鉤端螺旋體病

1、LeptospirosisA NEWS REPORTGeneral Review Etiology EpidemiologyPathogenesis and Pathology Clinical Manifestations Diagnosis Treatment and Prevention Leptospirosis A zoonoses of worldwide distribution caused by pathogenic leptospira speciesSource of infection: Rats, SwineBasic clinical Features: high

2、fever , conjunctival suffusion and myalgia Severe cases: jaundice ,renal failure, pulmonary hemorrhage and meningeal signsEffective with treatment of penicillin GGeneral Thin, flexible, finely coiled with a hook at the endGram-Negative, Giemsa stain: Light red0.1m in diameter 6-20m in lengthEtiology

3、: Morphology Scanning electron microscope Etiology: Picture (dark-field microscope)Motility can be seenIt is characterized by very active motility, by roating and bendingObligate aerobic, slow growingCultured in Korthol media enriched with rabbit serum or albumin, at 30 and an optimal PH 7.2 to 7.6，

4、 their generation time varies from 7 to 12 hoursIt can be isolated by intraperitoneally inoculating of young guinea-pigEtiology: Culture It is sensitive to dry, suds, ethanol and bleaching powderSurvive in damp soil and water for 4 wks-3 mthsEtiology: Resistance 23 Serogroups, 200 serotypes19 Serogr

5、oups and 74 serotypes in ChinaThe most common serogroups: L. icterohemorrhagic(黃疸出血群)L. pomona(波摩那群)L. canicola(犬群)L. hebdomadis(七日熱群)Widest distribution in China : L.pomonaL. icterohemorrhagic causes the most severe illnessEtiology: Classfication In 1886, Weil, a German doctor observed 4 cases of l

6、eptospirosis with jaundice, than this disease is called as Weil diseaseIn China: in 1937, Professor Tang zeguang (湯澤光)discovered leptospirosis in GuangzhouEpidemiologyReservoirs of infection: rodents, domestic livestock (swine and cattle), dogs and foxesSource of infectionLivestock：swine,dogs, cattl

7、e,sheep,horses Wild animals：rats(Apodemus agarius,黑線姬鼠), rabbits,wolfs,snakes and frogsEpidemiology： Source of InfectionThe main source of Infection： Apodemus agariu: L.icterohemorrhagic. Field style in south of ChinaSwine: L. pomona. Flood style and raining style in north of ChinaEpidemiology： Sour

8、ce of InfectionInfected animals excrete leptospiras in the urineExposure to the water, soil or plants contaminated by urine of Infected animals Direct contact with infected animal tissues and organsIngest the drink or food contaminated by the urine of the reservoir animalEpidemiology ： Routes of tra

9、nsmission Leptospiras can gain entry through cuts and abrasions in the skin or through mucous membranes of the eyes, nose and mouth Human-to-human transmission is rareShort time for human to excrete leptospiraAcidic urine of human Epidemiology ： Routes of transmission Universal: Human are susceptibl

10、e to leptospira Type-specific immunity: Get life long post-infection immunity to the same serotypeEpidemiology Susceptibility Geographic distribution: Worldwide Distribution, in both rural and urban areas and in temperate and tropical climates Seasonal distribution: Summer and early fall. Peak occur

11、rence from June to October in our country Age, sex : Young adult men. Males comprise 80% of casesEpidemiology ：Epidemiologic feature Occupation (a significant risk factor )It originally was thought of as being an occupational disease, and approximately 30-50% of human cases are occupation-relatedIt

12、is an occupational hazard for people who work outdoors or with animals, such as rice and sugar-cane field workers, farmers, sewer workers, veterinarians, dairy workers and military personnel . It is also a recreational hazard to those who swim or wade in contaminated watersEpidemiology ：Epidemiologi

13、c feature Epidemic style：field style, flood style and raining styleEpidemics also follow natural disasters, such as floods and earthquakes, which drive rats out of sewersEpidemiology ：Epidemiologic feature Epidemiologic styles：field styleraining styleflood styleSource of infectionApodemus agariusSwi

14、ne and dogSwineserogroupL.icterohemorrhagicL. pomonaL. pomonafactors of transmissioncontaminated rat urineraining water floodoverflowingarea rice fieldvillagethe area where floodedclinical typeInfluenza-typhoid feverPulmonary hemorrhageieterohemorrhageInfluenza-typhoid feverInfluenza-typhoid feverme

15、ningoencephalitisFrom 1958, the accumulated report of leptospirosis patients has more than 2.5 millions in our countryThe incidence over 10/100,000 epidemics were 10, 9 of them took place after floods Epidemiology ：Epidemiologic feature Pathogenesis: leptospiraSkin,mucous membranesBlood streamType o

16、f Influenza-typhoid feverPulmonary Hemorrhage ieterohemorrhage Renal failureMeningoencephalitisInterstitial nephritisHemorrhagic pneumonitisHepatitisMeningitis and EncephalitisOrgansleptospiramiaThe basic pathological finding is infectious-toxic lesion of the systemic capillaryIn some cases severe d

17、amage can be seen in the organs and tissuesLiver: cellular inflitration around the portal areaKidney: interstitial nephritisLung: pulmonary congestion and hemorrhageBrain: perivascular cuffingPathology：Diseased kidney affected by Leptospirosis Kidney tissue, using a silver staining technique, reveal

18、ing the presence of LeptospiraInterstitial nephritisPathological findingtype of severe hemorrhageComplicated clinical manifestationsOne serotype can result in many kinds of clinical manifestationsOne clinical type can be caused by many serotypesClinical manifestations vary greatly in different patie

19、ntsIncubation period: 7-13 days(2-28d)Clinical Manifestations3 phases (according to the course of disease) :Early phase: 1st3rd days after illness. common manifestations of all clinical typesSecond phase: 3rd10th days after illnessLate phase complications: 7th10th days after illnessClinical Manifest

20、ations Early phase (leptospiramia)Last 4-7daysBegin with abrupt fever to 39 - 40 Sometimes has a persistent high feverNon-specific symptoms caused by leptospiramia and its toxinsSuch as: chills, headache, myalgia, back pain, anorexia, nausea and vomitingA sore throat is common and herpes simplex lab

21、ialis may occurClinical ManifestationsSecond phase (organs damage)With prominent clinical presentationPatients can be classified into the following clinical types:1). Type of Influenza-typhoid fever (Ordinary leptospiremia)2). Pulmonary hemorrhage3). Type of ieterohemorrhage (Weil disease)4). Renal

22、function failure 5). MeningoencephalitisClinical ManifestationsClinical ManifestationsType of Influenza-typhoid fever3 Symptoms: Chills and Fever Myalgia Fatigue 3 signs: Conjunctival suffusion Calf muscle tenderness Enlargement of lymph nodes 寒熱身痛一身乏， 眼紅腿痛淋巴大。 Clinical Manifestations Type of pulmon

23、ary hemorrhage Pulmonary hemorrhageClinical feature of the early phase (3-4 days)Clinical Manifestations Type of pulmonary hemorrhage1 Type of mild hemorrhage Cough and hemoptysisA little bit of moist rale can be heardDot-like or small nodular densities in chest X-rayPrognosis is fine if treatment i

24、s given in timeClinical Manifestations Type of pulmonary hemorrhageClinical ManifestationsType of pulmonary hemorrhage2、Type of severe hemorrhage Fever and other toxicemia symptoms get worse Breath and pulse get faster and faster; Pallor or cyanosed ; With more hemoptysis or even bleeding from mouth

25、 and nose; With more moist rale; Patchy or confluent densities can be seen on chest X-ray Confusion ,fear or even coma ! 神色懼變心發(fā)慌, 脈速氣緊羅音現(xiàn)Clinical ManifestationsType of pulmonary hemorrhagecyanosedcomaClinical ManifestationsType of pulmonary hemorrhageCauses of severe hemorrhage High virulence of the

26、 leptospira L.icterohemorrhagic No immunity to leptospira Delayed treatment and no rest Herxheimer reaction after penicillin therapy Clinical ManifestationsType of ieterohemorrhage Hepatic function impairmentJaundiceHepatomegalyHemorrhage: Nose bleedingskin petechiae, purpuraHemoptysis, hematemesis,

27、 hematuriaKidney damageProteinurin, Renal failureLeptospirosis can cause jaundice Clinical ManifestationsType of meningoencephalitis headache vomiting neck stiffnessmental confusion Twitch,paralysis, brain edema, brain hernia, respiration failureCSF：pressure, protein WBC,Glu, chloride is normal2-3da

28、ysClinical feature in the early phaseClinical ManifestationsType of renal failure 1. Renal impairment can be found in all types of leptospirosis 2. However the type of renal failure is definitely uncommonClinical ManifestationsComplication in period of recovery Late phase complicationsLate fever: re

29、currence of fever in the phase of convalescenceReactive meningitis: Meningeal symptoms, aseptic meningitis. Leptospiras not detected in CSF, good prognosisOcular late complication: Iritis, Cyclitis, Optic neuritis, UveitisOcclusive cerebroarteritisAppears 0.5-5 mths after initial illness caused by L

30、.pomonaAbnormal CSF, basal multiple arteritisThe symptoms are hemiparalysis and aphasiaClinical ManifestationsComplication in period of recovery Diagnosis Based on : Information of epidemiology Clinical features Data of laboratoryEpidemic areaEpidemic season（June-Oct）Contact historyDiagnosisInformat

31、ion of epidemiology DiagnosisClinical Features 3 Symptoms 3 Signs Specific organ dysfunction3 Symptoms 3 Signs Specific organ dysfunction 3 Symptoms Chills and fever Myalgia Fatigue 3 signs Conjunctival suffusion Calf muscle tenderness Enlargement of Lymph nodesDiagnosisClinical Features Conjunctiva

32、l suffusion3 Symptoms , 3 Signs , Specific organ dysfunctionOrgansPulmonary hemorrhagehepatitisInterstitial nephritisMeningitis and encephalitisPulmonary hemorrhageIcterohemorrhage Renal failureMeningoencephalitisDiagnosisClinical Features DiagnosisData of laboratory Peripheral blood: WBCN Urine: pr

33、oteinuria, hematuria, cylindruria Kidney function tests:Blood Urea Nitrogen and creatinineBlood tests for liver functions Blood culture：the median time to positivity is 3 weeks with a maximum of 3 months culture techniques useless for diagnostic purposes, but is commonly used in researchDiagnosisDat

34、a of laboratorySerological testing, the MAT (microscopic agglutination test), is considered the gold standard in diagnosing leptospirosisMAT： live antigen, determination of titer and identification of serotype. Positive result appears in about 7 to 8 days after onset of illness, and persist for many

35、 years The titer 1:400 or fourfold increased in period of recovery supports a diagnosis of leptospirosisType of influenza and typhoid fever ： Influenza Typhoid fever SepticemiaType of pulmonary hemorrhage： Bacterial pneumonia Pulmonary tuberculosisType of icterohemorrhage： Viral hepatitis Differenti

36、al diagnosisType of meningoencephalitis： Viral encephalitis Tuberculotic meningitisType of renal failure： Acute nephritis Hemorrhagic fever with renal syndromeDifferential diagnosisEarly finding，early diagnosis, early treatment and treat in near hospital (三早一就地)Early diagnosis and effective treatmen

37、t are very importantAntibiotic treatment will shorten the duration of fever and reduce the incidence of complicationsTreatment principle of treatmentTreatmentEtiologic treatment Penicillin G is the first choice. The first dose of penicillin should be small, 50000U as the first one, then increase lat

38、er, 46 times/day, the duration is about 7 daysFor the patients who are allergic to penicillin , gentamycin can be used, the dose is 80000U/time, 3 times daily for 7 daysTetracycline 500 mg/time 4 times/day 57 daysClinical Manifestations Herxheimer Reaction (赫氏反應) The illness gets worse after the ini

39、tiation of penicillin G therapy In 0.5 to 4 hours after the first dose, it begins abruptly with chills, high fever and myalgia which persists for 0.5 to 1 hours, hypotension or shock, tachycardiaCaused by the lysis of massive leptospira and the release of toxin after PG therapy1. General supportive

40、measures 2. For the severe cases Tranquilizer: valium, luminal, wintermine and phenergan3. Treatment of Herxheimer reaction： Tranquilizer, Corticosteroid intravenous dripTreatmentSymptomatic treatment 4. Supportive therapy measures (esp. in severe cases) include detoxication and normalization of the

41、 hydro-electrolytic balance 5. dialysis is used in serious cases 6. Organ specific care and treatment are essential in cases of renal, liver or heart involvement TreatmentSymptomatic treatment TreatmentTreatment of pulmonary hemorrhage Tranquilizer Hydrocortisones Cedilanid for cardiac failureHaemos

42、tatic for bleedingTreatmentTreatment of type of icterohemorrhageIt is similar to the treatment of icteric hepatitis Bed rest Liver protection Supportive measure and nutritionThe treatment of renal failureFor mild type, if the treatment is given in time, the prognosis is fineFor the type of severe he

43、morrhage, severe ieterohemorrhage, severe meningitis and encephalitis, the mortality rate is highPrognosisA NEWS REPORTA NEWS REPORTDid the physician make any mistakes?What should the physician do after the first dose of PG therapy?What was the diagnosis of the patient when he came to the hospital again?What was the patient died from?disscutionControl the source of infection ： Maintain swine, dogs , cows Eradicate rats Interrupt the routes of transmission wearing