Acute lung injury and leptospirosis
Manchester, UK
E-mail: icudr{at}doctors.org.uk
Editor—I read with interest the case report on leptospirosis1 and would like to share my experience in managing this disease while working in an endemic area. Leptospirosis infection has protean manifestations. As a result, it is frequently misdiagnosed even in areas with high prevalence2 such as the Indian subcontinent, Latin America, and Southeast Asia. Any delay in diagnosis leads to progression of the disease with its complications. Pulmonary manifestations occur in 20–70% of patients and in many patients can progress to ARDS.3 An Indian study of autopsy findings in 62 cases of leptospirosis4 noted most patients were young males who presented with fever, breathlessness, haemoptysis, bleeding, oliguria, and icterus. They died after a brief stay in hospital. A post-mortem diagnosis of leptospirosis was made on the basis of characteristic organ findings, aided by results of serology, Levaditi's staining, and immunohistochemistry (IHC) on kidney sections. Massive intra-alveolar haemorrhage (48 cases), acute interstitial nephritis or acute tubular necrosis (45 cases), and myocarditis (24 cases) were the main autopsy findings. Haemorrhage in various organs such as the heart, gastrointestinal tract, brain, pancreas, and adrenals were also seen. Thirty of 54 kidney sections were positive for leptospiral antigens by IHC. There were extensive haemorrhages in the lungs in 48 (77%) cases and that was the cause of death in most of these cases. Some studies have tried to characterize the severity of disease process with serovar.5 Patients infected with Icterohaemorrhagiae progressed rapidly to multi-organ failure as reflected by this case report.
The patient described had all the classical features of leptospirosis and responded well to therapy initiated in a timely fashion and aggressive organ support. Hence the appropriate title for the report should be ‘Acute lung injury and multi-organ dysfunction; Usual manifestation of unusual leptospirosis in United Kingdom’.
Rotherham, UK
* E-mail: shankarsubash{at}yahoo.co.uk
Editor—We thank Dr Ramachandran for his comments and welcome the opportunity to reply. We agree that pulmonary manifestations occur in 20–70% of patients with leptospirosis, but most of them resolve without any sequelae.6 Very few progress to severe forms such as pulmonary haemorrhage and ARDS associated with very high mortality. Carvalho and Bethlem3 commented that ‘the severe form appears to be becoming more prevalent (at least in Brazil) and may be associated with higher mortality’, they have not categorically stated that fatal pulmonary manifestations is a usual finding universally. Further, the study of autopsy findings in 62 cases of Leptospirosis revealed pulmonary haemorrhages in 48 (77%) of patients. We would like to emphasize the fact that this is an autopsy finding and without the background information of the prevalence of the disease, it would be difficult to comment on the incidence of pulmonary and other organ involvement. Hence, we feel that the title is an appropriate one. However, since leptospirosis is a worldwide zoonosis with protean manifestation, the incidence of complications varies widely in different epidemiological regions. It would be very difficult to estimate the exact incidence of complications, hence the need for high index of clinical suspicion to diagnose and initiate early treatment for this potentially lethal disease.
References
1 Subash GS, Harling D. Acute lung injury and multi-organ dysfunction; an unusual manifestation of leptospirosis. Br J Anaesth (2007) 98:549–50.
2 Lomar AV, Diament D, Torres JR. Leptospirosis in Latin America. Infect Dis Clin North Am (2000) 14:23–39.[CrossRef][Web of Science][Medline]
3 Carvalho CR, Bethlem EP. Pulmonary complications of leptospirosis. Clin Chest Med (2002) 23:469–78.[CrossRef][Web of Science][Medline]
4 Salkade HP, Divate S, Deshpande JR, et al. A study of autopsy findings in 62 cases of leptospirosis in a metropolitan city in India. J Postgrad Med (2005) 51:169–73.[Medline]
5 Kuriakose M, Eapen CK, Paul R. Leptospirosis in Kolenchery, Kerala, India: epidemiology, prevalent local serogroups and serovars and a new serovar. Eur J Epidem (1997) 13:691–7.[CrossRef][Web of Science][Medline]
6 Thammakumpee K, Silpapojakul K, Borrirak B. Leptospirosis and its pulmonary complications. Respirology (2005) 10:656–9.[CrossRef][Web of Science][Medline]
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