta in 1938.1 In Thailand, 40 per cent of cases of acute renal failure (ARF)

are caused by leptospira.2 In this article, we report our experience with this

condition.

* Professor of Nephrology, **Tutor in Nephrology, Madras Medical College and Government General Hospital, Madras.

JAPI, 1987, VOL. 35, NO.9 631 – 633

51

MATERIAL AND METHODS

Leptospiral acute renal failure (L-ARF) was diagnosed according to the

following criteria; 1. Abrupt decline in glomerular filtration rate (GFR) shows by

progressive elevation of plasma urea (> 40 mg/dl) and plasma creatinine

(> 2 mg/dl). 2. Absence of pre renal (hypovolaemia) and post renal (obstructive)

factors. 3. Presence of jaundice. 4. Presence of any one of the following:

(a) Leptospira in blood (b) Positive micro-agglutination test for leptospira in

significant or rising titre. Dark field microscopy of blood for leptospira and the

micro agglutination test for leptospira were done by the method of Turner at the

department of Veterinary Preventive Medicine, Madras Veterinary College or the

Institute of Basic Medical Sciences, Taramani.3 Percutaneous kidney biopsy was

done in two patients. In 5 patients, the fractional excretion of sodium (FE Na) was

calculated according to the

Urine sodium Plasma Creatinine Formula FE Na = ------------------ X ------------------------- X 100 Plasma sodium Urine Creatinine After establishing the diagnosis, patients were started on conservative

treatment including maintenance of fluid and electrolyte balance, provision of high

carbohydrate calories and administration of Benzyl Penicillin 1 million units 4

times daily intramuscularly. Because of severe uraemia, peritoneal dialysis (PD)

was considered necessary in 4 patients. Haemodialysis was done in one patient.

RESULTS

Out of 80 patients of acute renal failure seen from January 1984 to

December 1985, 19 patients had leptospiral renal failure. Only one patient was a

female. The age distribution of these cases is given in Table 1. The clinical

features at presentation and hospital stay are tabulated separately (Table 2).

JAPI, 1987, VOL. 35, NO.9 631 – 633


52

Important biochemical parameters and agglutination titres are given in Table 3. A

characteristic feature was the association of high serum bilirubin with normal or

mildly elevated oxaloacetic and pyruvate transaminase levels in 10 of 19 patients.

Serum alkaline phosphatase was elevated in four patients. In 3 patients

microscopic haematuria was a prominent feature. Plasma creatinine was > 5

mg/dl in 13 of 19 patients. Dark-field microscopy of blood revealed leptospira in

7 of 19 cases. In the micro agglutination test all the 19 patients had a positive titre

of 1/10 or greater; 13 had a positive titre of 1/80 or more (Table 3). The FE Na

was available in five patients only in three of whom it was less than 1 per cent.

Renal biopsy in two patients showed tubular necrosis, interstitial edema

and diffuses interstitial infiltration.

Fifteen of 19 cases were seen during the three-month period, November

to January. Since October and November are the rainy months in Madras, it is

obvious that these cases occurred during or following monsoon rains. Eight of 19

cases came from T.Nagar, West Mambalam, Ashoknagar and Vadapalani,

contiguous divisions of Madras city.

Conservative management was adequate in 15 of 19 patients and

peritoneal dialysis was done in 4 patients because of severe renal failure and

oliguria. Of these, one patient subsequently needed haemodialysis because of

hypercatabolic renal failure, which could not be managed by PD alone. Fifteen of

19 patients recovered. In these patients, renal failure lasted 4 – 55 days, the mean

duration being 15.3 days. 4 patients died; two of them due to severe haemorrhage

and two died of uraemia before dialysis could be started.

JAPI, 1987, VOL. 35, NO.9 631 – 633

53

TABLE 1: AGE DISTRIBUTION

Age group No.

21 – 30 31 – 40 41 – 50 51 – 60 61 – 70

2 5 7 4 1

Total 19

TABLE 2: CLINICAL FEATURES

Clinical features No. of

patients GENERAL Fever Conjunctival suffusion haemorrhage Myalgia GI TRACT Vomiting diarrhoea, abdominal pain Hepatomegaly NEUROLOGIC Disorientation Seizures, coma Muscle Tenderness CARDIOVASCULAR Tachycardia Hypertension Hypotension BLEEDING Haematuria Petechiae GI Bleed Vaginal bleeding Epistaxis

17 10 6

17 12 7 1 2

18 3 8 3 2 2 1 1

JAPI, 1987, VOL. 35, NO.9 631 – 633


54

DISCUSSION

Leptospirosis is characterized by fever, severe Myalgia, conjunctival

suffusion, jaundice and acute renal failure. Since the first description by Weil in

1886, over 130 serotypes of the pathogenic leptospira interrogans and the disease

severity varying from a mild, self limiting, febrile illness to a life threatening

syndrome of hepatic and renal failure have been reported.4

TABLE 3

Parameter Mean SD Range Blood Urea (mg/dl)

Plasma Creatinine (mg/dl)

Serum Bilirubin (mg/dl)

SGOT (I.U)

SGPT (I.U)

Alkaline Phosphatase (KA Units)

Leptospiral agglutination titre

228.2

6.7

19.9

107.4

51.4

10.8

186.3

106.6

3.3

11.1

92.9

38.4

5.6

199.5

80 – 390

2.5 - 16

3.2 – 42.2

32 – 380

14 – 150

4.2 – 24.2

10 – 640

Ooi et al reported renal histological changes consisting of interstitial

infiltration and tubular necrosis inhuman Leptospirosis from Singapore.5 Inspite of

the close geographical similarity between Thailand and parts of India, viz. large

areas of paddy fields, stagnant water and the ubiquitous rodents, leptospiral renal

failure which is known to occur frequently in Thailand2, was not documented in

our country till 1965 when Krishnamurthy et al published the first case report of

leptospiral hepato renal syndrome in two patients seen in Government Royapettah

Hospital, Madras.6 Leptospirosis accounted for 19 of a total of 80 cases of ARF

seen by us over a two year period, thus accounting for 23.5 per cent of all cases of

ARF.

JAPI, 1987, VOL. 35, NO.9 631 – 633

55

Certain epidemiological features of this disease are worth noting. There

is a definite seasonal “clustering” since 15 of these 19 cases occurred during the

period, November to January. Also, 8 of 19 cases occurred in contiguous, low-

lying areas of Madras city following heavy monsoon rains in which several streets

were flooded. This is in keeping with a water-borne infectious disease. Identical

epidemiological features have been noted in USA and elsewhere.4,7

Only one out of 19 patients was a female (Table 1). The difference is

likely to be due to the greater exposure of males while wading through the

monsoon floods. The male preponderance has been noted by others.4,6

All the 19 patients had jaundice and acute renal failure. It is seen from

Table 2 that fever, abdominal pain, vomiting and diarrhoea were almost constant

features of this disease. This combination occurred in 17 of 19 patients (89%) and

has been reported in 95% of cases by MeCrumb and in 50% of cases by Edwards

and Domm.4 Abdominal pain is probably due to involvement of abdominal

muscles; subserosal haemorrhages, pancratitis and hepatitis are other factors

contributing to abdominal pain. Nausea and vomiting probably represent hepatic

dysfunction. Conjunctival suffusion or haemorrhage occurred in 10 of 19 patients

(52%). This is rather low as compared to 73% reported by Edwards and Domm.4

Since conjunctival injection is an early feature of this disease occurring in the

“Septicaemic” stage, it is possible that it had already resolved in many of our

patients, who were seen later in the course of the illness. The infrequency of

Myalgia (6/19) probably has a similar explanation. Liver was enlarged in12 of 19

patients. Its incidence was much lower (3/16) in the series of Edwards and

Domm.4 Other notable feature is a bleeding tendency, shown by Epistaxis,

gastrointestinal haemorrhage, haematuria and vaginal bleeding.

JAPI, 1987, VOL. 35, NO.9 631 – 633


56

Disorientation occurred in 7 of 19 patients. Severe central nervous

system involvement giving rise to seizures and coma was rare (1/19). Features of

meningitis like neck rigidity were also rare, as compared to other series.4

Biochemically, there were some characteristic features. Marked elevation

of serum bilirubin with near normal or minimally elevated SGOT and SGPT levels

occurred in 10 of 19 patients. Serum alkaline phosphatase was elevated in only 4

patients. Others have reported raised alkaline phosphatase levels in most patients.2

Renal failure was severe (Creatinine > 5 mg/dl) in 13 patients. The

fractional excretion of sodium (FE Na) is one of the most useful urinary indices in

diagnosing tubular injury. Since FE Na was available in only a small number of

cases its usefulness in this situation cannot be commented on.

Laboratory diagnosis of Leptospirosis involves the isolation of leptospiras

in culture of body fluids and serological tests. Leptospira in the blood was

demonstrated in 7 of 19 patients in this series. Macroscopic or microscopic

agglutination test was positive in all cases. Identification of the serogroup in 9

cases showed Leptospira autumnalis, L. Canicola and L. icterohaemorrhagic

species. Some studies have shown L. Autumnalis to be the commnest serotype in

this area.7,8

Renal failure could be managed by conservative measures along in14

patients; only 4 were dialysed peritoneally and one required haemodialysis. This

is consistent with our general experience.9

JAPI, 1987, VOL. 35, NO.9 631 – 633

57

Four patients in this series died. The mortality in L-ARF is about the

same as seen in the overall group of ARF in our series of 187 patients (21% vs

24%) (Unpublished data). The notable feature is the frequency of gastro-intestinal

bleeding as the cause of death in two of four patients.

In conclusion, Leptospirosis is responsible for nearly a quarter of our

cases of ARF. The diagnosis is often missed chiefly because of a lack of

awareness of the condition and inadequate facilities for confirmation of the

diagnosis.

JAPI, 1987, VOL. 35, NO.9 631 – 633


58

REFERENCE:

1. Das Gupta BM: Further observation of leptospiral infection in Calcutta.

Indian Med Gaz 1939; 74 : 31-2.

2. Sitprija V: Benyajatic. Tropical disease and acute renal failure. Ann Acad

Med (Supple) 1975; 4 : 112-4.

3. Turner LH, Leptospirosis LL. Trans R Sec Trop Med Hyg 1968; 62 : 880

4. Edwards GA Domm BM Human Leptospirosis. Medicine 1960; 39 : 117-

56.

5. Ooi BS, Beatrice TM, Chen TM et al. Human renal Leptospirosis. AM JI

Trop Med Hyg 21 : 336-41.

6. Krishnamurthy MV, Madanagopalan N, Tajmal Hussain A. Leptospirosis

in Madras. J Assoc Physicians India 1965; 13 : 737-40.

7. Ratnam S, Subramaniam S, Madanagopalan N, Sundaraj T, Jayanthi V.

Isolation of leptospiras and demonstration of antibodies in human

Leptospirosis in Madras, India. Transaction of the Royal Society of

Tropical Medicine and Hygiene 1983; 77 : 455-8.

8. Jayanthi V, Ratnam S, Madanagopalan N, Ramachandran MS,

Subramaniam S. Clinical Profile of Leptospirosis. Tropical

gastroenterology 1983; 4 : 100-3.

9. Muthusethupathi MA, Shivakumar S, Damodaran K. Management of renal

failure in India. J Assoc Physicians India 1985; 33 : 647-9.

JAPI, 1987, VOL. 35, NO.9 631 - 633

59

ARTICLE 11

LEPTOSPIRAL RENAL FAILURE IN MADRAS CITY (1988)

M.A. MUTHUSETHUPATHI, S. SHIVAKUMAR, SUGUNA RAJENDE RAN,

R. VIJAYAKUMAR, M. JAYAKUMAR

Madras Medical College & Government General Hospital, Madras.

Abstract

Eighteen patients with acute renal failure due to Leptospirosis were

encountered in November – December 1988. All patients had fever, Myalgia and

jaundice. The levels of blood urea and serum creatinine (mean ± SD) were 149.06

± 53.58 mg/dl and 4.8 ± 2.05 mg/dl respectively. Marked elevation of bilirubin

with near normal transaminases was characteristic. All patients had a positive

microscopic agglutination test for Leptospirosis. In five patients, leptospira were

isolated from urine by culture. L. icterohaemorrhagiae was the commonest

serogroup observed. Penicillin and conservative measures were adequate in 8

patients. Ten patients needed dialysis. Three patients (16.6%) died.

Key Words : Leptospirosis, Acute renal failure.

INTRODUCTION

Leptospirosis is an important cause of acute renal failure (ARF) in

Madras City.1 It usually occurs during and after the monsoon. This is a public

health problem of great importance as it affects people of various occupations and

can be prevented by taking appropriate measures.2 In this article, we report our

experience with leptospiral is ARF which occurred in November – December

1988.

INDIAN JOURNAL OF NEPHROLOGY NEW SERIES VOL 1 NO.1 JAN-MARCH 1991 15 - 17


60

MATERIAL AND METHODS

Leptospiral ARF was diagnosed according to the following criteria:

1. Abrupt decline in glomerular filtration rate (GFR) shown by progressive

elevation of plasma urea (> 40mg/dl) and plasma creatinine (> 2mg/dl),

2. Presence of jaundice,

3. Presence of any one of the following:

a. Positive leptospiral culture from blood or urine

b. Positive micro-agglutination test for leptospira in significant or

rising titre. These tests were done by the method of Turner.3-5

After establishing the diagnosis, patients were started on conservative

treatment, including maintenance of fluid and electrolyte balance and

administration of benzyl penicillin one million units four times a day. Peritoneal

dialysis (PD) was done in severe renal failure. Hemodialysis was done if there

was a contraindication to PD or if the patient was in hyper catabolic ARF.

RESULTS

18 patients had leptospiral ARF. There were 13 males. Mean age was 39

years (range 15 – 70 yrs). The clinical features are shown in Table I. Important

biochemical parameters and agglutination titres are given in Table II.

Renal failure was severe (plasma creatinine > 5mg/dl) in 9 patients.

Jaundice was characterized by high serum bilirubin with normal or mildly elevated

oxaloacetic and pyruvate transaminase levels. Positive urine culture for leptospira

was obtained in 5 patients. All patients demonstrated significant and rising

agglutination titres. The serogroups isolated are shown in Tamble III. All patients

were seen during the monsoon months (November – December). There was no

relationship to any specific occupation. Peritoneal dialysis was done in 10

patients, one of whom needed hemodialysis. Three patients (16.6%) died.

INDIAN JOURNAL OF NEPHROLOGY NEW SERIES VOL 1 NO.1 JAN-MARCH 1991 15 – 17

61

TABLE I

Symptoms and Signs of 18 patients with leptospiral ARF

No PERCENT Fever 18 100 Jaundice 18 100 Myalgia 18 100 Oliguria 14 77.7 Conjunctival suffusion 13 72.2 Vomiting 13 72.2 Hypovolemia 8 44.4 Altered Sensorium 8 44.4 Hematuria 6 33.3 Meningeal irritation 4 22.2 Diarrhoea 4 22.2 Arthralgia 4 22.2 Hypotension 4 22.2 Anuria 1 5.5 Pleural Effusion 1 5.5 Splenomegaly 1 5.5

TABLE II

Biochemical parameters and agglutination titres

Mean SD

Blood Urea (mg/dl) 149.06 53.58 Plasma creatinine (mg/dl) 4.8 2.05 S.Bilirubin (mg/dl) 16.87 8.17 Direct 11.78 5.46 SGOT (IU) 41.13 20.69 SGPT (IU) 28.13 19.4 Alk. Phosphatase (KA units) 16.65 10.57 Leptospiral agglutination titre Initial Repeat

480.00 1536.00

389.4

712.67

INDIAN JOURNAL OF NEPHROLOGY NEW SERIES VOL 1 NO.1 JAN-MARCH 1991 15 –1 7


62

TABLE III

Microbiology

Urine Culture Microscopic agglutination test (MAT) L. Icterohaemorrhagiae - 4 L. Icterohaemorrhagiae - 12 L. Autumnalis - 1 L. Canicola - 4 L. Autumnalis - 2

DISCUSSION Leptospirosis is a zoonosis caused by Leptospira interrogans. There are

19 serogroups6. The clinical features vary from a mild anicteric illness

characterized by fever, Myalgia and Conjunctival suffusion, to a severe illness in

which jaundice, renal failure and meningitis occur. It is transmitted to man by

contact with infected urine or water contaminated with infected urine.

In Madras City, Leptospirosis is commonly observed during the monsoon

months and is transmitted by rodents such as bandicoots7. It has also been

reported in domestic animals, such as dogs, cattle, goat, sheep and buffaloes8,9.

Studies have revealed that the common serogroups are L. autumnalis and L.

icterohaemorrhagiae though other groups such as L.Pomona and L. canicola are

also known to occur.10-12 India is predominantly an agricultural country which

provides the most important factors necessary for survival of leptospira, namely,

animals and water. It has been reported from other parts of the country such as

Kerala, Calcutta and Bombay.13-17 But it has not been well documented in other

regions because of lack of facilities for diagnosis.18

Renal involvement is the most serious complication and is the commonest

cause of death. Renal manifestations range from urinary sediment changes

(pyuria, hematuria and granular casts) to renal failure. Renal failure occurs in 44 –

67% of cases. Proteinuria is usually less than 1 gm/day. Leptospira by

INDIAN JOURNAL OF NEPHROLOGY NEW SERIES VOL 1 NO.1 JAN-MARCH 1991 15 -17

63

hematogenous spread reach the peritubular capillaries and migrate to interstitium,

renal tubules and tubular lumen causing interstitial nephritis and tubular necrosis19.

The pathogenesis of impaired renal function is both toxic and ischemic in origin.

Cytotoxic factors are responsible for the toxic injury. Hypovolemia in

Leptospirosis is due to decreased fluid intake, increased fluid loss and increased

vascular permeability caused by chemical mediators released during inflammation.

In addition, increased blood viscosity and low-grade intravascular coagulation

occur. Hypoperfusion may also result from cardiac dysfunction. Renal failure

occurs in the 2nd week but it can occur as early as the 4th day. It may be short lived

or prolonged for up to two weeks.

All the 18 patients in this study had fever, jaundice, Myalgia and ARF.

Oliguria occurred in 14 patients and 6 patients had hematuria. We have

documented in our earlier study that two patients with leptospiral ARF had acute

interstitial nephritis on kidney biopsy1. We have not thought it necessary to do

kidney biopsy in this series because the diagnosis was confirmed by other means

and because of the risk of bleeding.

Most patients with renal failure also have significant hepatic

involvement6. Jaundice occurs between the fourth and sixth day but may occur as

early as second day or as late as the 9th day. Jaundice is partly due to

hepatocellular damage. However, hepatocellular necrosis is usually mild and

additional factors include intrahepatic cholestasis and increased bilirubin load

from absorption of blood from tissue hemorrhage. Death is rarely due to hepatic

failure. In our patients, marked elevation of serum bilirubin with near normal or

mildly elevated SGOT and SGPT levels were characteristic. Serum alkaline

phosphatase was elevated in 7 patients.



64

Laboratory diagnosis involves the isolation of leptospira in culture of

blood and urine and serological tests. Leptospira were isolated in urine culture in

5 patients. Micro agglutination test was positive in significant and rising titres in

all patients. L.icterohaemorrhagiae was the common serogroup in this study

followed by L. canicola and L. autumnalis.

Renal failure could be managed by conservative measures alone in 8

patients. Ten patients were dialysed peritoneally and only one patient required

haemodialysis. This is consistent with out general experience20. Three patients

(16.6%), died which was less than the overall mortality of 27.8% of ARF in our

experience21.

In conclusion, Leptospirosis is an important cause of ARF in Madras

City. The diagnosis is often missed because of inadequate facilities for

confirmation of diagnosis. Establishment of a Central Leptospirosis Reference

Laboratory and making a screening test (microscopic agglutination test) available

in all microbiological laboratories should be taken up urgently to tackle this

problem.

Acknowledgement We express our grateful thanks to both Dr.N.Raghavan, MVSc., DVSM.,

Ph.D. (Edin), Professor and Head, Department of Preventive Medicine and

Mr.K.S.Venkataraman, Ph.D. student of the Madras Veterinary College, Madras

for their valuable help in doing microbiological investigations.


65

REFERENCES:

1. Muthusethupathi MA, Shivakumar S : Acute renal failure due to

Leptospirosis J Assoc Phys India 35 : 631-3, 1987.

2. Faine S: Guidelines for the control of Leptospirosis. WHO offset

publication 67 : 151-3, 1982

3. Turner LH: Leptospirosis I. Trans R Soc Trop Med Hyg 61 : 842-854,

1967.

4. Turner LH: Leptospirosis II. Trans R Soc Trop Med Hyg 62 : 880, 1968.

1967.

5. Turner LH: Leptospirosis III. Trans R Soc Trop Med Hyg 64 : 623-644,

1970.

6. Sitprija V: Leptospirosis, in Weatherall DJ, Ledingham JGG, Warrell DA

Eds. Oxford Text Book of Medicine, Oxford University Press 1987 : 5 :

327-5 : 331.

7. Ratnam S, Sundararaj T, Subramaniam S : Role of bandicoots in human

Leptospirosis in Madras City – An epidemiological approach. Ind J Pub

Health 30 : 167-168, 1986.

8. Ratnam S, Subramaniam S, Sundararaj T : Evidence of Leptospiral

antibodies among domestic animals in Madras City. Cherion 12 :

176-179, 1983.

9. Ratnam S, Sundararaj T, Subramaniam S: Serological evidence of

Leptospirosis in a human population following an outbreak of the disease in

cattle. Trans R Soc Trop Med Hyg 77: 94-98, 1983.

10. Ratnam S, Sundararaj T, Thiagarajan SP et al: Serological evidence of

Leptospirosis in jaundice and pyrexia of unknown origin. Ind. J Med Res.

77 : 427-430, 1983.

INDIAN JOURNAL OF NEPHROLOGY NEW SERIES VOL 1 NO.1 JAN-MARCH 1991 15 –17


66

11. Ratnam S, Subramaniam S, Madanagopalan N : Isolation of Leptospirosis

and demonstration of antibodies in human Leptospirosis in Madras, India.

Trans R Soc Trop Med Hyg 77 : 455-458, 1983.

12. Jayanthi V, Ratnam S, Madanagopalan N et al : Clinical profile of

Leptospirosis. Trop Gastroenterol 4 : 100-3, 1983.

13. Dalal PM : Leptospirosis in Bombay. Ind J Med Sci. 14 : 285-290, 1960.

14. Bhatnagar RK, Sant MC, Jhala H : Prevalence of Leptospirosis in Bombay

– Studies in man and animals. Ind J Path Bact 10 : 324-331, 1967.

15. Joseph KM, Kalra SL : Leptospirosis in India. J Med Res 54 : 611-614,

1966.

16. Das Gupta BM : Further observation of leptospiral infection in Calcutta.

Ind Med Gaz 74 : 31-2, 1939.

17. Kumar RS, Varghese PK, Ravindran M, Paulose K : Analysis of mortality

in Leptospirosis in central Kerala. J Assoc Phys India 37 : 7, 1989.

18. Muthusethupathi MA, Shivakumar S : Leptospirosis – need for urgent

action. J Assoc Phys India 37 : 477, 1989.

19. Sitprija V, Pipalanagul V, Metrowidjojo K, et al : Pathogenesis of renal

disease in Leptospirosis – Clinical and experimental studies. Kidney Int

17: 827-836, 1980.

20. Muthusethupathi MA, Shivakumar S, Damodaran : Management of renal

failure in India. J Assoc Phys India 33 : 647-9, 1985.

21. Muthusethupathi MA, Shivakumar S : Acute renal failure in South India. J

Assoc Phys India 36 : 504-506, 1987.


67

ARTICLE 12

SERODIAGNOSIS OF LEPTOSPIROSIS – A MADRAS STUDY (1994 – 95)

G. SUMATHI, CH.PRADEEP KUMAR SUBUDHI, HELEN P.S. MA NUEL,

KALPANA, S.SHIVAKUMAR, SUGUNA RAJENDRAN AND

M.A.MUTHUSETHUPATHI

Institute of Microbiology and Department of Nephrology, Madras Medical

College, Madras 600 003

ABSTRACT

Sera from patients with clinical suspicion of Leptospirosis during October

1994 to February 1995 were examined by a) Microscopic agglutination test

(MAT) b) Enzyme linked Immunosorbent Assay (ELISA) c) Patoc Slide

agglutination test (PSAT). The diagnosis of current Leptospirosis was may be

a) initial titre of > 1:80 or a four fold rise in the titre of MAT, b) a tire of > 1:40

IgM and above by ELISA, c) a 4+ agglutination titre by PSAT. 66 of 158 patients

showed significant MAT titre – 1:80 in 15, > 1:160 in 48 and 1:40 in 3 patients.

IgM ELISA was positive in all these 66 patients. Only 52 patients (79%) had

positive PSAT.

Key words: Leptospirosis, Microscopic Agglutination Test, ELISA, Patoc Slide Agglutination Test. Leptospirosis is an important zoonosis occurring in Madras City. It

usually occurs during the monsoon months (Oct – Dec).1-3 It has also been

reported from Kerala, Maharashtra, U.P. and Andaman.4 It has probably been

under-reported and under-diagnosed from other parts of the country due to lack of

diagnostic facilities. Laboratory diagnosis involved the isolation of Leptospira in

INDIAN JOURNAL OF MEDICAL MICROBIOLOGY, 13(4)(1995):192-195


68

culture of blood and urine and serological tests. The common serological tests

done are genus specific tests (ELISA and PSAT) and serovar specific test (MAT).

The presence of leptospiral antibiotics from previous infections (usually

mild or subclinical) in large proportion of people living in endemic areas

complicates laboratory diagnosis of current illness. Genus specific tests tend to

become positive early in the disease and also revert to negative relatively early;

and are of value in diagnosing current infection. As published data on all these 3

tests together are inadequate, this study has been done to evaluate their efficacy in

the diagnosis of human Leptospirosis.

MATERIALS AND METHODS

One hundred and fifty eight serum samples obtained from patients with

clinical features suggestive of Leptospirosis received at the Microbiology

Department, Madras Medical College during October 1994 – February 1995 were

examined by (a) MAT (b) ELISA (IgM) (c) PSAT.

The MAT was performed with 8 live culture antigens (Autumnalis,

Australis, Canicola, Javanica, Pomona, Icterohaemorrhagiae, Sejroe and Patoc)

using standard microtitre methodology.5-7 The sera were initially screened at

dilutions of 1:20 and those that were positive, were titrated further to the endpoint.

The highest dilution of serum which agglutinated 50% of leptospires under dark

field microscopy was presumed to represent the titre of antibody specific for the

particular serogroup used. When two or more serogroups reacted at the same

(highest) titre, the result was recorded as ‘mixed equal’. Controls were put up for

each one of the batteries of antigens used in the test.

INDIAN JOURNAL OF MEDICAL MICROBIOLOGY, 13(4)(1995): 192-195

69

The ELISA was undertaken using Leptospiraicterohaemorrhagiae

serovar copenhagani, reference strain Wijnberg as antigen to detect specific IgM

antibodies.8-9 The sera were initially screened at 1:20 dilution and if positive were

titrated upto 1:40 and 1:80. Negative and positive controls were put up. It was

read by naked eye. Colour change to a deep purple red was noted for positive

samples.

PSAT was done by mixing a drop of dense suspension of leptospires

(Leptospira biflexa serovar Patoc) with a drop of serum on a slide and rotated on a

rotator (120/min) for 4 minutes.10-11 It was then examined by naked eye for

presence of agglutination. Negative and positive controls were put up.

The following were considered as significant titres, diagnostic of

leptospiral infection.

a. An initial titre of > 1:80 or a four-fold rise in titre of MAT.

b. A titre of > 1:40 IgM by ELISA

c. A 4 + agglutination titre by PSAT

RESULTS

Antibody titres suggestive of current Leptospirosis was obtained in 66 of

the 158 patients. Of these 45 patients provided single serum samples and 21

provided paired sera. The mean age of the patients was 36 years (range 6 – 74

years) and 50 were males (76%). Most of the patients were outdoor manual

workers. The important clinical features are shown on Table 1.



70

Table 1 : Clinical spectrum in positive patients (n = 66)

Clinical Features Number % Fever

Renal Failure

Myalgia

Jaundice

Vomiting

Conj. Suffusion

Headache

66

42

37

36

30

22

14

100

64

56

55

44

33

21

Fifteen patients had MAT titres of 1:80, forty eight patients had MAT

titres of > 1:160 (Table 2) and 3 patients had a MAT titre of 1:40 to any one of the

antigens in the panel. Autumnalis was the common serogroup (GMT 437)

followed by Australis (GMT 307). Patoc was noted in 9 patients and mixed equal

in 7 patients. Of the 21 repeat samples, 16 showed 4 fold rise in titre, 3 showed 2

fold rise in titre, one showed the same titre and another showed a decline in titre.

ELISA (IgM) was positve in 66 patients. All patients with MAT titres of

> 1:80 had positive IgM ELISA confirming that it was current infection. In

addition, the 3 patients with MAT titre of 1:40 had positive IgM ELISA. Fifty-

two patients (79%) had positive PSAT.


71

Table 2 : Antibody titre in micro agglutination test

Serogroup

40

80

160

320

640

1280

2560

5120

*GM

T

TO

TA

L %

Autumnalis -- 4 6 1 12 3 -- 3 437 29 43.9

Australis -- 2 7 2 4 1 -- 1 307 17 25.7

Canicola -- 3 -- -- -- -- -- -- 80 3 4.5

Javanica -- -- -- 1 -- -- -- -- 320 1 1.5

Patoc 2 4 1 2 -- -- -- -- 101 9 13.6

Icterohaemorrhagiae -- -- -- -- -- -- -- -- -- -- --

Sejroe -- -- -- -- -- -- -- -- -- -- --

Pomona -- -- -- -- -- -- -- -- -- -- --

Mixed 1 2 -- -- 4 -- -- -- 238 7 10.6

Total 3 15 14 6 20 4 -- 4 66 100

DISCUSSION

All patients presented with fever. Anicteric Leptospirosis was noted in

only 45% of patients. It has been reported that 90% or more of all cases of

Leptospirosis are anicteric.12 This is probably because the clinical features of

Leptospirosis varies widely and can differ in different geographic regions. Renal

failure was noted in 64% of patients. In Madras City Leptospirosis is an important

cause of renal failure.13



72

MAT is the cornerstone of serodiagnosis. The main advantage is that the

serovar can be identified which is of epidemiological importance. The test is

complicated as it involves the use of a battery of leptospires of widely differing

antigenic structure to cover the spectrum of leptospiral infection and therefore

requires maintenance of stock cultures. Rising titres or initial high titres are

diagnostic of leptospiral infection. These titres begin to rise by end of first week

and peak about third or four week. The high titres of MAT take much longer time

to decline, which is of value for epidemiological surveys. In endemic areas

persisting antibodies may be found in a large proportion of the population, which

may complicate the diagnosis of current infection.14

Autumnalis was the most common serogroup observed in this study.

Mixed equal serogroups suggest the presence of heterologous antibodies. Repeat

titres may have revealed the probable infecting serogroup. Patoc was observed in

9 patients. It is presumed that a serogroup has not been identified by the panel of

MAT. Culture of blood and urine samples will help in identifying the local

serovars which can be subsequently used in the panel for MAT. Autumnalis was

the most common serogroup observed in a seroepidemiological study done in

Madras.15-16

ELISA IgM is now the test of choice for the diagnosis of current

infection. The test detects genus specific antibodies, which tend to become

positive early in the disease (5th day) and also reverts early (60 days). It measures

specific IgM antibodies. Detection of specific IgM antibodies helps in the rapid

diagnosis of current infection. It is a relatively simple test and the antigens can be

prepared from pathogenic leptospires (L. icterohaemorrhagiae) or saprophytic

leptospira (L. biflexa). This test cannot determine the infecting serogroup. A high

titre in a single sample can be diagnostic, though repeat samples may be necessary

if initial titres are low.


73

ELISA was positive in all the 66 patients. In 45 single samples ELISA

was positive and confirmed the diagnosis of current infection. In all these patients

the MAT titres were > 1:80. In 3 patients ELISA (IgM) was more sensitive in the

diagnosis of current infection. ELISA IgM should be the test of choice for the

diagnosis of current infection.16

PSAT is a simple, satisfactory and quick screening test for those

laboratories which do not have other facilities. In this study PSAT was positive in

52 patients (79%).

It is preferable to have repeat serum samples for diagnosis of

Leptospirosis. If single samples only are available it is essential to do both ELISA

(IgM) and MAT. ELISA (IgM) will help in the diagnosis of current infection and

MAT will give the serogroup. If facilities for ELISA are not available, PSAT

should be done to reveal the current infection.

From the results of this study, it can be concluded that a combination of at

least two serological tests should be carried out for diagnosis of human

Leptospirosis, especially when only single serum samples are available.



74

REFERENCES:

1. Krishnamurthy MV, Madanagopalan N, Tajmal Hussain AT. Leptospirosis

in Madras. J Assoc Physicians India 1965; 13 : 737-40.

2. Muthusethupathi MA, and Shivakumar S. Acute renal failure due to

Leptospirosis. J. Assoc. Phy India (1987) 35:631-633.

3. Muthusethupathi MA, Shivakumar S, Rajendran S, Vijayakumar R and

Jayakumar M. Leptospirala renal failure in Madras City. Ind J Neph (New

series) (1991)1:15-17.

4. South Asian Workshop on Diagnostic methods in Leptospirosis (Madras)

(1995):49-80.

5. Cole JR, Sulzer CR, Pursell AR. Improved micro technique for the

leptospiral microscopic agglutination test. Applied Microbiology.

(1973)25:976.

6. Sulzer CR and Jones WL. Leptospirosis: methods in laboratory diagnosis

(Revised edition – reprinted) U.S.Department of Health,education and

welfare, Public Health Service, Centres for Disease Control, Atlanta,

Georgia HEW Publications No(CDC)(1978):79-8275.

7. Wolff JW. The laboratory diagnosis of Leptospirosis. (Thomas,

Springfield, Illinois, USA)(1954).

8. Terpstra WJ, Ligthart GS and Schooner GJ. ELISA for detection of

specific IgM and IgG in human Leptospirosis. Journalof General

Microbiology (1985) 131:377-385.

9. Terpstra WJ, Ligthart GS and Schooner GJ. Serodiagnosis of human

Leptospirosis by ELISA, Zbl. Bakt. Hgy. I Abt. Orig. A (1980)247:400-405.

INDIAN JOURNAL OF MEDICAL MICROBIOLOGY, 13(4)(1995): 192-195

75

10. WHO. Guideline for the control of Leptospirosis. Faine S (ed) WHO offset

publication No.67, Geneva (1982).

11. Joyce D and Coghlan. Leptospira, Borrelia, Mackie and MeCartney

Practical Medical Microbiology, Thirteenth Edition, (Churchill

Livingstone, London) 671.

12. Ralph D. Fegin, Donald C and Anderson. Human Leptospirosis Crit Rev.

Cl Lab. Sci 5:413-467.

13. Muthusethupathi MA, Shivakumar S, Jayakumar M and Rajendran S.

Acute Renal failure in Madras City – Changing profile. Ind J Nehp (New

series) (1993)3:66-70.

14. Everard JD and Everard COR. Leptospirosis in the Caribbean. Reviews in

Medical Microb. (1993)4:114-122.

15. Ratnam S, Everard COR, Alex JC, Suresh B and Thangarju P. Prevalence

of leptospiral agglutinins among conservancy workers in Madras City,

India. Journal of Tropical Medicine and Hygiene (11993)96:41-45.

16. Muthusethupathi MA, Shivakumar S, Suguna R, Jayakumar M,

Vijayakumar R, Everard COR and Carrington DG. Leptospirosis in

Madras – A clinical and Serological study. J Assoc Phy. India

(1995)43:456-458.



76

ARTICLE 13

APPROACH TO LEPTOSPIROSIS IN INDIA S. SHIVAKUMAR INTRODUCTION Leptospirosis has long been considered a rare zoonotic disease where

only sporadic cases being recorded. Since 1980’s the disease has been reported

from various states during the monsoon months in mini epidemic proportions.

Cases have been reported from Kerala, Tamil Nadu, Gujarat, Andamans,

Kartnataka, Maharashtra, Orissa and Bihar.1,2

Leptospirosis has been under reported and under diagnosed from India

due to a lack of awareness of the disease and a lack of appropriate laboratory

diagnostic facility in most parts of the country. Combining clinical expertise and

awareness with confirmatory laboratory back up dramatically increases the

recognition of patients with Leptospirosis. In this article I shall discuss the

Epidemiology, clinical features, diagnosis and management of Leptospirosis.

EPIDEMIOLOGY

Leptospirosis is an infectious disease caused by leptospira interrogans

complex which has over 20 sero groups and more than 200 serovars. Rodents,

domestic and wild animals, form the reservoir of infection where domestic animals

such as cattle, dogs, pigs may act as carriers for several months (temporary

carrier), rodents usually remain carrier throughout their life (permanent carrier).

Thus rodents are considered the major reservoir of infection.3 Leptospirosis are

MEDICINE UPDATE 699 - 703

77

excreted in the urine of the animals and they affect man when he comes into

contact with urine of infected animals, directly or indirectly, when he is exposed to

an environment contaminated by the urine of the infected animals such as soil and

surface water following monsoon rains. Therefore the illness commonly occurs

during the monsoon. The infection is probably transmitted when they wade

through stagnant rainwater contaminated by infected urine of animals.

These organisms survive for 6 hours in dry soil and for 6 months in

flooded condition. They enter the host through abrasion of the skin (of the feet

when they come into contact with infected water) or intact mucous membranes of

eye, throat, and gut.

Leptospirosis can occur in both urban and rural areas. In urban areas of

developing countries, a contaminated environment due o various factors such as

overcrowded slums, inadequate drainage and sanitation facilities for both man and

animals, presence of stray dogs, cattle pigs, domestic rats, bandicoots, poor

condition of slaughter houses and people walking bare footed, contribute to the

spread of the illness.4,5 In rural areas, high risk groups are workers in rice fields,

cane fields and other agricultural crops and animal husbandry staff. In addition,

workers in sewers mines and military personnel are also at risk.

Person of all ages and races are susceptible. Adult men however are more

frequently infected because they tend to work in high-risk jobs. The number of

cases in a region often fluctuates from year to year due to various factors such as

rainfall, flooding and animal infections. Leptospirosis infections tend to occur as



78

individual/small cluster of cases or large outbreaks/epidemics. In India, urban

Leptospirosis has been reported from Chennai and Mumbai, while rural

Leptospirosis has been reported from Gujarat, Kerala and Andamans. Non

reporting of Leptospirosis from other states parts of India does not mean that it is

absent in those parts.

CLINICAL FEATURES

Leptospirosis can manifest in many ways. The various syndromes of

presentation are as follows:3,4

1. Anicteric Leptospirosis

2. Icteric Leptospirosis (Weil’s disease)

3. Haemorrhagic fever with renal syndrome

4. Atypical pneumonia syndrome

5. Myocarditis

6. Aseptic meningo-encephalitis

7. Ocular manifestations

The incubation period is 7 – 14 days, but ranges from 2 – 21 days. 90%

or more of all cases of Leptospirosis are anicteric. In general both anicteric and

icteric cases follow a biphasic course ‘septicaemia’ or ‘leptospiremic’ phase.

I. ANICTERIC LEPTOSPIROSIS This can be mild with fever, headache, and body pains or more severe

which is a biphasic illness. The onset is abrupt with chills, rigor, fever

(temperature 30 - 40˚C), severe headache and body pain. The body aches are

severe and most marked in the lower limbs especially thighs and calves. The pain

and weakness make walking difficult. Severe pain in the back, neck, abdomen and


79

upper limbs are frequent. The headache is throbbing and often severe. Anorexia,

nausea and vomiting are frequent and may be associated with constipation or

diarrhoea. Epistaxis may occur during the early stage. Chest pain, dry cough and

haemoptysis may occur. Mental symptoms such as restlessness, confusion,

delirium, hallucination and occasional psychotic behavior may occur. Abdominal

pain and vomiting are frequent. The most characteristic findings on examination

are conjunctival suffusion and severe myalgia. A transient rash can occur. The

‘septicaemia’ phase subsides after 4 – 7 days. The temperature than becomes

normal and the patient feels well. The second or immune phase is characterized

by severe headache due to meningeal involvement, uveitis and low grade fever.

This lasts from 4 to 30 days longer. The biphasic course may not be seen in all

patients.

II. ICTERIC LEPTOSPIROSIS

In some patients, the septicaemic phase instead of subsiding progresses to

a severe icteric illness with renal failure. Meningeal symptoms are frequent, but

are overshadowed by hepatic or renal features. Severe bleeding, hypotension,

cardiac and pulmonary complications are frequent. Death occurs usually due to

renal failure. Sudden death may occur due to massive bleeding, arrhythmias or

cardiac and respiratory failure. In those who are not severely ill, diuresis occurs

and renal failure improves. The fever subsides and the general condition gradually

improves. Some of the important clinical features are:

Kidneys: Renal involvement is the most serious complication and is the

commonest cause of death. Renal manifestations range from urinary sediment

changes (pyuria, haematuria and granular casts) to severe renal failure. Renal



80

manifestations are observed commonly in all forms of Leptospirosis regardless of

the severity of disease or of the infecting sero-group. In anicteric patients,

proteinuria, microscopic haematuria and azotaemia have been noted. Proteinuria

is mild and is due to the febrile state. Haematuria may be due to hemorrhagic

diathesis rather than glomerular injury. Azotaemia has been divided into two

groups. The first is characterized by decreased renal perfusion with diagnostic

indices suggesting pre-renal azotaemia, with a good response to fluid

administration. The second is characterized by features consistent with tubular

necrosis, with no response to fluid challenge and has been emphasized that

hemodynamic alterations, (hypotension, volume depletion) responsible for the

former may result in acute tubular necrosis, if uncorrected. In addition, acute

interstitial nephritis may account for renal failure regardless of hemodynamic

state. Renal failure occurs in the second week but it can occur as early as the

fourth day. It may be short lived or prolonged for up to two weeks.

Hypotension: Hypotension is an important complication, noted in patients with

severe Leptospirosis. The causes of hypotension are 1) hypovolaemia secondary

to vomiting, increased insensible water losses and diminished fluid intake; 2)

massive haemorrhage most often gastrointestinal; 3) unidentified vasoactive

endotoxin; 4) widespread vascular injury leading to fluid shifts from intravascular

to extra vascular fluid spaces; 5) myocardial dysfunction and 6) rarely adrenal

haemorrhage.

Liver: Jaundice is the most important clinical feature of the severity of illness.

Jaundice occurs between the fourth to sixth day but may occur as early as the

second day or as late as the ninth day, deepens rapidly, reaching a peak within a

week. The liver is often enlarged and tender. Jaundice is mainly due to

hepatocellular damage. However, hepatocellular necrosis is usually mild and


81

additional factors include intrahepatic cholestasis and increased bilirubin load

from absorption of tissue haemorrhage. Marked elevation of serum bilirubin with

mildly elevated transaminases is characteristic. Death is rarely due to hepatic

failure.

III. HAEMORRHAGIC FEVER WITH RENAL SYNDROME

Bleeding is a constant feature of Leptospirosis and is due to vascular

damage. It is usually mild in anicteric cases but more common is a severe icteric

patient. Bleeding may occur from respiratory, alimentary, renal and genital tracts

and occasionally into sub arachnoid space and adrenal glands. Death may occur

from massive bleeding usually gastrointestinal or into internal organs. This may

be associated with renal failure.

IV. ATYPICAL PNEUMONIA SYNDROME

Severe hemorrhagic pneumonitis may occur usually in the second week,

but occasionally as early as 24 – 48 hours after onset. This may present with

haemoptysis, chest pain, respiratory distress and cyanosis. Massive haemoptysis

may cause asphyxiation. Radiological abnormalities range from single ill-defined

opacity, multiple areas of infiltration to a large area of consolidation. This clears

up within 2 weeks without any residual damage.

V. MYOCARDITIS

Cardiac complications are frequent in severe Leptospirosis. They are

usually mild and are observed as electrocardiographic abnormalities ranging from

low voltage complexes, non specific ST and T wave changes, conduction defects



82

and arrhythmias. Atrial fibrillation is the most common arrhythmia observed.

Severe manifestations such as cardiomegaly, cardiac failure and severe

arrhythmias due to hemorrhagic myocarditis are observed. Sudden death may

occur from cardiac failure or arrhythmias. All cardiac abnormalities revert to

normal within 2 to 3 weeks.

VI. ASEPTIC MENINGOENCEPHALITIS

This usually occurs in the immune phase and may present with signs of

meningeal irritation. The CSF shows lymphocyte pleocytosis, raised proteins

(1 – 2 gm/L) and normal sugar. Convulsions, focal neurological deficits, myelitis,

polyneuritis, encephalitis are rare. Prognosis in meninigitic illness is excellent.

VII. OCULAR MANIFESTATIONS

Conjunctival suffusion is a common feature of the septicaemic phase and

is usually associated with conjunctival haemorrhage. There is no inflammatory

exudates and true conjunctivitis does not occur. It usually occurs in the first three

days and lasts for one day to more than a week. It subsides within a week without

any complications. More important is the late complication of anterior uveal tract

inflammation and presents clinically as iritis, iridocyclitis, and rarely as

chorioretinitis. This may occur as early as the second week or may be delayed up

to a year but are more frequent in the first 6 months. Uveitis may be unilateral or

bilateral and the course is variable (i.e. acute benign episode, recurrent episodes or

a chronic process). The ultimate prognosis is good but chronic Uveitis may cause

blindness from cataract formation and hypopyon in the anterior chamber.


83

DIFFERENTIAL DIAGNOSIS Leptospirosis with its varied manifestations may mimic a large number of

diseases processes.

Anicteric leptospirosis is usually misdiagnosed as pyrexia of unknown

origin, viral fever, malaria, enteric fever, influenza or pyelonephritis.

Severe Icteric leptospirosis may be confused with febrile icteric illness such

as a) viral hepatitis, b) septicemia with jaundice and c) malaria. In Leptospirosis the

onset is abrupt. Severe headache, myalgia and conjunctival suffusion are constant

features, and proteinuria is common, whereas in viral hepatitis, onset is gradual,

headache and myalgia are mild and proteinuria and conjunctival suffusion are absent.

Jaundice also occurs in malaria and sepsis.


Jau

ndic

e

R

enal

Fai

lure

Fev

er

Hyp

oten

sion

Con

junc

tival

B

leed

ing

Mya

lgia

Pne

umon

ia

Hea

dach

e

M

yoca

rditi

s

Men

ingi

tis

Uve

itis

SUMMARY OF CLINICAL FEATURES

MILD IMMUNE LEPTOSPIREMIC PHASE SEVERE


84

Leptospiral renal failure must be differentiated from renal failure due to

malaria, sepsis and hanta virus.

Hemorrhagic manifestations are noted in infection due to hanta virus. The

diagnosis can be confirmed by microbiological investigations.

In those presenting with Meningitis, leptospirosis has to be differentiated

from bacterial and viral meningitis and encephalitis. Bacterial meningitis can be

confirmed by spinal fluid examinations. Viral meningitis is indistinguishable from

leptospiral meningitis.

Conjunctival suffusion, myalgia and evidence of bleeding suggest the

diagnosis of Leptospirosis and this can be confirmed by the serological tests. In

children, clinical features that are not seen or are rare in adults such as hypertension,

acalculus cholecystitis and pancreatitis can occur.

DIAGNOSIS OF LEPTOSPIROSIS Culture: The isolation of Leptospirosis by culture of blood, CSF and urine is the

most definite way of confirming the diagnosis of Leptospirosis. Unfortunately,

culture of blood does not contribute to an early diagnosis as results come late, weeks

or even months after inoculation of culture medium.

PCR is promising on both sensitivity and specificity, but is complicated and

expensive.

Serology: The serological tests from diagnosis of Leptospirosis have been classified

as serovar specific tests and genus specific tests.


85

Serovar specific tests: Microscopic agglutination test (MAT): MAT is the gold

standard test for diagnosis of Leptospirosis. The main advantage is that serovar can

be identified which is of epidemiological importance. The test is complicated as it

involves the use of a battery of leptospira of widely differing antigenic structure to

cover the spectrum of leptospiral infection. Therefore, it requires the maintenance of

stock cultures. Rising titres or an initial high titre is diagnostic of leptospiral

infection. These titres begin to rise by the end of the first week, peak about the third

or fourth week, therefore are not valuable for the diagnosis of current infection. The

high titres take a much longer time to decline, which is of value for epidemiological

surveys, but the presence of high titres from previous infection complicate the

diagnosis of recent infection.

Genus specific tests: The two common tests are the ELISA & Macroscopic slide

agglutination tests (MSAT). The other tests are latex agglutination test, complement

fixation test and haemagglutination tests. The genus specific tests are the test of

choice for the diagnosis of current infection. These tests are simple, more sensitive

and become positive earlier than MAT. In India ELISA SAT is available. MAT is

available in specialaized microbiological centers.

ELISA : The test detects genus specific antibodies, which tend to become positive

early in the disease (4th and 5th day). Detection of specific IgM antibodies helps in

rapid diagnosis of current infection. Commercial kits are available in India, but they

are expensive.

MSAT : The slide agglutination test is a simple macroscopic test is a simple

macroscopic test in which a drop of the dense suspension of leptospira is mixed with

drop of serum on a slide is examined by the naked eye from agglutination.



86

The physicians has to rely on clinical features, characteristic of Leptospirosis for

early diagnosis and start treatment, but should be confirmed by serological tests. At

present, it is adequate to ELISA/SAT to diagnose current Leptospirosis. If MAT is

available, rising titres will help confirm the diagnosis.

MANAGEMENT Chemotherapy: The aims of chemotherapy are to eradicate Leptospirosis and to

prevent complications. Leptospirosis are sensitive to most antibiotics.

Penicillin is the most effective antibiotic when given early. In severe illness large

doses (6 – 8 million units per day) of benzyl penicillin may be given in divided doses,

preferably by IV route, for 5 – 7 days. Fever subsides in 24 – 36 hours.

Ampicillin I g IV qid in severe illness or 500 – 750 mg quid PO in mild illness.

Doxycyline 200 mg / day, Amoxicillin 500 mg qid and Erythromycin 250 mg

quid are effective. Quinolones and Cefotaxime are also effective against

leptospira. Recently there is evidence to suggest that antibiotics are useful even in

the late stages of illness.

Symptomatic and supportive treatment: Of primary importance is the

meticulous attention to fluid and electrolyte balance. Hypovolaemia and

hypotension need prompt and specific treatment with intravenous luids. In patient

With oliguria, if pre renal azotaemia is suspected, prompt diuresis should be

attempted with fluid therapy. Patients who have no response to therapy should be

managed as established renal failure. Headache and myalgia are treated with

analgesics; fever with anti pyretics, restlessness and anxiety with sedatives and

anaemia with blood transfusion.


87

Peritoneal dialysis has been found to be safe, simple and effective procedure for

management of Leptospiral renal failure. If there is contraindication to peritoneal

dialysis, haemodialysis can be done.

PROGNOSIS

Most patients recover. Overall mortality used to be about 15 – 40% and

has been reduced to about 5% with better management. Death is usually due to

renal failure but it can also occur due to massive bleeding or cardiac

complications.

Faine’s Criteria

Faine has evolved criteria for diagnosis of Leptospirosis on the basis of

clinical, epidemiological and laboratory data. Certain necessary modifications

have been made by us to make the diagnosis more practical in Indian institutions.9

The modifications have been made in the epidemiological and laboratory criteria.

The reasons of the modifications are:

1. Laboratory tests are essential for diagnosis. ELISA IgM/SAT are adequate for

the diagnosis of current infection. In MAT is available, rising titres would

confirm the diagnosis and identify the serovars.

2. Epidemiological factors such as rainfall and contact with contaminated

environment are important for diagnosis. Most of the cases of Leptospirosis

are reported in the monsoon or post monsoon season.

3. Clinical features if combined with epidemiological and laboratory data

confirm the diagnosis of Leptospirosis.

Presumptive diagnosis of Leptospirosis is made of: Part A or part A & part B score : 26 or more Part A, B, C (Total): 25 or more A score between 20 and 25 suggests Leptospirosis as possible but unconfirmed

diagnosis.

MEDICINE UPDATE 699 – 703


88

Faine’s Criteria Modified Faine’s Criteria Part A : Clinical Data Part A : Clinical Data

Question Score Question Score Headache 2 Headache 2 Fever 2 Fever 2 Temp > 39˚C 2 Temp > 39˚C 2 Conjunctival suffusion 4 Conjunctival suffusion 4 Meningism 4 Meningism 4 Muscle pain 4 Muscle pain 4 Conjunctival suffusion Meningism Muscle pain

10

Conjunctival suffusion Meningism Muscle pain

10

Jaundice 1 Jaundice 1 Albuminuria/Nitrogen Retention

2 Albuminuria/Nitrogen Retention

2

Total score Total score Part B: Epidemiological factors Contact with animals or

Contact with known Contaminated water

10

Part B: Epidemiological Factors Rainfall Contact with contaminated Environment Animal contact

Total

5 4 1

10

Part C: Bacteriological and Lab Findings



Findings Isolation of leptospira in culture – Diagnosis certain

Positive Serology (MAT) Leptospirosis Endemic

Positive Serology

Single positive – Low titre Single positive – High titre Leptospirosis Non Endemic Single positive – Low titre Single positive – High titre Rising titre (Paired sera) Total

2 10 5 15 25

ELISA IgM Positive SAT – Positive MAT – Single High titre Rising titre (Paired sera) Total

15 15 15 25


89

The Faine’s criteria is valuable for diagnosis of anicteric Leptospirosis.

Severe Leptospirosis can be diagnosed by the presence of fever, jaundice and renal

failure. This is the pattern commonly seen in Kerala, Tamil Nadu and Gujarat.

Atypical pneumonia has been reported from Andamans. To conclue, Leptospirosis is

a common cause of fever during monsoon month. There is an urgent need to develop

diagnostic facilities in the country10. By combining clinical, epidemiology and

laboratory data, I hope the clinician would able to diagnose Leptospirosis without

difficulty.

EXAMPLES UTILISING MODIFICED FAINE’s CRITERIA

1. A Patient with fever during the monsoon month with positive ELISA IgM

A Fever 2 B Rain Fall + Contact with

contaminated environment 9

Score

C ELISA IgM positive 15 Score = 2+9+15 = 26 Diagnosis Leptospirosis (confirmed)

2(a) A patient with fever, myalgia and headache in the month of April (Non monsoon period) without contact with contaminated environment

A Fever, Headache, Myalgia 2 + 2 + 4 = 8 B No contact with contaminated

environment 0

Score

C ELISA 1gM positive 15 Score = 8 + 15 = 23

Diagnosis Possible Leptospirosis (Confirm by MAT – raising titres)



90

2(b) A patient with fever, myalgia and headache in the month of April (Non monsoon period) with contact with contaminated environment is positive for Leptospirosis ELISA IgM:

A Fever, Headache, Myalgia 2 + 2 + 4 = 8 B Contact with contaminated

environment +(e.g. Infected dog at home) animal contact

4 + 1

Score

C ELISA IgM positive 15 Score = 8 + 5+15 = 28

Diagnosis Leptospirosis (definite)

3. A patient with fever, myalgia and headache in the monsoon and contact with contaminated environment is negative by SAT.

A Fever, Headache, Myalgia 2 + 2 + 4 = 8 B Rainfall + Contact with contaminated

environment 4 + 5 = 9

Score

C SAT – Negative 0 Score = 8 + 9 = 17

Diagnosis Leptospirosis – Negative


91

REFERENCES:

1. Singh J & Sokhey J. Epidemiology, Presentation & Control of Leptospirosis.

Proceedings of the third round table conference. Series-Leptospirosis.

Ranbaxy science foundation(3);1998: 17-31

2. Verma R & Srivastava SK. Leptospirosis in Animals. Prevalence &

Distribution. Proceedings of the third round table conference. Series-

Leptospirosis. Ranbaxy science foundation (3);1998: 49-64

3. Faine S. guidelines for the control of Leptospirosis. WHO offset publication.

1982; 67

4. Everard JD, Everard CM; Leptospirosis in the Caribbean. Reviews in Medical

Microbiology, 1993; 4: 114-22

5. Muthusethupathi MA, Shivakumar S, et al. Leptospirosis in Chennai. A

clinical & serological study. J. Assoc. phys. India. 1995; 43: 450-58

6. Feigin RD, Anderson DC. Human Leptospirosis. CRC Cri Rev lab sci. 1975;

5: 413-67

7. Sumathi G, Chinari Pradeep KS & Shivakumar S MSAT – A screening test for

Leptospirosis .Indian J Med Microbiol(1997) 15:84

8. Chinari Pradeep KS, Sumathi G, Vimala RangaRao G, Shivakumar S

Leptospirosis laboratory. Chennai Medical College – A three year experience

in serodiagnosis (1995-1997). Indian J Med Microbiol (1999) 17(10): 50-51.

9. Shivakumar S Leptospirosis –Evaluation of clinical criteria J.Assoc Phys India

2003,51:329-330

10. Kamath SA, Joshi SR. Re-emerging of infections in urban India – Focus

Leptospirosis. .J.Assoc Phys India 2003,51:247-248



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ARTICLE 14

LEPTOSPIROSIS IN MADRAS, INDIA – A STUDY OF 206 CASES

(1987 – 95)

M.A. MUTHUSETHUPATHI, S.SHIVAKUMAR

Department of Nephrology, Madras Medical College and Government General Hospital, Madras.

OBJECTIVE:

To study the epidemiological factors, clinical features, diagnosis,

management and prognosis of patients with Leptospirosis admitted in Government

General Hospital, Madras.

PATIENTS & METHODS:

A retrospective analysis of patients admitted with Leptospirosis during

the period 1987 – 1995 was undertaken. Microscopic Agglutination Test (MAT),

ELISA (IgM) and Patoc Agglutination Test (PSAT) were utilized for diagnosis.

RESULTS

206 patients with Leptospirosis were studied. There were 171 males

(83%). Most of them were outdoor manual workers. No specific occupational

risk groups could be identified and there was no geographical clustering. 178

(86%) patients were admitted during the “monsoon” months (Nov. - Dec.). The

important clinical features noted were a) Fever – 100% b) Jaundice – 83%

c) Renal Failure – 79% d) Myalgia – 79% e) Conjunctival suffusion – 43%

f) CNS – 43% g) Bleeding – 28%. Autumnalis was the common serogroup.

First Meeting of the International Leptospirosis Society, Nantes (France) 9 – 13 September 1996

93

Lcterohaemorrhagiae, Canicola, Australis were the other serogroups noted. 102

patients (49.5%) needed dialysis. Peritoneal dialysis was adequate for 83 patients

and 19 patients needed Haemodialysis. 32 patients died (mortality – 15.5%).

CONCLUSIONS:

1. Most patients with Leptospirosis were seen during the “monsoon” months.

2. No specific occupational risk – groups were observed.

3. Jaundice, Renal failure and Myalagia were the common clinical features

noted.

4. Autumnalis was the most common serogroup.

5. Peritoneal dialysis was adequate for most patients with renal failure.

6. The mortality was 15.5%.

LEPTOSPIROSIS CASES DATA (1987 – 1995)

Total cases = 206 Males = 171 (83%)

ANNUAL INCIDENCE

1987 1988 1989 1990 1991 1992 1993 1994 1995 Total 4 21 26 60 48 8 9 6 24 206

MONTHLY INCIDENCE (1987 – 1995)

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Total

7 3 -- -- 3 2 1 -- 8 4 110 68 206



94

CLINICAL FEATURES

Fever 100% Jaundice 83%

Renal Failure 79% Myalgia 79%

Conjunctival Suffusion 43% CNS dysfunction 43%

Bleeding 28%

DIALAYSIS DONE

Total = 102 (49.5%)

Peritoneal dialysis = 83

Hemodialysis = 19

MORTALITY = 32 (15.5%)


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ARTICLE 15

LEPTOSPIROSIS - CURRENT SCENARIO IN INDIA

S. SHIVAKUMAR

INTRODUCTION Leptospirosis has long been considered a rare zoonotic disease in India with

only sporadic cases being recorded1,2. Since 1980’s the disease has been reported

from various states during monsoon months in mini epidemic proportions. The

disease is endemic in Kerala Tamilnadu, Gujarat, Andamans, Karnataka,

Maharashtra. It has also been reported from Andhra Pradesh, Orissa, West Bengal,

Uttar Pradesh, Delhi & Puducherry.3,4

Leptospirosis has been under reported and under diagnosed from India due to

a lack of awareness of the disease and lack of appropriate laboratory diagnostic

facilities in most parts of the country. Combining clinical expertise and awareness

with confirmatory laboratory back up dramatically increases the recognition of

patients with leptospirosis. Clinical features of leptospirosis vary from mild illness to

severe life threatening illness. Leptospirosis can be diagnosed only by laboratory tests

as the clinical features are nonspecific. But the laboratory tests are complex and hence

definite guidelines for diagnosis of human leptospirosis is necessary. In this article,

the current scenario of leptospirosis in various endemic states of India will be

highlighted and the problems in diagnosis and management will be discussed.

EPIDEMIOLOGY Leptospirosis is an infectious disease caused by leptospira interrogans

complex, which has over 20 serogroups and more than 200 serovars. Rodents,

Medicine Update 2008 Vol. 18 799 – 809


96

domestic & wild animals form the reservoir of infection where domestic animals such

as cattle, dogs, and pigs may act as carriers for several months (temporary carrier)

while rodents usually remain carrier throughout their life (permanent carrier). Rodents

are therefore considered as the major reservoir of infection. Leptospires are excreted

in the urine of the animals and they affect man when he comes into contact with urine

of infected animals, directly or indirectly, when he is exposed to an environment

contaminated by the urine of the infected animals such as soil and surface water

following monsoon rains. Therefore this illness commonly occurs during the monsoon

months. The infection is probably transmitted when they wade through stagnant

rainwater contaminated by infected urine of animals. These organisms can survive for

6 hours in dry soil and for 6 months in flooded condition. They enter the host through

the abrasions of the skin of the feet or intact mucous membranes of eye, throat and

gut5.

Leptospirosis can occur in both urban and rural areas. In urban areas of

developing countries, a contaminated environment due to various factors such as

overcrowded slums, inadequate drainage and sanitation facilities for man and animals,

presence of stray dogs, cattle, pigs, domestic rats, bandicoots, poor condition of

slaughter houses and people walking bare foot contribute to the spread of the illness.

In rural areas, high-risk groups are workers in rice fields, cane fields and other

agricultural crops and animal husbandry staff. In addition, workers in sewers mines

and military personnel are also at risk. History of animal contact is not essential for

diagnosis for leptospirosis in developing countries. It is impossible to trace the source

of infection and any person can be infected, irrespective of direct contact with

animals, due to contaminated environment. Therefore the more important

epidemiological factors are rainfall and contact with contaminated environment5.


97

Persons of all ages and races are susceptible. Adult men however are more

frequently infected because they tend to work in high-risk jobs. The number of cases

in a region often fluctuates from year to year due to various factors such as rainfall,

flooding and animal infections. Leptospiral infections tend to occur as

individual/small cluster of cases or large outbreaks/epidemics. In India, urban

leptospirosis has been reported from Chennai & Mumbai while rural leptospirosis has

been reported from Gujarat, Kerala and Andamans. Non-reporting of leptospirosis

from other states of India does not mean that it is absent in those parts.

CLINICAL FEATURES Leptospirosis can manifest in many ways.6 The various syndromes of

presentation are as follows.

1. Acute febrile illness

2. Weil’s syndrome characterized by jaundice, renal failure and Myocarditis

with cardiac arrhythmias

3. Pulmonary Haemorrhage with respiratory failure

4. Meningitis / Meningo encephalitis

The incubation period is 7—14 days, but ranges from 2—21 days.

The incidence rate ranges from 0.1 – 1/100,000 per year in temperate climates

to 10- 100/100,000 in tropical countries. During outbreak the incidence may reach

over 100/100,000. Hospital based data on clinical manifestations confirmed by

laboratory tests (Rapid tests / MAT) are usually needed to obtain the incidence rates.

Mild cases may not be admitted to hospitals and hence these data may result in a bias

towards severity in assessing the public health importance of leptospirosis.6



98

The prevalence rates are obtained from asymptomatic individuals of selected

high risk groups. Sero surveillance provides data on infection rather than as a disease.

MAT is required for sero surveys.

INDIAN SCENARIO The current scenario of leptospirosis in various endemic states will be

discussed. Data from other states will also be analyzed. In addition, the problems in

diagnosis and management will be highlighted.

ANDAMAN AND NICOBAR ISLANDS Andaman and Nicobar Islands are endemic for leptospirosis since early part

of the 20th century. Outbreaks of Andaman Haemorrhagic Fever (AHF) were reported

since 1988.3,7,8 This was proved to be leptospirosis in 1994. 524 cases of AHF

(leptospirosis) were reported from 1988 - 97. The disease presented as febrile illness

with pulmonary haemorrhage during post monsoon periods. As the disease presented

with predominant pulmonary involvement, a Leptospiral etiology was never

considered. In addition, absence of diagnostic facilities were responsible for not

diagnosing leptospirosis7.

During 2000-04, 544 cases were reported in Andamans by disease

surveillance system. There were total of 93 deaths with the highest incidence in

2002.3 At present, Andaman islands has probably the highest incidence rates of

leptospirosis in the country with figures ranging between 50 - 65 cases / 100,000 per

year7.


99

In 2005, 58 cases of confirmed leptospirosis were admitted and 14 patients

died [Case Fatality Rate (CFR) - 24.1%]. Majority of deaths were due to pulmonary

haemorrhage and occurred within 48 hours. Rural urban ratio was 46:12 with

exposure to agriculture being 69% and history of contact with animals being 72.4%3.

In 2004, 322 of 611 sera samples from different high risk populations were

positive giving an overall sero prevalence of 52.7%. The sero prevalence was highest

among agricultural workers (62.5 %) followed by sewage workers (39.4%), animal

handlers (37.5%), butchers (30%) and forest workers (27.3%). Among the control

group the sero prevalence was 14.7%. Grippotyphosa followed by Australis were the

common sero groups identified.9

These studies were done at the Regional Medical Research Centre (ICMR),

WHO Collaborating Centre for Diagnosis Reference, Research and training in

leptospirosis which is situated in Andaman and Nicobar Islands.

GUJARAT The disease is endemic in south Gujarat since 1994.3,10,11 The endemic

districts are Valsad, Navsari and Surat. Cases are seen during the monsoon months.

The annual data of leptospirosis in Gujarat are shown in Table 1 which shows yearly

fluctuations in numbers with the highest CFR in 2005 (20.6 %).3,11

TABLE 1 : Year wise cases & deaths due to leptospirosis in South Gujarat

Year 1997 1998 1999 2000 2001 2002 2003 2004 2005

Cases 657 515 357 156 4 37 373 630 392

Death 76 40 32 16 0 6 40 92 81

CFR % 11.5 7.77 8.96 10.26 0 16.2 10.7 14.6 20.66



100

In the year 2005, 392 cases and 81 deaths due to leptospirosis were reported

from various districts of south Gujarat (Table 2). There were 310 males and 82

females, mostly in the age group of 26 - 45 year.11 Jaundice, renal failure and

haemorrhagic pneumonitis were the common complications noted.

TABLE 2: Summary of Leptospirosis cases and associated deaths in the year 2005

Districts Cases Deaths CFR Taluks PHCs Villages

Surat 185 43 23.24 10 41 123

Navsari 114 26 22.80 5 31 70

Valsad 88 11 12.50 5 25 58

Bharuch 2 0 0 2 2 2

Gandhinagar 2 1 50 2 2 2

Others 1 0 0 1 1 1

Total 392 81 20.66 25 102 256

Based on extensive studies conducted in Gujarat, it was highlighted that

agro-climatic conditions for south Gujarat favour endemicity for leptospirosis.

These include heavy rainfall, clay soil and high water table3.

Public health control measures have been directed towards source

reduction to begin with followed by case reduction and then subsequent reduction

in case mortality. This is achieved through a mulitsectoral approach involving

collaborative work between Department of health, Irrigation, Agriculture, Animal

Husbandry, Tribal Development and Public works3.

Gujarat has a well organized leptospirosis control programme extending

from primary health centre to district hospital / medical college hospitals in

endemic areas. A medical officer at PHC can treat any febrile illness during


101

monsoon months with chloroquine and doxycycline. If leptospirosis is suspected,

I.V Penicillin is given. If there is organ dysfunction, he refers them to the nearest

hospital for laboratory diagnosis and management.11

Chemoprophylaxis is given to all persons working in agricultural farms

and those involved in animal husbandry. They are given doxycycline 200 mg once

a week for a period of 6 weeks, during the period of maximum rains and water

stagnation in a particular district. Public awareness is created by Television and

pamphlets at PHCs.11

MAHARASHTRA: Leptospirosis has been reported regularly since 1998.3,12,13 The annual

data from 1998 - 2005 is shown in table 3.

TABLE 3: Year wise cases and deaths due to leptospirosis (1998 - 2005) Year 1998 1999 2000 2001 2002 2003 2004 2005

Cases 197 120 324 860 53 350 225 2355

Deaths 7 3 59 111 5 24 18 167

2355 cases and 167 deaths were reported in 2005, mainly due to large

outbreak during the post monsoon floods. The number of districts in Maharashtra

reporting leptospirosis has expanded from two in 1998 to ten districts in 2005. The

important districts are Mumbai, Thane, Kolhapur, Sangli and Sindhudurg which

are affected by leptospirosis. The serovars isolated were L. icterhaemorrhagie

(rats), L. canicola (canines) and L. australis (cattle).



102

In a study of 74 cases, haemorrhagic pneumonitis occurred in 35.1 %

cases. Of the 11 deaths (14.8%), 9 were due to pulmonary haemorrhage.14

Autopsy findings of 62 cases of leptospirosis revealed pulmonary intra alveolar

hemorrhage in 48 cases and renal acute tubular necrosis / acute interstitial

nephritis in 45 cases15.

In a study of ICU admissions, 7.2% of cases were due to leptospirosis

(60/834). Mortality due to leptospirosis was 52% and 95% of these patients needed

ventilatory support for respiratory failure16.

KERALA Leptospirosis is endemic in many areas of Kerala. Kolenchery is in the

midlands of Kerala. In this area leptospirosis was rarely diagnosed before 1987.

Since then a yearly increase in incidence was observed. In a study of 976 cases of

leptospirosis confirmed by culture and / or serological tests, a mortality rate of 5.32

% was observed. Autumnalis, Australis and Icterohaemorrhagiae were the common

serogroups identified17.

In study of 282 cases of leptospirosis from Calicut, hepatic (69.8%), renal

(56.3%) involvement and thrombocytopenia (65.8%) were the common

complications noted. The mortality was 6.03%.18 Sero prevalence in Calicut among

high risk groups was 38.1% (Fishermen – 52.8%, Sanitary workers – 56.2 %,

Agricultural workers - 30 %, and sewarage workers was 28.2%). The rate in healthy

control was 24 %. Pomona, Shermani, Canicola were the common serogroups

identified19.

In a study of leptospirosis from kottayam of 900 cases treated over 10

years, Jaundice - (80%), renal failure (59%), hypotension (20%) were the common


103

complications noted. The disease was commonly seen in agricultural workers,

fishermen and oyster shell catchers (82%). 74% were seen during the monsoon

months with a male/female ratio 7:1.20

A model leptospirosis control programme has been formulated by Kerala

state and is awaiting implementation. A state level diagnostic and epidemiology

centre at each district has been established to provide technical leadership with the

aim to reduce the incidence/prevalence of leptospirosis. This is not a separate

programme to control leptospirosis but is integrated with other illness at the district

levels.21

TAMILNADU: Leptospirosis has been reported from Chennai since 1980’s.22,23 The

leptospirosis laboratory at Institute of Microbiology, Madras Medical College was

established in 1994.24 This laboratory receives samples from both government and

private hospitals. Data on leptospirosis from government hospitals during the period

2004 – 2006 is given in Table 4.

TABLE 4: Leptospirosis: Annual data of public sector hospitals - Chennai

(2004-2006):

Year 2004 2005 2006 Leptospirosis 963 1724 2765

There has been a dramatic increase in the number of leptospirosis cases &

during 2006, 2765 cases were reported. The data on leptospirosis from various

major public sector hospitals from Chennai city is given in Table 5.

TABLE 5: Year 2006 - Government hospital data - Chennai ( No. 2765 cases):

Hospital General Hospital

Stanley hospital

Kilpauk MC Hospital

Royapettah Hospital

Children’s Hospital

Leptospirosis 965 511 563 169 557 Medicine Update 2008 Vol. 18 799 – 809


104

All the Chennai city government hospitals reported cases of leptospirosis.

Data on leptospirosis in private sector hospitals are not available and therefore the

incidence of leptospirosis is under reported.

During the period 1987 – 91, there were 159 cases of leptospirosis at the

General Hospital, Chennai. There were 108 males and the mean age was 40.1 years.

136 (85%) had jaundice and 120 (75%) had renal failure. 70 patients were dialyzed

and 25 patients died (15.6%).25

In the recent past, acute renal failure due to leptospirosis at general hospital

Chennai has significantly declined from 31% in 1987 – 91 to 7.5% in 1995 – 2004.26

Of the 120 cases of leptospiral ARF during the period 1987 - 91, the highest number

of 45 cases were reported in 1990. Since 1992 there has been a decline in

leptospiral renal failure cases and during a 10 year period from 1995 - 2004 only 84

cases were reported.27

Though severe leptospirosis has declined, mild leptospirosis has increased.

In a collaborative study with Leptospirosis Laboratory, Barbados of 57 cases in

1990 - 91 Jaundice occurred in 84 %, and acute renal failure occurred in 72%. Sero

group Autumnalis was the most common sero group encountered. 26 patients were

dialyzed and 2 patients died.28 In a recent study of 106 cases of leptospirosis from

north Chennai, Jaundice occurred in 17.8% and renal failure occurred in 10.3%

showing a decline in complications. Only two patients were dialyzed and there were

no deaths. Fever, headache, myalgia were the common presentations. Contaminated

environment (95%) and rainfall (50%) were the important epidemiological risk

factors. Icterohaemorrhagiae was the most common serogroup and Autumnalis was

not detected.27


105

The reasons for the decline in severe leptospirosis suggested were greater

awareness of disease, availability of better diagnostic facilities and wide spread use

of antibiotics. In addition, serogroup Autumnalis, a virulent serogroup causing

severe leptospirosis has also declined since 1995. The increase in mild leptospirosis

suggest that contaminated environment plays an important role in the persistence

and spread of the disease.27

Leptospirosis is an important cause of acute febrile illness. In a recent study

of 500 cases of fever at government Stanley hospital, leptospirosis was the second

common cause of fever contributing to 17%, following malaria which was 27%. Co-

infection of leptospirosis (48 cases) with malaria (220 cases) occurred in 22% of

cases.29 Co-infection of Malaria and Leptospirosis has been reported from

Chandigarh.30

A sero survey in Chennai revealed a seroprevalence rate of 32.9% (Range

17.8% - 40.5%).31 Uveitis due to leptospirosis has been reported from Madurai.32 A

majority of 73 cases had panuveitis (95.5%), retinal phlebitis (51.4%) and hypopyon

(12.6%).

PUDUCHERRY

In a study of 33 icteric patients from Puducherry, 22 had altered sensorium

and 20 had multiorgan failure and thrombocytopenia. 13 patients died (39.3%).33

KARNATAKA Leptospirosis outbreaks have been reported from 15 districts of Karnataka.

The highest incidence of cases have occurred in Bangalore city, Uttara kannada,

Shimoga, Bidar, Gulbarga, Udupi and dakshina kannada districts. During the year

2004, 152 cases and 11 deaths were reported and during 2005, 224 cases and 19

deaths were reported. Patients responded to treatment with amoxicillin and

paracetamol3.



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In study of 733 patients suspected of leptospirosis, 84 (11.45%) were found

positive by ELISA. The important complications noted were hepatic (65%) and renal

failure (63%).

Diarrhoea occurred in 24% of cases. 54.7% were agriculture workers and

55.9% gave history of contact with animals.34

ORISSA: After the cyclone during the October-November 1999, 142 patients with

febrile illness and haemorrhagic manifestations were evaluated. 28 (19.2%) had

evidence of leptospirosis which was confirmed by MAT. 6 were positive by

culture/PCR.35

143 people suspected of leptospirosis in a remote village of Mayurbhanj

district in north Orissa was evaluated by the Orissa Multi-disease Surveillance

System (OMDSS) during the period June - July 2002. The attack rate was 5.95%

(143/2404) and the CFR was 7.69% (11/143). There was exposure to infected water

in a canal which was probably the source of infection.36

OTHER STATES Data from Andhra Pradesh, Uttar Pradesh, West Bengal and Delhi are

becoming available. Evaluation of acute febrile patients in Uttar Pradesh revealed

that 7% had leptospirosis (25/346). 17 of the 25 patients had jaundice.37 In a study

of 55 cases of leptospirosis in Hyderabad, 52% had renal failure and jaundice

occurred in 42%.38 Out of 42 persons with jaundice who were evaluated in Calcutta,

10 (23.8% ) were found positive for leptospirosis.39 75 patients from Delhi with

symptoms of leptospirosis were evaluated, 32 were found positive for leptospirosis

and 5 died.40 180 febrile patients from urban slums of Delhi were evaluated and 27

(15%) were positive for leptospirosis.41


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All the available evidence from endemic states suggests that the disease is

now emerging in India as an important public health problem. Inspite of adequate

knowledge, we do not have an accurate estimate of the disease burden in the

country, as data from many other states is not available probably because of lack of

diagnostic facilities. The importance of early diagnosis and case management should

be emphasized and appropriate modification in approach is essential.3

This should include,

a. Guidelines for simple case definition and empiric therapy in small rural hospitals,

where diagnostic facilities are not available.

b. Diagnosis of leptospirosis utilizing Modified Faine’s Criteria for in patients

admitted to district / teaching hospitals where diagnostic facilities are available.3

DIAGNOSIS OF LEPTOSPIROSIS Laboratory support is needed: 1. To confirm the diagnosis 2. For epidemiological and public health reasons, to determine which serovar caused the infection, the likely source of infection, potential reservoir and its location.

The tests depend on the phase of the infection. During leptospiremic phase

(< 7days) leptospires can be isolated by blood culture and PCR, while in the immune

phase, rising antibodies can be detected by serological tests.

Culture

The isolation of leptospirosis by culture of blood, CSF and urine is the most

definite way of confirming the diagnosis of leptospirosis. Unfortunately, culture of

blood does not contribute to an early diagnosis as results come late, weeks or even

months after inoculation of culture medium, however it is valuable in critically ill

patients who might die in the first week before the development of antibodies.



108

PCR is promising on both sensitivity and specificity, but is complicated and

expensive. Its value for rapid diagnosis is being evaluated and is used in higher

centres.42,43

Serology

The serological tests for diagnosis of leptospirosis have been classified as

serovar specific tests and genus specific tests.

SEROVAR SPECIFIC TESTS

Microscopic Agglutination Test (MAT)

MAT is the gold standard test for diagnosis of leptospirosis because of its

unsurpassed diagnostic specificity. The main advantage is that serovars can be

identified which is of epidemiological importance. The difficulties in utilizing MAT

are due to the following factors.44

a. The antibody titers rise and peak only in 2nd or 3rd week, making it a less

sensitive test. A study of 108 cases of leptospirosis from Brazil have revealed

that 65% of the first sample were positive by SAT compared to 44% by

MAT.45

b. A four fold rise in titer or seroconversion is the most definitive criteria for

diagnosis of leptospirosis. Therefore a second sample is mandatory, which is

difficult to obtain. In such circumstances, a single high titer in MAT can be

taken as diagnostic criteria. As MAT titers peak and persist for a long time (5 -

10 years), they would interfere with current diagnosis. Therefore many

workers use different criteria.

A titer of 1:100 is taken as significant criteria, but there is controversy on the

single diagnostic titer as they depend on endemicity. In endemic areas, a titer

of 1/100 or 1/200 is considered low; while high titer is usually > 1/400 (some

consider 1/800 or 1/1600 as diagnostic criteria). In non- endemic areas, 1/100


109

titer is taken as the diagnostic criteria. It is preferable to do rapid tests along

with single high titers. Positive rapid tests with high titers suggest current

infection while negative rapid tests is probably due to past infection. In

Andamans, a titer of 1/200 is taken as diagnostic titer. Serosurvey in the

asymptomatic high risk group should be done with MAT only and a titer of

> 1/50 can be taken as cut off titer.

c. The test is complicated requiring dark field microscopy and cultures of various

live serovars. This may not be available in small laboratories.

Genus specific tests (Rapid tests)

The common tests are the ELISA, Macroscopic slide agglutination test

(MSAT), latex agglutination test, Dipstick tests (Lepto dipstick, Lepto Tek lateral

flow) and Lepto Tek Dri-Dot test.6,11,44,46,47 The genus specific tests are the tests of

choice for the diagnosis of current infection. These tests are simple, more sensitive

and become positive earlier than MAT. These tests detect genus specific antibodies,

which are shared by pathogenic and saprophytic leptospira. These test become

positive early in the disease (5-6th day) as they detect specific IgM antibodies and

help in the rapid diagnosis of current infection.

LABARATORY CRITERIA FOR DIAGNOSIS OF CURRENT LEPTOS PIROSIS CONFIRMED

1. CULTURE: Positive

2. MAT: a) Seroconversion / 4 fold rise in the titer

PROBABLE

1. Rapid tests: Positive

2. MAT: High titer (Single sample)

The approach to diagnostic tests for leptospirosis is given in Table 6. Medicine Update 2008 Vol. 18 799 – 809


110

TABLE 6: Approach to Diagnosis of Leptospirosis.

COMMENTS

1) Rapid tests are adequate for diagnosis of current infection. This can be done in smaller laboratories in both rural and urban areas. If positive, confirm the diagnosis with MAT, which would be available in larger specialized laboratories.

2) MAT—Seroconversion / 4 fold rise in the titre is necessary for diagnosis. (2nd sample is essential). Single high titre in MAT combined with positive rapid tests confirms the diagnosis of leptospirosis.


Clinical features suggestive of current leptospirosis

Leptospiremic phase< 7days Immune phase > 7 days

Negative Positive

Positive Negative

Repeat (if low titre)

Rising titre

Repeat (> 3 days)

Blood culture / PCR Rapid tests

Repeat

Seroconversion

High titre

MAT

111

3) Blood culture - not sensitive but can be done in critically ill patient. (As they may

not survive to produce antibodies).

MODIFIED FAINE’S CRITERIA

Faine has evolved criteria for diagnosis of leptospirosis on the basis of

clinical, epidemiological and laboratory data (WHO guidelines).Certain necessary

modifications have been made by us in the epidemiological (Part B) and the

laboratory criteria (Part C) of original Faine’s criteria to make the diagnosis more

practical in Indian institutions. (Shown in Table 7). In the Modified Faine’s Criteria

rapid tests (ELISA / SAT) have been introduced in Part C and Rainfall has been

included in Part B to make the diagnosis early and simple.48,49 This criteria can be

utilized for diagnosis of leptospirosis in district / teaching institutes.3



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TABLE 7: DIAGNOSIS OF LEPTOSPIROSIS-MODIFIED FAINE’ S CRITERIA

Name: Age: Sex: Occupation: Residence (rural/urban ): Date:

Presumptive diagnosis of leptospirosis is made of:

Part A or part A & part B score : 26 or more

Part A, B, C (Total) : 25 or more

A score between 20 and 25 suggests leptospirosis as a possible diagnosis. MANAGEMENT Mild leptospirosis can be treated with Doxycycline or Amoxycillin or

Erythromycin and severe leptospirosis with I.V. Penicillin or Ceftriaxone.


PART A: Clinical Data Score Part B: Epidemiological factors Score Headache 2 Rainfall 5

Fever 2 Contact with contaminated

Temp > 39 C 2 Environment 4

Conjunctival suffusion 4 Animal Contact 1

Meningism 4

Myalgia 4

Conjunctival suffusion Part C : Bacteriological Lab findings

Meningism 10 Isolation of leptospira in Culture –

Myalgia Diagnosis certain

Jaundice 1 Positive Serology

Albuminuria / 2 ELISA IgM Positive 15 Nitrogen retension SAT - Positive 15

MAT- Single positive 15 in high titre

Rising titre / seroconversion (paired sera) 25

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RECOMMENDATIONS FOR MANAGEMENT BASED ON THE AVAILAB ILITY OF DIAGNOSTIC FACILITIES In centers where no diagnostic facilities are available (Rural areas) The common causes of acute febrile illnesses are Malaria, Leptospirosis,

Dengue and Viral respiratory diseases. It is difficult to diagnose these illness without

laboratory facilities. It is recommended that all febrile patients can be treated with

doxycycline and chloroquine which is the empiric therapy for Malaria &

Leptospirosis. If there is organ dysfunction and / or fever persists, they should be

transferred to higher centres for further management. This is being implemented in

the state of Gujarat11.

In centres where diagnostic facilities are available

Even in centres with laboratory facilities, empiric therapy is recommended

for leptospirosis where the disease is endemic, since serological tests become positive

only after one week (unless PCR is available). Mild cases can be treated with

chloroquine and doxycycline and severe cases with I.V. crystalline penicillin /

quinine or artemisinin and doxycycline50.If they are admitted later (after a week),

rapid tests would confirm leptospirosis and appropriate treatment can be given. It is

essential that all febrile patients are investigated for leptospirosis, Malaria and

Dengue fever as co-infection can occur29. In addition, dialysis and ventilatory support

for renal and respiratory failure would definitely decrease mortality.

To conclude, data on leptospirosis is urgently needed from all states of the

country. This can be done by making rapid tests available at all district / teaching

hospitals. The National Institute of Communicable Diseases (NICD) utilizing the

Integrated Disease Surveillance Programme (IDSP) should organize the availability

of rapid tests.3 Appropriate guidelines for management should be implemented to

reduce the morbidity and mortality of leptospirosis.



114

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in south Gujarat. .Indian J Med Microbiol 2006 24(4). 322-326.

12.Karande S, Kulkarni H, Kulkarni M et al. Leptospirosis in children in Mumbai

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16.Chawla V , Trivedi TH, Yeolkar. Epidemic of leptospirosis- An ICU experience.

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18.Pappachan MJ,Mathew S,Aravindan KP et al. Risk factors for mortality in

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19.Swapna RN, Tuteja U, Nair L et al.Seroprevalence of leptospirosis in high risk

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20.Vimala A , Kasi Visweswaran . Leptospirosis in kottayam. South Asian Work

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21.John TJ. The prevention and control of Human leptospirosis. J Post Grad Med

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22.Ratnam S, Sundararaj T, Thiagarajan SP et al. Serological evidence of

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23.Ratnam S, Suramaniam S, Madanagopalan T. Isolation of leptospirosis and

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24.Chinari Pradeep KS, Sumathi G, Vimala RangaRao G, Shivakumar S

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serodiagnosis (1995-1997). Indian J Med Microbiol (1999) 17(10): 50-51.

25.Muthusethupati MA, Shivakumar S, Vijaykumar R et al. Renal involvement in

Leptospirosis- Our Experience in Madras City. J Post Grad

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26.Jayakumar M, Ram Prabakar H, Edwin Fernando M et al. Epidemiologic trend

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31.Ratnam S, Evarard COR, Alex JC et al. Prevalence of leptospiral agglutinins

among conservancy workers in Madras City, India. Journal Of Tropical

Medicine and Hygiene 1993; 96:41-45.

32.Rathinam SR, Rathinam S, Selvaraj D et al. Uveitis associated with an epidemic

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33.Dutta TK, Christopher M, Leptospirosis – An Overview. J.Assoc Phys India

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34.Jagadishchandra K,Prathb AG, Rao SP. Clinical and epidemiological correlation

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35.Sehgal SC, Sugunan AP, Vijayalakshmi P. Outbreak of leptospirosis after the

cyclone in Orissa. Nat Med J India. 2002.15, 22-23.

36.Jena AB, Mohanty KC, Devadasan N. An outbreak of leptospirosis in Orissa,

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37.Manocha H, Gushal V, Singh SK et al. Frequency of leptospirosis in patients of

acute febrile illness in Uttar Pradesh. J.Assoc Phys India 2004,52:623-625.

38.Velineni S,Asuthkar S, Umabala P et al. Serological evaluation of leptospirosis

in Hyderabad,Andhra Pradesh: A retrospective hospital – based study. Indian J

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39.Debnath C, Pal NK, Pramanik AK et al. A serological study of leptospirosis

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41.Kaur I, Sachdeva R, Arora V et al. Preliminary survey of leptospirosis among

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Antigen Detection in Blood. Indian J Med Microbiol 2006.24 (4):342-345.

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45.Angelo P. Brendo et al. Macroscopic agglutination test for Rapid diagnosis of

Human Leptospirosis. Journal of Clinical Microbiology {1998}; 36(11): 3138-

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Foreword

When Dr. Bichile asked me to write the Foreword to API Medicine Update

2008, I went down the memory lane. When the first meeting of API took place in

1945 I was a 17 years old second year student at the Osmania Medical College in

Hyderabad where Urdu was the medium of instruction. Mine was the last batch of

students who wrote the final MBBS examination papers in 1949 in Urdu. Eleven

years after my graduation my first participation was in APICON 1960 in New Delhi

where I presented a paper on “Sensory Dissociation”. In the APICON 1979 at Chenni

I delivered the Netaji Oration “Never Vistas in Nuclear Medicine” with Dr.BK Naik,

previously my teacher at the Osmania Hospital, as President. During APICON 1984

at Hyderabad, my home-town, my first book “Principles & Practice of Nuclear

Medicine” was released by Dr.BB Tripathy as President. He said he always

remembered my guest lecture at APICON 1968 at Cuttack organized by him, on

Nuclear Medicine and Radio immuno assay. APICON 2008 marks my 48th active

participation, on the verge of my 80th birthday on 16th January 2008. My Guest

Lecture in the CME is on “Information and Communication Technology (ICT) in day-

today clinical practice”.

When the API Medicine Update was started in 1990, the impact of the

Internet was neither felt not anticipated. Today every API member has access to the

Internet by just a click on the mouse. Searching the Internet is now part of my daily

routine. I also have on my table the latest edition of Harrison’s Principles of Internal

Medicine as well as the API Text Book of Medicine, whose utility for me, in

competition with Harrison’s, is determined by how much incremental Indian

experience it provides to me. The legitimate expectation from API Medicine Update

is that it necessarily provides incremental Indian experience. This does not apply to

new concepts, new diagnostic and therapeutic innovations introduced in Medicine.

Every one is always eager to know all about them.


120


I went through the last 8 API Medicine Updates (2000 to 2007), about 6800

pages produced by 8 editors and over 2000 contributors. I found only about 20%

articles with great incremental value. Another 10% articles had some Indian data

in the text and 1 – 3 Indian references which have marginal incremental value.

Over 65% articles neither had any Indian content in the text nor a single Indian

reference; hence these have zero incremental value. This is “redundant recycling

of information”. Some 5% of the articles represent “futile recycling of

information”, reminding one of the limerick: “The cow kicked Nelly in the belly in

the barn : did not do her any good, did not do her any harm”.

I do not claim my personal assessment to be representative of the

consensus of the API readership. If any editors or contributors are hurt or

offended by my candid appraisal, I offer my sincere apology.

Applying my touch-stone to Medicine Update 2008, again I find 20%

articles with high incremental value. To give a few examples – BM Hegde :

Wavelength analysis of heart rate variability – new method of studying the heart’s

function; S. Shivakumar : Leptospirosis – Current Indian Scenario; M. Ganu

& AS Ganu : Chikungunya an overview : Siddharth Das : Lean T2DM, Profile,

Peculiarities and paradox; SG Godbole : Breaking bad news.

Articles published in JAPI are available on the Internet while articles

published in Medicine Update are not. My suggestion to Dr.Bichile is that during

his tenure as President he initiates steps to bring all high value Update articles

published so far on the Internet. I give below a sample list.

Model Concept articles

� Neuronal control of Aging : Hormonal Signaling and Metabolic pathways

(JS Bajaj 2007)

� Deadly Quartet Revisited (Prakash Deedwania 2000)


121

Model Indian Work

� Metabolic Bone Disease. Past present and future challenges (SNA Rizvi

2007)

� Rising prevalence of diabetes in India and the implications of ADA-EASD

concensus on management (R.Ramachandran 2007).

Articles with high Indian Content

� Hyperhomocysteinemia and its implications in atherosclerosis – the Indian

Scenario (GS Sainani et al 2007)

� Epidemiology of Hypertension in India (Rajeev Gupta 2006)

� Emerging Trends and unsolved issues in the management of HCV-Indian

perspective (SN Arya 2006).

� Five decades of nephrology (KS Chugh 2004)

� Falciparum malaria – complications and management (BB Thakur 2001).

� CAD in the young – Indian scenario (Satyawan Sharma 2001)

� Telemedicine at the turn of Millenium (Rissam HS 2000).

Thought provoking articles

� Genes, dreams and realities (BM Hegde 2001)

� Cardiopulmonary manifestations of tobacco : Physician’s role in their

prevention (RS Bhatia 2001)

� National TB control program – involvement of Physician (KJR Murthy

2006)

� Economic burden of Diabetes (Siddharth Shah 2001)

� Changing doctor – patient relationship in 21st Century (YP Munjal 2001)

� Chloroquin in HBV and HCV Hepatitis (M. Chandramohan 2004)

� Demise of the physical examination (Jain & Ingole 2007).



122

A provocative question – After 18 years of experience should future API

Medicine Updates continue in the present form or can we do better? All of us

appreciate that “The cow is as eager to suckle as the calf is eager to suck”.

Henceforth, if the cow is eager to suckle she should make it worthwhile for the

calf to suck, since the calf has the better option of clicking the mouse!

Dr. R.D. Lele M.B.B.S. (OSM), DTM & H(Eng.), MRCP(Edin.), FRCP(London), FNAMS Hon.DSc. Hon. Chief Physician & Director Nuclear Medicine Dept. Jaslok Hospital & Research Centre Hon. Director of Nuclear Medicine & RIA Dept. Lilavati Hospital & Research Centre Emeritus Professor of Medicine (for life) & Ex-Dean, GMC & Sir J.J.Hospitals, Mumbai Emeritus Professor of the National Academy of Medical Sciences (India)


123

ARTICLE 16

LEPTOSPIROSIS LABORATORY, MADRAS MEDICAL COLLEGE:

REVIEW OF OUR EXPERIENCE (2004 – 2006)

G. Sumathi, R Narayanan, S Shivakumar

The Leptospira Laboratory in Madras Medical College at Chennai was

established in 1994. We have already published our experience during the period

1995 – 19971. In this article, we discuss our experience during the period 2004 –

2006, with the samples received from public hospitals in Chennai. There has been

a dramatic increase in the numbers of both samples and of positive cases, probably

because of increased awareness of the illness (Table 1). These samples were from

patients suffering from fever. During 2006, 2765 positive cases were reported

from public sector hospitals. The data of numbers of samples and positive

samples from city hospitals are shown in Table 2. Government Stanley Hospital

(GSH) caters to patients from North Chennai while Government Royapettah

Hospital (GRH) caters to patients from south Chennai. Government General

Hospital (GGH) and Kilpauk Medical College and Hospital (KMC) cater to

patients from central Chennai and the surrounding areas. The Institute of Child

Health (ICH) caters to children from all areas.

Table 1: Year wise distribution of leptospirosis in Chennai (2004-6)

Year No. of samples Postives (%)

2004

2005

2006

Total

6,512

6,909

8,537

21,958

963 (14.7%)

1724 (24.9%)

2765 (32.3%)

5452 (24.8%)

Indian Journal of Medical Microbiology Vol.26. No.2 April-June 2008 p.206 – 207


124

Table 2: Hospital wise distribution of patients with leptospirosis 2004 2005 2006

Hospitals No. of Samples

Positives No. (%)

No. of Samples

Positives No. (%)

No. of samples

Positives No. (%)

GGH 1986 370 (18.6) 2347 592 (25.2) 3396 965 (28.4) GSH 1214 198 (16.3) 1605 439 (27.3) 1440 511 (35.4) KMCH 1202 157 (13.0) 1123 261 (23.2) 1758 563 (32.0) GRH 430 55 (12.7) 564 124 (21.9) 500 169 (33.8) ICH 1680 183 (10.8) 1270 308 (24.2) 1443 557 (38.6)

GGH – Government General Hospital; GSH – Government Stanley Hospital; KMCH – Kilpauk Medical College and Hospital; GRH – Government Royapettah Hospital; ICH – Institute of Child Health and Hospital

Samples were received throughout the year and the data reveal that

leptospirosis occurs throughout the year although the number may increase during

the monsoon season (June to January). This emphasizes the importance of a

polluted environment which is an important epidemiological risk factor.

It has been our policy to do the macroscopic slide agglutination test

(MSAT) as a screening test for all the samples received. All positive MSAT

results are confirmed by the Microscopic Agglutination Test (MAT)2 – 4 Nine

pathogenic and one nonpathogenic serovars were included in antigen preparation.

L. icterohaemorrhagiae, L. australis, L. grippotyphosa, L. Pomona, L. sejroe,

L.bataviae, L. Louisiana, L. hebdomadis, L. javanica and L. patoc were the

serovars used. The antigen was prepared using standard methods5.

The common serovars found were L. icterohaemorrhagiae (48.0%)

followed by L. australis (37.0%) and L. grippotyphosa (26.0%). During our study

in 1995 – 1997, L. autumnalis (48.3%) was found to be the predominant serovar

followed by L. icterohaemorrhagiae (31.1%).1


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Therefore, we conclude that there has been a dramatic increase in the

number of leptospirosis cases reported in our laboratory during the period 2004 –

2006 and the common serovars are L. icterohaemorrhagiae, L. australis and L.

grippotyphosa. We also conclude that leptospirosis in Chennai occurs throughout

the year.

References:

1. Pradeep KS, Sumathi G, Rao GV, Kumar SS. Leptospirosis laboratory,

Chennai Medical College: A three year experience in serodiagnosis (1995

– 1997). Indian J Med Microbiol 1999; 17:50 – 1.

2. Shivakumar S, Krishnakumar B. Diagnosis of leptospirosis: Role of mat. J

Assoc Physicians India 2006;54:338 – 9.

3. Sumathi G, Pradeep KS, Subudhi CH, Helen PS, Kalpana, Shivakumar S,

et al. Serodiagnosis of leptospirosis: A Madras study. Indian J Med

Microbiol 1995;13:192 – 5.

4. Sumathi G, Shivakumar S, Chinari Pradeep KS. MSAT: A screening test

for leptospirosis. Indian J Med Microbiol 1997;15:84.

5. Faine s, editor. WHO Guidelines for the control of leptospirosis. Geneva;

WHO Offset publication No.67; 1982.


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