MDI - 2

D2

Approach to a
Patient with Fever
Ruiz, L. Salcedo, J.
Sagario, P. Samson, D.
Saguros, S. Samson, V.
Salas, A. San Juan, M.
Salas, C. San Pedro, P.
Salaysay, J. Santos, J.
 PART 1
Subjective Data
 Samson, Victoria Gabrielle P.

General Data
40 year old male, MMDA traffic guide
Chief complaint: fever

Missing Data:
❏ Name
❏ Birthdate and birthplace
❏ Civil Status
❏ Address
❏ Religion
 Samson, Victoria Gabrielle P.

History of Present Illness

4 DAYS PTA 1 DAY PTA HOURS PTA ADMISSION

➔ Moderate ➔ “Red eyes” ➔ 40 C

grade fever ➔ Visine fever
➔ Muscle ➔ No relief
pain (legs)
➔ Bioflu
➔ No relief
 Samson, Victoria Gabrielle P.

History of Present Illness

4 DAYS PTA Missing Data:
❏ Muscle pain and fever not
characterized
➔ Moderate ❏ Dose and frequency of
grade fever medication not described
➔ Muscle
pain (legs)
➔ Bioflu
➔ No relief
 Samson, Victoria Gabrielle P.

History of Present Illness

1 DAY PTA Missing Data:
❏ Eye redness not characterized
❏ Dose and frequency of
➔ “Red eyes” medication not described
➔ Visine
➔ No relief
 Samson, Victoria Gabrielle P.

History of Present Illness

HOURS PTA Missing Data:
❏ Fever not characterized
➔ 40 C fever
 Samson, Victoria Gabrielle P.

Critique
❏ OLDCAARTS for symptoms were not described
❏ Medical term for “red eyes” not used
❏ Generic names for medicines given were not included
❏ Details regarding events prior to admission are lacking
 Samson, Victoria Gabrielle P.

Review of Systems
(+) (-)
❏ Anorexia ❏ Loss of consciousness, headache
❏ Muscle pains ❏ Blurring of vision
❏ Ear discharge, tinnitus
❏ Dyspnea, rhinitis, cough, hemoptysis
❏ Chest heaviness, palpitations,
*2 weeks prior, infected wound on orthopnea
R toe after wading in flood waters ❏ Epigastric pain, diarrhea,
constipation, melena, hematochezia
❏ Dysuria, frequency, urgency,
pollakuria
❏ Polyuria, polydipsia, polyphagia
❏ Heat or cold intolerance
 Samson, Victoria Gabrielle P.

Review of Systems
Critique:
❏ Data not organized by body system
❏ Infected wound on R toe and anorexia should have been included in the
HPI
❏ Muscle pain already mentioned in HPI

Missing Data:
❏ Weight loss
❏ Fatigue
❏ Night sweats
❏ Rashes Bush, L. Fever of Unknown Origin. Retrieved from
https://www.msdmanuals.com/professional/infectious-diseases/biology-of-
❏ Jaundice infectious-disease/fever-of-unknown-origin-
fuo?fbclid=IwAR3iZ_GJbYChT8f_o5ZQBbRn-
tbBuRf6V66IDiepkY7yYC7Tx0NWaPdBSuI
 Samson, Victoria Gabrielle P.

Past Medical History

❏ Dengue (2009)

Family History
❏ Father: Diabetes Mellitus (+)

Personal and Social History

❏ Smokes 5-7 sticks/day, since the age of 15
❏ Assigned to España - A Lacson intersection
 Samson, Victoria Gabrielle P.

Past Medical, Family, Personal and Social History

Missing Data:
❏ Environmental exposure to flood water was not included
 Samson, Victoria Gabrielle P.

Revising History of Present Illness

2 Weeks PTA

➔ Infected Add infected wound on R toe to HPI

wound on R
toe after
wading
through
flood water
 Samson, Victoria Gabrielle P.

Revising History of Present Illness

4 Days PTA

Character: Continuous? Intermittent?

➔ Moderate Duration? How severe? When?
grade fever
➔ Muscle Severity?
pain (legs) Aggravating
factors?
➔ Bioflu
Duration?
➔ No relief
Generic name
 Samson, Victoria Gabrielle P.

Revising History of Present Illness

1 Day PTA

➔ “Red eyes” Duration? Severity?

➔ Visine
➔ No relief

Generic name
 Samson, Victoria Gabrielle P.

Revising History of Present Illness

Hours PTA

Character: Continuous? Intermittent?

➔ 40 C fever
Duration? How severe? What time?
 Samson, Victoria Gabrielle P.

Revising History of Present Illness

Admission

➔ Anorexia Anorexia and muscle pains should

be part of HPI
➔ Myalgia
 Samson, Victoria Gabrielle P.

Revised History of Present Illness

2 Weeks PTA 4 Days PTA 1 Day PTA

➔ Wound on ➔ Moderate grade ➔ Eye redness

R toe fever ➔ Took Visine
infected ➔ Myalgia (legs) (Tetrahydrozoline
ophthalmic)
after ➔ Took Bioflu ➔ No relief
(Phenylephrine HCl
wading in Chlorphenamine maleate
flood Paracetamol)

waters ➔ No relief
 Samson, Victoria Gabrielle P.

Revised History of Present Illness

Hours PTA Admission

➔ 40 C Fever ➔ Anorexia
➔ Myalgia
Revised Review of Systems Samson, Victoria Gabrielle P.

GENERAL EENT SKIN

(?) Weight loss (-) Blurring of vision (?) Rashes
(?) Fatigue (-) Ear discharge, tinnitus
(?) Night sweats
PULMONARY CARDIAC GASTROINTESTINAL
(-) Dyspnea, rhinitis, (-) Chest palpitations, (-) Epigastric pain,
cough, hemoptysis heaviness, orthopnea diarrhea, constipation,
melena, hematochezia
(?) Jaundice

NEUROLOGIC ENDOCRINE GENITOURINARY

(-) Loss of (-) Polyuria, polydipsia, (-) Dysuria, frequency,
consciousness, headache polyphagia urgency, pollakuria
(-)Heat or cold
intolerance
Q&A
 PART 2
Objective Data
 Sagario, Patrick Louis G.
Sagario, Patrick Louis G.

Physical Examination
● Conscious, coherent, ambulatory with assistance
● Vital Signs:
○ BP 90/70
○ PR 120/min regular
○ RR 21 breaths/min
○ T 39.9 ℃
○ BMI 22
● Pale palpebral conjunctiva, anicteric sclerae, no nasal nor aural discharge
● No neck masses, JVP 3 cm at 30 degrees angle, carotid artery pulse showed
rapid upstroke, gradual downstroke
 Sagario, Patrick Louis G.
Sagario, Patrick Louis G.

Physical Examination
● Symmetrical chest expansion , no retractions, unimpaired tactile fremiti,
resonance, no adventitious breath sounds
● Adynamic precordium, apex beat at 5th L ICS MCL, no heaves, no thrills, heart
sounds normal
● Abdomen flat; normoactive bowel sounds; tympanitic; tenderness over whole
abdomen, liver dullness 10 cm; traube’s space not obliterated
● No pedal edema , tenderness of both calf muscles; infected wound on R big
toe; Pulses ++ on all extremities
 Sagario, Patrick Louis G.
Sagario, Patrick Louis G.

Critique

● There was no data regarding the physical appearance of skin

● Eye examination was not done properly
● There should be a pharyngeal inspection

Bush, L. Fever of Unknown Origin. Retrieved from

https://www.msdmanuals.com/professional/infectious-diseases/biology-of-
infectious-disease/fever-of-unknown-origin-
fuo?fbclid=IwAR3iZ_GJbYChT8f_o5ZQBbRn-
tbBuRf6V66IDiepkY7yYC7Tx0NWaPdBSuI
Q&A
PART 3
 Santos, Joanne B.

Chief Complaint: FEVER

Elevation of body temperature that exceeds the normal
daily variation

Increase in the hypothalamic set point

Abnormalities in the brain itself or by toxic substances

Harrison’s Principle of Internal Medicine 19th ed. P.124 Akizhanova, Hulak, Plaza and Zhumadilov (2016)
Medical Physiology by Guyton and Hall p. 898
 Santos, Joanne B.

Thermoregulation
Maintenance of a relatively constant core body
temperature (36.5 - 37.5 C)

Heat production from metabolic activity

(muscle & liver)

=
Heat dissipation (skin & lungs)

Harrison’s Principle of Internal Medicine 19th ed. P.123 Akizhanova, Hulak, Plaza and Zhumadilov (2016)
 Santos, Joanne B.

Thermoregulation
Preoptic and Anterior hypothalamus

Heat loss center: cutaneous vasodilation and sweating

Posterior hypothalamus

Heat conservation center: cutaneous vasoconstriction

and shivering

Primary motor center for shivering

Atlas of Neuroanatomy and Neurophysiology by Netter p68

Medical Physiology by Guyton and Hall p. 895
 Santos, Joanne B.

Mechanisms
Body Too Hot?

- Vasodilation of skin blood vessels

- Sweating
- Decrease in heat production

Medical Physiology by Guyton and Hall p. 895

 Santos, Joanne B.

Mechanisms
Body Too Cold?

- Skin vasoconstriction throughout the

body
- Piloerection
- Increase in heat production

Medical Physiology by Guyton and Hall p. 895

 Santos, Joanne B.

Medical Physiology by Guyton and Hall p. 899

 Santos, Joanne B.

Harrison’s Principle of Internal Medicine 19th ed. P.125 Akizhanova, Hulak, Plaza and Zhumadilov (2016)
 Santos, Joanne B.

Fever: Classification
Temperature: 39.9 ℃

°C °F

Normal 37-38 98.6-100.4

Mild/ Low grade fever 38.1-39 100.5-102.2

Moderate grade fever 39.1-40 102.2-104.0

High grade fever 40.1-41.1 104.1-106.0

Fever in handbook of signs & symptoms (3rd Ed.) Lippincott Williams and Wilkins (2006)
 Santos, Joanne B.

Fever: Duration
Moderate grade fever, 4 days PTA

TYPE OF FEVER DURATION

Acute <7 days

Subacute <2 weeks

Chronic/Persistent >2 weeks

Harrison's principles of internal medicine., 17th edition, 2005, p. 90–4 [chapter 17]
 Santos, Joanne B.

Fever: Patterns

Hutchinson’s Clinical Methods (21st Ed.) WB Saunders Harcourt Publication Limited (2002) p. 17–8
SALIENT FEATURES 40 y/o ♂MMDA traffic guide c ℅ fever Jason Salcedo

Subjective Pertinent (+) Subjective Pertinent (-)

(+) mod gr fever for 4 days PTA (40°C ~ “few” hrs PTA) (-) headache
(+) myalgia specifically in legs (-) dyspnea (-) orthopnea
(+) “red eyes” 1day PTA (-) chest heaviness
(+) Anorexia (-) palpitations
(+) infected wound on R toe ~2 wks ago (infection p pt. waded in (-) epigastric pain (-) diarrhea
flood water) (-) constipation (-) melena
PSHx (-) hematochezia
smokes 5-7 sticks/day since 15 y/o
Assigned ro España - Lacson intersection

Objective Pertinent (+) Objective Pertinent (-)

(+) amb c assist (+) symmetrical chest expansion
(+) Conscious, Coherent (+) unimpaired tactile fremitus
VS: (+) resonance
(+) Flat Abdomen
↓BP: 90/70 mmHg ↑PR (120bpm regular)
(+) Normative bowel sounds
↓RR: 21rpm BMI: 22 ↑T(39°C) (+) Liver dullness ~10cm
(+) DM (+) Traube’s space not obliterated
(+) Anicteric Sclerae (-) adventitious breath sounds
(+) pale palpebral conjunctiva (-) retractions
(+) rapid upstroke gradual downstroke carotid pulse (-) blurring of vision
(+) Pulse ++ on all extremities (-) dyspnea, rhinitis, cough, hemoptysis
(+) red eyes (-) chest heaviness, palpitations was , orthopnea
(-) epigastric pain, diarrhea, constipation, melena, hematochezia
(+) tenderness of B gastrocnemius & whole abdomen
(-) polyuria, polydypsia, polyphagia
(+) infected would on R big toe 2wks PTA (-) heat or cold intolerance
(+) Anorexia (-) Bipedal edema
SALIENT FEATURES 40 y/o ♂MMDA traffic guide c ℅ fever Jason Salcedo

Gastrointestinal System
Subjective Pertinent (+) Subjective Pertinent (-)
(+) mod gr fever for 4 days PTA (40°C ~ “few” hrs PTA) (-) headache
(+) myalgia specifically in legs (-) dyspnea (-) orthopnea
(+) “red eyes” 1day PTA
(-) chest heaviness
(+) Anorexia (-) palpitations
(+) infected wound on R toe ~2 wks ago (infection p pt. waded in flood water)
PSHx
(-) epigastric pain (-) diarrhea
smokes 5-7 sticks/day since 15 y/o
Assigned ro España - Lacson intersection (-) constipation (-) melena
(-) hematochezia

Objective Pertinent (+) Objective Pertinent (-)

(+) amb c assist (+) symmetrical chest expansion
(+) Conscious, Coherent (+) unimpaired tactile fremitus
VS: (+) resonance
↓BP: 90/70 mmHg ↑PR (120bpm regular)
↓RR: 21rpm
(+) DM
BMI: 22 ↑T(39°C) (+) Flat Abdomen
(+) Anicteric Sclerae
(+) pale palpebral conjunctiva (+) Normative bowel sounds
(+) rapid upstroke gradual downstroke carotid pulse
(+) Pulse ++ on all extremities
(+) red eyes
(+) Liver dullness ~10cm
(+) tenderness of B gastrocnemius & whole abdomen (+) Traube’s space not obliterated
(-) adventitious breath sounds
(+) infected would on R big toe 2wks PTA
(-) retractions
(+) Anorexia
(-) blurring of vision
(-) dyspnea, rhinitis, cough, hemoptysis
(-) chest heaviness, palpitations, orthopnea
(-) epigastric pain, diarrhea, constipation, melena, hematochezia
(-) polyuria, polydipsia, polyphagia
(-) heat or cold intolerance
(-) Bipedal edema
SALIENT FEATURES 40 y/o ♂MMDA traffic guide c ℅ fever Jason Salcedo

Subjective Pertinent (+) Subjective Pertinent (-)

(+) mod gr fever for 4 days PTA (40°C ~ “few” hrs PTA) (-) headache

Respiratory System
(+) myalgia specifically in legs
(+) “red eyes” 1day PTA
(+) Anorexia
(-) dyspnea (-) orthopnea
(+) infected wound on R toe ~2 wks ago (infection p pt. waded in flood water)
(-) chest heaviness
PSHx (-) palpitations
smokes 5-7 sticks/day since 15 y/o (-) epigastric pain
(-) constipation
(-) diarrhea
(-) melena

MMDA assigned toEspaña - Lacson intersection (-) hematochezia

Objective Pertinent (+) Objective Pertinent (-)

(+) amb c assist
(+) Conscious, Coherent
VS:
(+) symmetrical chest expansion
↓BP: 90/70 mmHg ↑PR (120bpm regular)
(+) unimpaired tactile fremitus
↓RR: 21rpm BMI: 22 ↑T(39°C)
(+) resonance
(+) DM
(+) Anicteric Sclerae (+) Flat Abdomen
(+) pale palpebral conjunctiva (+) Normative bowel sounds
(+) rapid upstroke gradual downstroke carotid pulse (+) Liver dullness ~10cm
(+) Pulse ++ on all extremities (+) Traube’s space not obliterated
(+) red eyes
(+) tenderness of B gastrocnemius & whole abdomen
(+) infected would on R big toe 2wks PTA
(-) adventitious breath sounds
(+) Anorexia
(-) retractions
(-) blurring of vision
(-) dyspnea, rhinitis, cough, hemoptysis
(-) chest heaviness, palpitations , orthopnea
(-) epigastric pain, diarrhea, constipation , melena, hematochezia
(-) polyuria, polydipsia, polyphagia
(-) heat or cold intolerance
(-) Bipedal edema
SALIENT FEATURES 40 y/o ♂MMDA traffic guide c ℅ fever Jason Salcedo

Subjective Pertinent (+) Subjective Pertinent (-)

(-) headache
(+) mod gr fever for 4 days PTA (40°C ~ “few” hrs PTA) (-) dyspnea (-) orthopnea
(-) chest heaviness
(+) significant muscle pains (specifically his legs)

Immune System
(-) palpitations
(+) “red eyes” 1day PTA (-) epigastric pain (-) diarrhea
(+) Anorexia (-) constipation (-) melena
(-) hematochezia
(+) infected wound on R toe ~2 wks ago (infection p pt.
waded in flood water)
PSHx
smokes 5-7 sticks/day since 15 y/o
Assigned ro España - Lacson intersection

Objective Pertinent (+) Objective Pertinent (-)

(+) amb c assist (+) symmetrical chest expansion
(+) Conscious, Coherent (+) unimpaired tactile fremitus
(+) resonance
VS: (+) Flat Abdomen
(+) Normative bowel sounds
↓BP: 90/70 mmHg ↑PR (120bpm regular) (+) Liver dullness ~10cm
(+) Traube’s space not obliterated
↓RR: 21rpm BMI: 22 ↑T(39°C) (-) adventitious breath sounds
(+) DM (-) retractions
(+) Anicteric Sclerae (-) blurring of vision
(+) pale palpebral conjunctiva (-) dyspnea, rhinitis, cough, hemoptysis
(+) rapid upstroke gradual downstroke carotid pulse (-) chest heaviness, palpitations , orthopnea
(+) Pulse ++ on all extremities (-) epigastric pain, diarrhea, constipation , melena, hematochezia
(+) red eyes (-) polyuria, polydipsia, polyphagia
(-) heat or cold intolerance
(+) tenderness of B gastrocnemius & whole abdomen
(-) Bipedal edema
(+) infected wound on R big toe 2wks PTA
(+) Anorexia
Discussion of Other
Signs and Symptoms
and Pathophysiology
 SALAS, CHRISTIAN RENZO C.

Muscle Pain (Myalgia)

- muscle aches and pain, which can involve ligaments,
tendons and fascia, the soft tissues that connect
muscles, bones and organs.
- In cases of leptospirosis, the calf and lower lumbar
muscles are more commonly affected

PGE2

IL-1 IL-6
TNF
John Hopkins Medicine. (n.d.). Myalgia. Retrieved from www.hopkinsmedicine.org/
Harrison’s Principle of Internal Medicine 19th ed.
 SALAS, CHRISTIAN RENZO C.

Anorexia
- A lack or loss of appetite
leading to the inability to eat
- Mediated by leptin

Anorexia

Deboer, M. D. (2010). Update on melanocortin interventions

for cachexia: Progress toward clinical application.
 SALAS, CHRISTIAN RENZO C.

Anorexia

IL-1 IL-6 POMC/CART

Leptin neuron
TNF activation

Deboer, M. D. (2010). Update on melanocortin interventions

for cachexia: Progress toward clinical application.
 SALAS, CHRISTIAN RENZO C.

Conjunctival suffusion
- Redness of the conjunctiva but WITHOUT inflammatory exudate
- most reliable distinguishing features since it rarely occurs with any infectious
illness other than leptospirosis

Day, N. (2019). Leptospirosis: Epidemiology,

microbiology, clinical manifestations, and
diagnosis. Retrieved from https://www.uptodate.com/
 SALAS, CHRISTIAN RENZO C.
SAMSON, DEDAN ANGELO

Conjunctival suffusion

Day, N. (2019). Leptospirosis: Epidemiology,

microbiology, clinical manifestations, and
diagnosis. Retrieved from https://www.uptodate.com/
 SAMSON, DEDAN ANGELO

Suspected Leptospirosis
● Acute febrile illness (at least 2 days) AND
● Has high-risk exposure, defined as:
○ Wading in floods and contaminated water
○ Contact with animal fluids
○ Swimming in flood water
○ Ingestion of contaminated water with/without wounds; AND
● At least 2 of the ff:
○ Myalgia
○ Calf tenderness
○ Conjunctival suffusion
○ Chills
○ Abdominal pain
○ Headache
○ Jaundice
○ Oliguria

National Antibiotics Guidelines (DOH, 2017)

 SAMSON, DEDAN ANGELO

Leptospirosis Classification

National Guidelines for Leptospirosis (NCDC, 2015)

Pathophysiology SAMSON, DEDAN ANGELO
Q&A
PART 4
Pathology
 Ruiz, Louise Mari A.
Saguros, Suzette Angelica A.

Leptospira
● Spirochete, thin, highly motile
● Hooked ends and 2 periplasmic flagella
● Best seen in dark field microscope
 Ruiz, Louise Mari A.
Saguros, Suzette Angelica A.

Normal Lungs Lungs with Leptospirosis

From Harrison’s Principles of Internal Medicine,

Kasper, D. L., Fauci, A. S., Hauser, S. L., Longo, D. L. 1., Jameson, J. L., & Loscalzo, J. (2015). Harrison's principles of internal medicine (19th edition.). New York: McGraw
Hill Education. Kasper, Dennis L.,, et al. Harrison's Principles of Internal Medicine. 20th ed.
 Ruiz, Louise Mari A.
Saguros, Suzette Angelica A.

Normal Lungs Lungs with Leptospirosis

From
De Brito T, Silva AMGD, Abreu PAE. Pathology and pathogenesis of human leptospirosis: a commented Harrison’s
review Principles
[published correction ofinInternal
appears Medicine,
Rev Inst Med Trop Sao Paulo.
2018;60:e23err]. Rev Inst Med Trop Sao Paulo. 2018;60:e23. doi:10.1590/s1678-9946201860023
20th ed.
 Ruiz, Louise Mari A.
Saguros, Suzette Angelica A.

Normal Liver Liver with Leptospirosis

Shintaku, M., Itoh, H., & Tsutsumi, Y. (2014). Weil's disease (leptospirosis) manifesting as fulminant hepatic failure: report of an autopsy case. Pathology,
research and practice, 210 12, 1134-7 .
 Ruiz, Louise Mari A.
Saguros, Suzette Angelica A.

Normal Liver Liver with Leptospirosis

De Brito T, Silva AMGD, Abreu PAE. Pathology and pathogenesis of human leptospirosis: a commented review [published correction appears in Rev Inst Med Trop Sao Paulo.
2018;60:e23err]. Rev Inst Med Trop Sao Paulo. 2018;60:e23. doi:10.1590/s1678-9946201860023
 Ruiz, Louise Mari A.
Saguros, Suzette Angelica A.

Normal Kidney Kidney with Leptospirosis

De Brito T, Silva AMGD, Abreu PAE. Pathology and pathogenesis of human leptospirosis: a commented review [published correction appears in Rev Inst Med Trop Sao Paulo.
2018;60:e23err]. Rev Inst Med Trop Sao Paulo. 2018;60:e23. doi:10.1590/s1678-9946201860023
 Salas, Aubrey Anne A.

Supportive Ancillary Procedures

● Complete Blood Count (CBC)
○ RBC count & indices
○ WBC count
○ WBC differential count
○ Platelet count
● C-reactive protein (CRP) & Erythrocyte Sedimentation Rate (ESR)
● Urinalysis & Fecalysis

Henry’s Clinical Diagnosis and Management by Laboratory Methods; Bailey & Scott’s Diagnostic Microbiology
 Salas, Aubrey Anne A.

Laboratory Diagnostic Procedures: Leptospirosis

CULTURE & SENSITIVITY TESTING - GOLD STANDARD but time consuming

Specimen to be collected:

● CSF, blood, tissues - bacteremic phase (first 10 days)

● Urine - immune phase (2nd wk to 30 days)

Media to be used:

● Fletcher’s medium
● Ellinghausen-McCoullough-Johnson-Harris medium
○ Note that Leptospira spp. require a specialized medium & prolonged incubation time.

Henry’s Clinical Diagnosis and Management by Laboratory Methods; Bailey & Scott’s Diagnostic Microbiology
 Salas, Aubrey Anne A.

Laboratory Diagnostic Procedures: Leptospirosis

● Leptospires growing below
the surface of the medium
may be viewed under dark
field microscopy in which
spinning leptospires with
hooked ends are visible.

Henry’s Clinical Diagnosis and Management by Laboratory Methods; Bailey & Scott’s Diagnostic Microbiology
 Salas, Aubrey Anne A.

Laboratory Diagnostic Procedures: Leptospirosis

SEROLOGICAL TESTING
○ Note that agglutinating antibodies appear during first week of illness,
peak at around 3-4 weeks, and may persist for years.

1. Microscopic Agglutination Test (MAT)

○ Established serologic reference method
○ Employs antigen from live bacteria
○ Able to detect infecting serovars
○ Four fold or greater rise in antibody titers between
acute and convalescent sera suggests recent
Leptospira infection

Henry’s Clinical Diagnosis and Management by Laboratory Methods; Interpretation of microscopic agglutination test for leptospirosis diagnosis and seroprevalence (Chirathaworn et.al., 2014)
 Salas, Aubrey Anne A.

Laboratory Diagnostic Procedures: Leptospirosis

2. Specific IgM Rapid Diagnostic Tests:

● LeptoDipstick®
● Leptospira IgM ELISA (PanBio)
● Microcapsule Agglutination Test
(MCAT)
● Dridot®

Henry’s Clinical Diagnosis and Management by Laboratory Methods; Bailey & Scott’s Diagnostic Microbiology
 Salas, Aubrey Anne A.

Laboratory Diagnostic Procedures: Leptospirosis

2. Specific IgM Rapid Diagnostic Tests:

● LeptoDipstick®
● Leptospira IgM ELISA (PanBio)
● Microcapsule Agglutination Test
(MCAT)
● Dridot®

Henry’s Clinical Diagnosis and Management by Laboratory Methods; Bailey & Scott’s Diagnostic Microbiology
 Salas, Aubrey Anne A.

Laboratory Diagnostic Procedures: Leptospirosis

2. Specific IgM Rapid Diagnostic Tests:

● LeptoDipstick®
● Leptospira IgM ELISA (PanBio)
● Dridot®

Henry’s Clinical Diagnosis and Management by Laboratory Methods; Bailey & Scott’s Diagnostic Microbiology
 Salas, Aubrey Anne A.

Laboratory Diagnostic Procedures: Leptospirosis

3. Molecular Diagnostic Tests:

● Hybridization techniques
● Polymerase Chain Reaction (PCR)
○ Note that these procedures are expensive and
not readily available in all laboratories.

Henry’s Clinical Diagnosis and Management by Laboratory Methods; Bailey & Scott’s Diagnostic Microbiology
Radiology
 San Juan, Mary Jane O.
CHEST X-RAY

NORMAL
Chest X-Ray - Lung disease. (n.d.). Retrieved from Bilateral alveolar pulmonary infiltration
(Pulmonary hemorrhage)
http://www.radiologyassistant.nl/en/p50d95b0ab4b90/chest-x-ray-lung-
disease.html
 San Juan, Mary Jane O.
LIVER ULTRASOUND

NORMAL HEPATOMEGALY
Normal Values - Ultrasound. (n.d.). Retrieved from http://www.radiologyassistant.nl/en/p5a3056eebe646/normal-values-
ultrasound.html
 San Juan, Mary Jane O.
KIDNEY ULTRASOUND

NORMAL ACUTE KIDNEY INJURY

Hansen, K. L., Nielsen, M. B., & Ewertsen, C. (2015, December 23). Ultrasonography of the Kidney: A Pictorial Review. Retrieved from
https://www.mdpi.com/2075-4418/6/1/2/htm
Q&A
PART 5
Pharmacology
 SAN PEDRO, PRESCILLA DIORGIA G.

Goals of Treatment
● Eliminate organism (Leptospira)
● Target symptoms (fever, myalgia) - provide symptomatic relief
● Prevent dehydration - fluid and electrolyte resuscitation
● Avoid future episodes - non-pharmacologic preventive measures
● Patient education and patient education
 San Pedro, Prescilla Diorgia G.

Pathophysiology of Fever

Antibiotic

Analgesic/
NSAIDs

Doxycycline

Harrison’s Principle of Internal Medicine 19th ed.

 SAN PEDRO, PRESCILLA DIORGIA G.

Pharmacologic Approach
● Fever
○ Paracetamol or Acetaminophen
■ Management and treatment of fever
■ Treats mild to moderate pain (myalgia)
■ Weak COX-1 and COX-2 inhibitor in peripheral tissues
■ Site of action has recently been identified as a COX-3 isoenzyme
■ 500 mg/tab every 4 hours PRN

Basic and Clinical Pharmacology, Katzung 14th Ed.

 SAN PEDRO, PRESCILLA DIORGIA G.

Pharmacologic Approach
● Fever
○ Aspirin
■ Anti-pyretic, anti-inflammatory, analgesic
■ Irreversibly inhibits COX-1 and 2
■ Initially, 300-900 mg, every 4-6 hours

Basic and Clinical Pharmacology, Katzung 14th Ed.

MIMS 2019
 SAN PEDRO, PRESCILLA DIORGIA G.

Pharmacologic Approach
● Fever
○ Ibuprofen
■ Indication and mechanism of action same as aspirin
■ 200-400 mg every 4-6 hours

MIMS 2019
 SAN PEDRO, PRESCILLA DIORGIA G.

Pathophysiology of Leptospirosis

Antibiotics

Tetrahydrozoline
Analgesic/NSAID
(Visine)
s
- unresolved
 SAN PEDRO, PRESCILLA DIORGIA G.

Leptospirosis Classification

National Antibiotics Guidelines (DOH, 2017)

 SAN PEDRO, PRESCILLA DIORGIA G.

Pharmacologic Approach
● Mild leptospirosis
○ Oral treatment
■ Doxycycline*
■ Amoxicillin
■ Ampicillin
■ Azithromycin*
○ Given for 7 days
○ Prophylaxis:
■ Once a week
■ disputed

Harrison’s Principle of Internal Medicine 19th ed.

 SAN PEDRO, PRESCILLA DIORGIA G.

Pharmacologic Approach
Mechanism of Action

Doxycycline
Attenuates leptospira-induced IL-1β by suppressing NLRP3 inflammasome
priming. Inhibits the activation of caspase-1 and the expression of mature IL-1β.

Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and
possibly 50S ribosomal subunits of susceptible bacteria; may block dissociation
of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to
arrest.

Zhang, Wenlong. (2017, July 24). Doxycycline Attenuates Leptospira-Induced

IL-1β by Suppressing NLRP3 Inflammasome Priming. Retrieved August 19,
2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5522854;
National Antibiotics Guidelines (DOH, 2017)
 SAN PEDRO, PRESCILLA DIORGIA G.

Pharmacologic Approach
Mechanism of Action

Amoxicillin & Ampicillin

Interfering with the transpeptidation reaction of bacterial wall synthesis
Exact mechanism of cell death is not completely understood but disruption of cell
wall synthesis is involved.

Basic and Clinical Pharmacology, Katzung 14th Ed.

 SAN PEDRO, PRESCILLA DIORGIA G.

Pharmacologic Approach
Mechanism of Action

Azithromycin
Inhibition of protein synthesis occurs via 50s subunit ribosomal RNA binding

Peptidyl-tRNA is dissociated from the ribosome.

Basic and Clinical Pharmacology, Katzung 14th Ed.

 SAN PEDRO, PRESCILLA DIORGIA G.

● Tachycardia, anorexia, tachypnea and conjunctival suffusion

○ Resolved once fever is down and the organism is eliminated
 SAN PEDRO, PRESCILLA DIORGIA G.

Non-pharmacologic Approach
● Oral rehydration salts

www.unilab.com.ph
 SAN PEDRO, PRESCILLA DIORGIA G.

Non-pharmacologic Approach
● Rest
● Proper/ well-balanced meals
● Cooling Methods:
a. Sponge Bath (Tepid)
b. Avoid putting on excessive clothing/blanket
c. Adjust room temperature
d. Increase oral fluid intake
 SAN PEDRO, PRESCILLA DIORGIA G.

Non-pharmacologic Approach
EFFICACY, SAFETY, SUITABILITY, COST
EFFICACY SAFETY SUITABILITY COST TOTAL

Doxycycline +++++ ++ +++++ +++ 15

Azithromycin +++++ ++++ +++++ ++++ 18

Amoxicillin ++++ ++++ +++ +++++ 16

Ampicillin +++ ++++ +++ + 11

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2043199/?fbclid=IwAR3sbVpS8a
DpPikyzQoWFOArPRuYHScSISy_X2xbQsSIu-5eb16NrtxsXok
PRICE COMPARISON
PRICE DOSAGE RATING

Ampicillin Php 85 per 500g 3 times a day X for 1785 +

Vial 7 days

Doxycycline Php 45 per 2 times a day X for 630 +++

100mg Capsule 7 days

Azithromycin Php 105 per Once a day X for 3 210 ++++

500mg Tablet days (mild dosage)

Amoxicillin Php 7.50 per 3 times a day X for 157.5 +++++

500mg Tablet 7 days

*All prices are from RiteMED except the ampicillin which is Ampivex
EFFICACY, SAFETY, SUITABILITY, COST
EFFICACY SAFETY SUITABILITY COST TOTAL

Paracetamol ++++

Ibuprofen +++++

Aspirin ++

https://jamanetwork.com/journals/jamapediatrics/fullarticle/485730
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