NOTA:

Para alterar a

imagem neste

diapositivo,

selecione a

imagem e

elimine-a. Em

seguida, clique

no ícone

Imagens no

marcador de

posição para

inserir uma

imagem à sua

escolha.

LEPTOSPIROSIS WITH SEPTIC SHOCK

Rui Domingues1, C Brandão2, V Brites2, M Santos2, F Candeias1, MJ Brito1

1 - Pediatric Infectious Diseases Unit 2 - Pediatric Intensive Care Unit

Hospital Dona Estefânia – CHLC - EPE, Lisbon Portugal

Head of Department: Gonçalo Cordeiro Ferreira

Leptospirosis is the most common zoonosis in the world

Worldwide distribution

Caused by spirochetes

Clinical history - the key to diagnosis

Broad spectrum of clinical findings

Clinical syndromes: anicteric (90%) and icteric

Can develop circulatory collapse and shock

INTRODUCTION

Introduction

Conclusion

References

Case presentation

Marr JS, Cathey JT. New Hypothesis for Cause of Epidemic among Native Americans, New England, 1616–1619. Emerg Infect Dis. 2010 February; [Epub Ahead of Print] DOI: 10.3201/edi1602.090276

CASE PRESENTATION

Conclusion

References

Case presentation

Introduction

1. Identification, Personal and

Family History

2. Clinical History and

Presentation

3. Investigation

4. Diagnosis and Treatment

5. Evolution

DM 14-year-old boy

Caucasian

Urban setting

Irrelevant personal and family history

No allergies and current medication

Contact with dogs, cats and rats

FEVER + ASTHENIA + PALLOR

CASE PRESENTATION

Conclusion

References

Case presentation

Introduction

1. Identification, Personal and

Family History

2. Clinical History and

Presentation

3. Investigation

4. Diagnosis and Treatment

5. Evolution

Pallor

Poor peripheral perfusion

Anicteric

No rash or tache noir

Hepatomegaly and splenomegaly

Tachypnea

Hypoxemia

Tachycardia (140 bpm)

Hypotension (60/30 mmHg)

Oliguria (0.7 mL/Kg/h)

- Fever (40 ºC)

- Asthenia

- Headache

- Neck pain

- Vomiting

- Pallor

- Fever

- Pallor

- Palpitations

- Chest pain

D1 D5 D7 D3

Conclusion

References

Case presentation

Introduction

1. Identification, Personal and

Family History

2. Clinical History and

Presentation

3. Investigation

4. Diagnosis and Treatment

5. Evolution

CASE PRESENTATION

Labs D5 D7 D8

Haemoglobin (g/dL) 12,3 ↓ 11,9 ↓ 10,2 ↓

WBCs (/uL) 7800 13000 ↑ 11300

Neutrophils (%) 79,02 ↑ 87,52 ↑ 90,32 ↑

Platelets (/uL) 180000 143000 ↓ 226000

PT (seconds) 13,6 ↑ 12 12

APTT (seconds) 36,2 31,9 30,9

Fibrinogen (g/L) 6 ↑ 7,6 ↑ 6,1 ↑

D-Dimer (ug/L) - 1137 ↑ 1639 ↑

CRP (mg/dL) 119,4 ↑ 259,6 ↑ 252,7 ↑

GOT (U/L) 80 ↑ 28 13 ↓

GPT (U/L) 150 ↑ 76 ↑ 46 ↑

Albumin (g/L) - - 23,9 ↓

Enlargement of the

cardiac silhouette

Conclusion

References

Case presentation

Introduction

1. Identification, Personal and

Family History

2. Clinical History and

Presentation

3. Investigation

4. Diagnosis and Treatment

5. Evolution

CXR

D7 [08Aug2015]

D8 [09Aug2015]

CASE PRESENTATION

D8 [09Aug2015]

Echocardiogram

Pericardial

effusion

D7 [08Aug2015]

Conclusion

References

Case presentation

Introduction

1. Identification, Personal and

Family History

2. Clinical History and

Presentation

3. Investigation

4. Diagnosis and Treatment

5. Evolution

CASE PRESENTATION

Pleural effusion

Hepatomegaly

Splenomegaly

Ultrasound

Splenomegaly

8

Conclusion

References

Case presentation

Introduction

1. Identification, Personal and

Family History

2. Clinical History and

Presentation

3. Investigation

4. Diagnosis and Treatment

5. Evolution

CASE PRESENTATION

Ultrasound

Pleural effusion

Pleural effusion

D8 [09Aug2015]

Doppler

Doppler study

of the

portal vein

and

inferior vena cava

without changes

Fever of unknown origin

Pallor + Asthenia

Hepatomegaly + Splenomegaly

Tachycardia + Hypotension + Oliguria

Tachypnea + Hypoxemia

↑ WBCs + ↑ Neutrophils + ↓ Platelets

↑ CRP

↑ Liver enzymes

↓ Albumin

Polyserositis

Contact with dogs, cats and rats

ICU Circ

ula

tory

co

llap

se

Inotropic support

Supplementary oxygen

Ceftriaxone

Doxycycline

Ciprofloxacin

D8

Conclusion

References

Case presentation

Introduction

1. Identification, Personal and

Family History

2. Clinical History and

Presentation

3. Investigation

4. Diagnosis and Treatment

5. Evolution

CASE PRESENTATION

Blood culture, Rickettsias,

Bartonella, Enterovirus,

Leptospira - urine direct test

and RT-PCR

- No supplementary oxygen & normal urine output

- Apyrexia

- Episcleritis

- Urine direct test documented forms of leptospira

- Infectious diseases unit

- Progressive improvement on clinical condition

D11 D13 D20 D12 Conclusion

References

Case presentation

Introduction

1. Identification, Personal and

Family History

2. Clinical History and

Presentation

3. Investigation

4. Diagnosis and Treatment

5. Evolution

CASE PRESENTATION

D18 [19Aug2015]

Ultrasound Dexamethasone

Neomycin

Ursodeoxycholic acid D21 [22Aug2015]

Ultrasound

Conclusion

References

Case presentation

Introduction

1. Identification, Personal and

Family History

2. Clinical History and

Presentation

3. Investigation

4. Diagnosis and Treatment

5. Evolution

CASE PRESENTATION

Labs

D5 D7 D8 D9 D16 D20

Haemoglobin (g/dL) 12,3 ↓ 11,9 ↓ 10,2 ↓ 10,9 ↓ 12,2 ↓ 12,7 ↓

WBCs (/uL) 7800 13000 ↑ 11300 12300 10500 8200

Neutrophils (%) 79,02 ↑ 87,52 ↑ 90,32 ↑ 86,82 ↑ 48,86 ↑ 27,78

Platelets (/uL) 180000 143000 ↓ 226000 252000 648000 ↑ 262000

PT (seconds) 13,6 ↑ 12 12 12 12,3 -

APTT (seconds) 36,2 31,9 30,9 31,7 30,7 -

Fibrinogen (g/L) 6 ↑ 7,6 ↑ 6,1 ↑ 5,5 ↑ 3,7 -

D-Dimer (ug/L) - 1137 ↑ 1639 ↑ 1842 ↑ 1127 ↑ -

CRP (mg/dL) 119,4 ↑ 259,6 ↑ 252,7 ↑ 250,6↑ 15,8 ↑ 1,7

GOT (U/L) 80 ↑ 28 13 ↓ 12 ↓ 26 17

GPT (U/L) 150 ↑ 76 ↑ 46 ↑ 31 ↑ 30 ↑ 13

Albumin (g/L) - - 23,9 ↓ 27,6 ↓ 39,8 -

Blood culture, rickettsias, bartonella

and enterovirus negatives

Leptospira

urine direct test and RT PCR

Positive

- No supplementary oxygen & normal urine output

- Apyrexia

- Episcleritis

- Urine direct test documented forms of leptospira

- Infectious diseases unit

- Progressive improvement on clinical condition

D11 D13 D20 D12

Conclusion

References

Case presentation

Introduction

1. Identification, Personal and

Family History

2. Clinical History and

Presentation

3. Investigation

4. Diagnosis and Treatment

5. Evolution

CASE PRESENTATION

Ends the

inotropic support

LEPTOSPIROSIS

14 days of ceftriaxone

NOTIFICATION OF INFECTION

DISEASE

public health delegate was called

to intervene

CONCLUSION

Leptospirosis can be an underdiagnosed infection in our country

It is a frequent acute systemic infection

Has diverse and nonspecific manifestations

Potentially life threatening

The physician has to have a high clinical suspicion to do the diagnosis

Introduction

Conclusion

References

Case presentation

REFERENCES

Introduction

Conclusion

References

Case presentation

Feigin & Cherry’s, Pediatric Infectious Diseases, 6th edition, 2009.

Human leptospirosis: guidance for diagnosis, surveillance, and control. Geneva,

Switzerland: World Health Organization/International Leptospirosis Society: 2003.

http://www.who.int/csr/don/en/WHO_CDS_CSR_EPH_2002.23.pdf.

Gompf S., et al, Leptospirosis, Medscape, April 2015.

http://emedicine.medscape.com/article/220563-overview.

Doudier B., Garcia S. Quennee V., et al, Prognostic factors associated with severe

leptospirosis, Clin. Microbiol. Infect., 2006.

Daher E., Zanetta D., Abdulkader R.; Pattern of renal function recovery after

leptospirosis acute renal failure. Nephron Clin. Pract., 2004.

Levett PN, Leptospirosis, Clin Microbiol Rev. 2001.

NOTA:

Para alterar a

imagem neste

diapositivo,

selecione a

imagem e

elimine-a. Em

seguida, clique

no ícone

Imagens no

marcador de

posição para

inserir uma

imagem à sua

escolha.

Hospital Dona Estefânia, Lisboa

Thank you