Readings

about
LEPTOSPIROSIS

Submitted by:

IGNACIO, Dianne Grace C.

Group 3, BSN 4 Barcelo Submitted to:

Ms. Yolanda Borda, RN

Clinical Instructor

OVERVIEW: Leptospirosis
*DEFINITION Leptospirosis is a complex bacterial disease that affects both humans and animals. It is caused by spiral shaped bacteria called spirochetes of the genus Leptospira. Two types of leptospirosis present: Anicteric leptospirosis and Icteric leptospirosis. People get leptospirosis when broken skin or mucous membranes (eyes, nose, mouth) comes in contact to either infected animal urine or water, soil, or vegetation contaminated with such urine. The bacteria survive best in warm water72F (22C)that is fairly stagnant. Most reported cases have occurred from swimming, wading, or splashing in pools, streams, or puddles contaminated with infected dog or rat urine. The animals most commonly infected are rats, dogs, swine, and raccoons. Leptospirosis occurs worldwide and is more common in the tropics. Most cases occur in the summer. Leptospirosis has two phases: The first phase starts suddenly with headaches, severe muscle pains in the calves and thighs, chills, and fever, and lasts 6 to 15 days. The second phase starts a few days after your temperature has returned to normal. Fever will return, and you may get meningitis because the bacteria will have spread to the lining of the spinal cord, causing headaches and a stiff neck. Other serious symptoms include jaundice, mental confusion, depression, or decreased urine output. The second phase lasts another seven to ten days.

*RISK FACTORS Leptospirosis is a zoonosis of worldwide distribution. Leptospirosis infects many species of wild and domestic animals that have been isolated from birds, fish and reptiles. The infected animals excrete spirochetes in urine for an extended period of time. The majority of human cases world wide result from occupational exposure to rat contaminated water or soil. At risk are people who work with animals, on farms, in rice paddies or sugar cane fields, or in sewers are most at risk. Seventy-five percent of victims are male, from teenagers to young adults. Water activity in endemic areas (Hawaii, Malaysia) Fresh-water related activities such as farming or gardening, hiking across streams and swimming

*PATHOPHYSIOLOGY Leptospires enter the host through abrasions in skin, or through mucus membrane, conjunctiva and nasal mucosa. Followingthe penetration, leptospirosis gain rapid access and circulate in the blood stream through the lymphatics, resulting in leptospiremia and spread to all organs of the body. The primary lesion causes damage to the endothelial lining of small blood vessels which results in ischemic damage to the liver, kidney, meninges and muscles.

During acute infection, leptospires multiply in the small blood vessel endothelium, resulting in damage and vasculitis. The major clinical manifestations of the disease are believed to be secondary to this mechanism, which can affect nearly any organ system. In the kidneys, interstitial nephritis, tubular necrosis, and impaired capillary permeability, as well as the associated hypovolemia, result in renal failure. Liver involvement is marked by centrilobular necrosis and Kupffer cell proliferation, with hepatocellular dysfunction. Pulmonary involvement is secondary to alveolar and interstitial vascular damage resulting in hemorrhage. This complication is considered to be the major cause of leptospirosis-associated death. The skin is affected by epithelial vascular insult. Skeletal muscle involvement is secondary to edema, myofibril vacuolization, and vessel damage. The damage to the vascular system as a whole can result in capillary leakage, hypovolemia, and shock. Many patients with leptospirosis may develop disseminated intravascular coagulation (DIC), hemolytic uremic syndrome (HUS), thrombotic thrombocytopenic purpura (TTP), and vasculitis. Thrombocytopenia indicates severe disease and should raise suspicion for a risk of bleeding. After an incubation period of 6-15 days, an initial septicemic phase, leptospires can be isolated from the blood; cerebrospinal fluid and other tissues. Initial symptoms: last for 2-7 days and a second symptomatic or immune phase begins. The immune phase is associated with the appearance of circulating antibodies, despite the presence of these antibodies still leptospires can be found in kidney and urine.

*CLINICAL MANIFESTATIONS The course of the disease is a 6-15 days asymptomatic incubation period followed by roughly a 7-day period of flue-like symptoms where the patient is febrile and experiences chills, severe headache, chills, muscle aches, and vomiting, and may include jaundice (yellow skin and eyes), red eyes, abdominal pain, diarrhea, or a rash. If the disease is not treated, the patient could develop kidney damage, meningitis (inflammation of the membrane around the brain and spinal cord), liver failure, and respiratory distress. There is a brief asymptomatic period as the first phase resolves, and then the second, more dangerous phase commences. During this phase, the disease mounts an attack on vascular linings, liver, generates a high fever, and can complicate into meningitis. Anicteric Leptospirosis (90% of cases) Phase 1: Initial septicemic phase (lasts 3-7 days) Headache High fever Myalgia Conjunctivitis Maculopapular rash Hepatomegaly Splenomegaly

Phase 2 (follows brief improvement from phase 1) Meningitis Uveitis Chorioretinitis Icteric Leptospirosis (Weil's Syndrome, 10% of cases) Much more severe than anicteric form Fever Jaundice Azotemia Hypotension Hemorrhagic Vasculitis

*LABORATORY AND DIAGNOSTIC TESTS Samples of blood, urine, or fluid from around the spinal cord will grow bacteria on special culture plates. The blood can also be sent to state laboratories for antibody testing. Some people with leptospirosis have no symptoms at all, others have a mild illness, and still others have a severe illness with meningitis and liver failure. It depends upon what type of leptospire infects you. Culture (Growth may require 16 weeks) Blood Culture Urine Culture Cerebrospinal Fluid Culture

*NURSING MANAGEMENT Monitor vital signs Monitor fluid intake and output strictly Advise patient to rest Treat the fever with acetaminophen (antipyretic) as prescribed Inform the doctor if the following signs and symptoms occur: Headache Stiff neck Changes in amount or color of urine Jaundice Nausea Bruising or hemorrhage Rashes Dyspnea Oliguria Change in consciousness Advise client to avoid swimming or wading in warm waters that may be contaminated by animal urine (such as dog or rats)

 Daily weight and abdominal girth should be taken for the patients with ascites Severely ill patients should be nursed in propped-up position to lessen the risk of secondary pulmonary complications. Patients with vomiting should be managed by I/V fluids and electrolyte replacement. *NURSING DIAGNOSIS Impaired nutritional needs related to anorexia Give small, frequent meals Assess eating patterns Give warm meal Measure patients body weight daily Hyperthermia related to increased metabolic diseases Give warm compress, avoid alcohol use Instruct patient to drink plenty of fluids Administer antipyretic as ordered Knowledge Deficit Activity Intolerance Risk for fluid volume imbalance

*MEDICAL MANAGEMENT Leptospira are sensitive to Penicillin given through IV; Tetracycline and Erythromycin, and Doxycycline given by mouth for 5 to 7 days Treatment within first few days of illness may reduce the severity of disease but has little effect if started later on. These antibiotics are usually given for 10 days. Symptomatic and supportive care is initiated particularly for renal and hepatic failure.

*COMPLICATIONS Weils syndrome is a severe form of leptospirosis that affects the liver and kidneys, causing jaundice, decreased urine (Oliguria), azotemia, jugular vein distention, orthostatic hypotension, change in consciousness, fever, internal bleeding (GI bleeding), and anemia due to hemolysis, and thrombocytopenia.

*PREVENTION Avoid the use of contaminated water and soil, Use rodent control measures. Immunization of dogs and other domestic animals and birds. Good environmental sanitation Immunization/antimicrobial prophylaxis with doxycycline.may be,of value to certain high risk occupational groups