An unusual case of Weil's syndrome with paraparesis

Leptospirosis is an important emerging zoonosis with a worldwide distribution that is characterized by a broad spectrum of clinical manifestations ranging from inapparent infection to fulminant disease. Leptospirosis has protean clinical manifestations. The classical presentation of the disease is an acute biphasic febrile illness with or without jaundice. Unusual clinical manifestations may result from involvement of pulmonary, cardiovascular, neural, gastrointestinal, ocular and other systems. Immunological phenomena secondary to antigenic mimicry may also be an important component of many clinical features and may be responsible for reactive arthritis. The presentation of paraparesis in combination with Weil''s syndrome is rare. Few cases were reported with leptospirosis and paraparesis in India and abroad. It is important to bear in mind that leptospiral illness may be a significant component in cases of dual infections or in simultaneous infections with more than two pathogens. Here we are reporting a case of Weil''s syndrome with paraparesis in 28-year-old male patient who was critically ill due to severe hepatorenal dysfunction and hyperkalemia.     

Leptospiral Infections in Humans

Leptospirosis is a globally widespread spirochetal infection spread from animals to humans. Infections are common in settings of endemicity, primarily in tropical regions of the world. Leptospirosis is typically a self-limited febrile illness but may progress to potentially fatal multiorgan system failure. Patients often present with a nonspecific acute febrile illness that is clinically difficult to distinguish from other similarly presenting infections endemic to tropical regions, including dengue fever, influenza, and malaria. A high index of suspicion is essential to early identification of patients who may benefit from antimicrobial therapy. Diagnostic testing is key to both recognition of early infection and outbreak investigation, typically in the setting of water exposure after heavy rainfall and flooding. This review focuses on the epidemiology, clinical manifestations, and laboratory diagnosis of leptospirosis, including nucleic acid amplification tests, culture, direct detection, and serological approaches.     

Haemorrhagic pneumonitis: A rare presentation of leptospirosis

Leptospirosis is an uncommon zoonosis. As a systemic disease, it presents itself by multisystem involvement. Pulmonary involvement with leptospirosis often is manifested by respiratory symptoms; but pneumonia commonly is not a prominent clinical manifestation of the illness. We report a case of leptospiral pneumonia in which pulmonary manifestations were primary clinical features of the illness. The prompt resolution of chest x-ray on institution of treatment is noteworthy.     

Prognostic factors associated with severe leptospirosis

Leptospirosis is an anthropozoonosis caused by Leptospira interrogans. It occurs worldwide and is endemic in French Polynesia. Leptospirosis is associated with a large variety of clinical symptoms. Most infections caused by leptospires are either sub-clinical or of very mild severity, but 5-10% of infections result in multiple organ damage, including kidney, liver and lung lesions. Among 71 patients hospitalised in Papeete for severe leptospirosis during a period of 2 years, the main risk-factors for a severe outcome were hypotension, oliguria and an abnormal chest auscultation at the first physical examination. Survival depends on rapid diagnosis and early appropriate management. Well-defined criteria may help physicians to improve the timely treatment of high-risk patients.     

Sickle cell disease: a chronic inflammatory condition.

Homozygous sickle cell disease (SCD) has a wide spectrum of clinical manifestations which varies from an almost asymptomatic condition to severe illness, despite the fact that all subjects with this disease have the same base change in their DNA. The source of this variation is partly environmental, but a large part of this variability can derive from the presence of genetic modulators which are not fully understood. It was postulated that some degree of immunodeficiency should be associated with this condition, but no deficiency, directly related to a given component of the immune system, was observed that could explain the high levels of recurrent infections presented by sickle cell disease patients. Reviewing data from the literature we suggest that the influence of the immune system in the variation of clinical manifestations presented by SCD patients is not related with any immunodeficiency but is rather the result of a chronic inflammatory condition.     

Leptospirosis in pregnancy

Leptospirosis is a direct zoonotic disease caused by spirochetes belonging to the genus Leptospira. Many animals act as carriers or vectors. Human infection results from accidental contact with carrier animals or environment contaminated with animal urine containing the organism. Epidemics of leptospirosis result from poor sanitation in urban areas and are aggravated following natural calamities. The majority of leptospiral infections are either subclinical or result in very mild illness and patients recover without complications. In a few cases it may manifest as multiorgan failure where the mortality can go up to 40%. Infection in pregnant women may be grave leading to severe fetal and maternal morbidity and mortality. The presentation may mimic other viral, bacterial, and parasitic infections, acute fatty liver, pregnancy-induced hypertension, and HELLP syndrome. Owing to the unusual presentation, leptospirosis in pregnancy is often misdiagnosed and under-reported. Preventive public education regarding hygiene, personal practices, source reduction, environmental sanitation, early diagnosis, and treatment of the condition are needed to avoid perinatal and maternal mortality.     

Manifestations of West Nile neuroinvasive disease

Since its introduction to North America in 1999, West Nile virus, an arthropod-borne flavivirus, has become the most significant cause of epidemic encephalitis in the western hemisphere. While most human infections with the virus are asymptomatic and the majority of symptomatic persons experience febrile illness, severe neurologic manifestations, including meningitis, encephalitis, and poliomyelitis may be seen. This review summarizes the virology, epidemiology and pathogenesis of human infection with West Nile virus, and details recent advances in our understanding of the pathophysiology and various clinical manifestations of infection.     

Leptospirosis mimicking acute cholecystitis among athletes participating in a triathlon

Leptospirosis, a disease acquired by exposure to contaminated water, is characterized by fever accompanied by various symptoms, including abdominal pain. An acute febrile illness occurred in athletes who participated in an Illinois triathlon in which the swimming event took place in a freshwater lake. Of 876 athletes, 120 sought medical care and 22 were hospitalized. Two of the athletes had their gallbladders removed because of abdominal pain and clinical suspicion of acute cholecystitis. We applied an immunohistochemical test for leptospirosis to these gallbladders and demonstrated bacterial antigens staining (granular and filamentous patterns) around blood vessels of the serosa and muscle layer. Rare intact bacteria were seen in 1 case. These results show that leptospirosis can mimic the clinical symptoms of acute cholecystitis. If a cholecystectomy is performed in febrile patients with suspicious environmental or animal exposure, pathologic studies for leptospirosis on formalin-fixed, paraffin-embedded tissues may be of great value.     

Recombinant multiepitope protein for diagnosis of leptospirosis

Leptospirosis is an emerging infectious disease and is considered to be the most widespread zoonotic disease in the world. It can be misdiagnosed because manifestations of this febrile disease vary from mild flu-like symptoms to severe illness involving vital organs such as the liver and lungs. Therefore, accurate diagnosis for differentiation of leptospirosis from other pyrogenic infections prevailing in the same locality is imperative for proper treatment. Here, we report a customized recombinant leptospirosis multiepitope protein (r-LMP) that can specifically detect the immunoglobulin class of anti-leptospirosis antibodies in patient sera. Immunodominant epitopes from leptospire outer membrane proteins OmpL1, LipL21, and LipL32 were predicted and confirmed using phage display and immunity reaction. On the basis of the sequences of the identified epitopes, five major immunodominant epitopes were selected to construct a synthetic gene, recombinant lmp. The recombinant lmp gene was doubled and expressed in Escherichia coli. The recombinant protein was purified and used as an antigen to develop an enzyme-linked immunosorbent assay for detection of special immunoglobulin M (IgM) or IgG in sera from patients with leptospirosis or other febrile illnesses and healthy subjects. The results showed that the r-LMP protein recognized IgG and IgM in all the sera that were microscope agglutination test positive, and there were no cross-reactions with other patient sera. This approach of creating customized antigens coupled to overexpression and simple purification offers a promising alternative option for leptospirosis diagnosis, with the potential to circumvent the drawbacks of whole-leptospirosis-antigen-based assays.     

Growth failure, intracranial calcifications, acquired pancytopenia, and unusual humoral immunodeficiency: a genetic syndrome?

We report on two children who may represent a novel syndrome consisting of a deficiency of immunoglobulin-bearing B lymphocytes and serum antibody, deficient intrauterine and/or postnatal growth, intracranial calcifications, and acquired pancytopenia. Poor growth, intracranial calcifications, developmental delay, and hematological abnormalities are common manifestations of congenital infection. However, humoral immunodeficiency is not characteristic in these infections, and no infection was found on extensive evaluation. Rare genetic syndromes may mimic intrauterine infections and may also include immunodeficiency. However the children reported here lack important characteristics or share distinctive manifestations not described in these disorders. Infants presenting with apparent congenital infections in whom a specific infectious cause cannot be identified should be followed carefully with immunological evaluations since this disorder may be progressive and considerable morbidity is attributable to hematological and immunological manifestations.     

Viral infections transmitted by blood and its products

Modern transfusion practice is associated with an increased risk of transmitting viral agents because of the changing nature of the patients and of the therapeutic blood products. More immunosuppressed patients are receiving blood released faster and with more elaborate blood components. In addition to the classically recognized importance of hepatitis B virus (itself disseminated most efficiently by contamination of products derived from large pools of plasma containing many donations) other agents are assuming increasing importance. They frequently display one or more of the predisposing characteristics of prolonged viraemia, inapparent infections and a carrier or latent state. Some of these infections like cytomegalovirus and the human T-cell leukaemia virus are transmitted only by the cellular component of blood. Others like B and non-A, non-B hepatitis and the putative agent(s) of the newly recognized acquired immune deficiency syndrome can also be transmitted in the plasma or its products. Not all the agents transmitted cause severe illness, however; human parvovirus appears to cause no clinical illness when transmitted by transfusion and infections with non-A, non-B hepatitis are largely detected only by elevations in transaminase levels. Screening tests for the presence of these agents in donor blood or for evidence of infection by them in donors continue to be studied. Other approaches, related in particular to the selection of donors, are becoming increasingly important where serological screening tests are not available.     

Cytomegalovirus infections in organ transplantation and post transfusion

Summary The incidence and manifestations of cytomegalovirus (CMV) infections after organ transplantation and transfusion is reviewed. Since transfused individuals receive unmatched leukocytes, they share certain responses with recipients of organ grafts. In this regard enhanced replication of lymphoid elements, probably common to both groups, may be responsible for the frequent occurrence of primary as well as reactivated CMV infections in these patients. New CMV infections may be transmitted within transplanted cells — in blood leukocytes, wandering macrophages, infected and sloughed endothelial cells, or in carrier cells latently infected within an organ. Reticuloendothelial cells of the donor and the recipient receive a significant antigenic stimulus after transplantation or perfusion. This may lead to the replication and release of latent CMV if the virus is endogenous to the recipient or if it has been transmitted with leukocytes or within a donated organ. The nature of the resultant clinical illness depends in part upon the prior CMV antibody status of the recipient. Immunosuppressive regimens administered to organ recipients probably enhance the dissemination of CMV but not the acquisition of the virus.This paper was supported in part by a grant from the National Institutes of Health # 7 RO1 HDO4183-01 and by a grant from the American Cancer Society #IN-61J-5.This paper was presented at the 1st International Conference On Cytomegaloviras Infections which took place in St. Gallen, Switzerland, from April 1–3, 1970.     

Growth failure,intracranial calcifications,acquired pancytopenia,and unusual humoral immunodeficiency: A genetic syndrome?

We report on two children who may represent a novel syndrome consisting of a deficiency of immunoglobulin‐bearing B lymphocytes and serum antibody, deficient intrauterine and/or postnatal growth, in‐tracranial calcifications, and acquired pancytopenia. Poor growth, intracranial calcifications, developmental delay, and hematological abnormalities are common manifestations of congenital infection. However, humoral immunodeficiency is not characteristic in these infections, and no infection was found on extensive evaluation. Rare genetic syndromes may mimic intrauterine infections and may also include immunodeficiency. However the children reported here lack important characteristics or share distinctive manifestations not described in these disorders. Infants presenting with apparent congenital infections in whom a specific infectious cause cannot be identified should be followed carefully with immunological evaluations since this disorder may be progressive and considerable morbidity is attributable to hematological and immunological manifestations. Am. J. Med. Genet. 95:17–20, 2000. © 2000 Wiley‐Liss, Inc.     

Gastrointestinal strongyloidiasis in immunocompromised patients: a case report

Strongyloides stercoralis is an intestinal nematode, endemic in tropical countries. The parasite has a complex life cycle, causing a long-lived auto infection in hosts. It may remain asymptomatic or with minor symptoms; the dormant carrier state of the illness may persist for a long period of time. Inflammatory bowel disease (IBD) including Crohn's disease (CD) and ulcerative colitis (UC), commonly treated with immunosuppressive drugs is a well-known condition predisposing individuals to various infections. The condition is more prevalent among immunocompromised patients; the diagnosis of which, however, is troublesome in such individuals. The present article reports a 45- year-old female with gastric strongyloides stercoralis infection while receiving the treatment for her underlying UC. Strongyloides stercoralis can easily be missed especially in IBD patients in the absence of accompanying diarrhea or any symptom of lower GI discomfort because it presents with various manifestations including multiple GI symptoms, multiple stool exams and special attention to peripheral eosinophilia are specially important but not so sensitive or specific.     

Fungal infections of the immunocompromised host: clinical and laboratory aspects.

Fungal infections of the immunocompromised host are being seen with greater frequency than ever before. In addition, a growing list of unusual and unexpected etiologic agents presents a unique and difficult challenge to the clinician and microbiologist. The clinical manifestations of opportunistic fungal infections are often not characteristic and, in many instances, may prevent a rapid diagnosis from being made. Clinical microbiology laboratories should consider any organism as a potential etiologic agent. This requires that all fungi recovered from immunocompromised patients be thoroughly identified and reported so that their clinical significance may be assessed. This review presents a brief discussion of the clinical and laboratory aspects of some fungal infections seen in this important group of patients.     

Potential benefit of plasma exchange in treatment of severe icteric leptospirosis complicated by acute renal failure

Leptospirosis is a common zoonosis seen worldwide, but it is rare in our locality (Hong Kong). Clinical manifestations of leptospirosis are variable and may range from subclinical infection to fever, jaundice, hemorrhagic tendency, and fulminant hepato-renal failure. Severe hyperbilirubinemia and acute renal failure have been associated with high mortality. We report our experience with a patient who developed severe Weil's syndrome with marked conjugated hyperbilirubinemia and oliguric acute renal failure. These complications persisted despite treatment with penicillin and hemodiafiltration. Plasma exchange was instituted in view of the severe hyperbilirubinemia (970 micromol/liter). This was followed by prompt clinical improvement, with recovery of liver and renal function. The beneficial effects of plasma exchange could be attributed to amelioration of the toxic effects of hyperbilirubinemia on hepatocyte and renal tubular cell function. We conclude that plasma exchange should be considered as an adjunctive therapy for patients with severe icteric leptospirosis complicated by acute renal failure who have not shown rapid clinical response to conventional treatment.     

Autopsy pathology in the acquired immune deficiency syndrome.

The acquired immune deficiency syndrome (AIDS) is a devastating new illness which appears to be sexually and parenterally transmissible. AIDS was first described in the male homosexual community; however, the disease has more recently been described among intravenous drug abusers, Haitians, hemophiliacs, and others. The etiologic agent is unknown. AIDS may represent an infection by a previously undescribed organism, a mutant of a known microorganism, or a multifactorial combination of environmental, immunologic, and genetic factors. As a consequence of the disease's seemingly irreversible ablation of the cell-mediated immune system, AIDS victims succumb to a variety of infections and/or unusual neoplasms. In its fully developed form, mortality approaches 100%. At autopsy the gross and microscopic pathology of the syndrome can be divided into three general categories: 1) morphologic manifestations of profound lymphoid depletion; 2) infections, usually with mixed opportunistic pathogens; and 3) unusual neoplasms, most frequently Kaposi's sarcoma or high-grade lymphomas.     

Acute infectious mononucleosis and coincidental measles virus infection.

BACKGROUND: Both Epstein-Barr and measles viruses (MV) cause immune suppression, and the association of the two viruses is evaluated as life threatening. The cell immune impairment caused by simultaneous Epstein-Barr and measles viral infections was responsible for the complicated course of the disease in all described previously reports and for unfavorable outcomes in most of the cases. Timely diagnosis of coincidental viral infections could be a useful predictor for the clinical course and complications. Diagnosis must be based on an accurate assessment of clinical, hematologic, serologic manifestations and supported by appropriate laboratory methods. Recognizing the infectious etiology of concomitant infections is important for both clinicians and epidemiologists. OBJECTIVE: To describe a case report of a 20-year-old woman previously vaccinated against measles infected with acute mononucleosis and coincidental measles virus infection. STUDY DESIGN: The clinical, routine laboratory, as well as serological and virologic findings of this patient were scrutinized. Special emphasis was placed on the use of RT-PCR/PCR for confirming the involvement of both measles virus and Epstein-Barr virus (EBV) in this patient's illness. RESULTS: Infectious mononucleosis was not suspected at admission to the hospital. The final diagnosis of a concomitant measles virus infection and acute infectious mononucleosis was facilitated using viral serology to detect virus-specific IgG and IgM antibodies and by RT-PCR for the detection of measles virus RNA and EBV DNA from peripheral blood monocyte cells (PBMC). CONCLUSION: The present report highlights the difficulty of diagnosing two coincidental virus infections on clinical grounds. Serological and molecular laboratory methods, specifically the PCR (RT-PCR) analysis, are found to be useful for confirming the concomitant viral infections and proper identification of the infecting pathogens.     

Development of a Lepto-IgM EIACR test to diagnose leptospirosis disease in Costa Rican patient samples

Leptospirosis is an endemic disease throughout Costa Rica, which could be misdiagnosed because manifestations of this febrile disease may vary from mild flu-like symptoms to severe illness involving vital organs such as liver and lungs. Therefore an early specific diagnosis is important to ensure a favorable clinical outcome. The purpose of this study was to develop a Leptospira sp. anti-IgM EIA (Lepto-IgM EIACR) test and to compare it using Lepto-Dipstick IgM (Lepto-DS IgM) and PanBio-EIA IgM with the Microscopy Agglutination test (MAT) as a reference assay. Sera from 736 healthy blood donors were used as negative controls to calculate specificity (97.1%), Confidence Interval 95 (CI (96-98). Cross reactivity was evaluated in 268 patient samples with 6 different diseases. Dengue and measles had the highest cross reactivity (16%) while rubella showed the lowest (3%). To determine the sensitivity of the Lepto- IgM EIACR, 33 samples positive by MAT of 96 paired samples from patients with symptoms related to leptospirosis infection were tested. Lepto-IgM EIACR reached a sensitivity of 90.9% (CI 81-100), while Lepto-DS IgM was 48.5% (CI (31-66). The most frequent serovars detected by MAT in these paired samples were Hebdomadis 14.7%, Hardjo 11.8%, Pomona 8.8% and Icterohaemorrhagiae 5.9%. Furthermore 59 febrile patient samples were tested initially with PanBio-EIA IgM, 21 samples (35%) were positive. When these samples were re-tested by Lepto-IgM EIACR and Lepto-DS IgM, 80.9% and 33% were positive, respectively. The results of the evaluation indicate that Lepto-IgM EIACR test could be a good alternative to detect acute leptospirosis in Costa Rica.     

Clinical and epidemiological correlation of Leptospirosis among patients attending KMCH, Manipal

Leptospirosis is one of the most widespread zoonotic diseases in the world. Infection may range from sub clinical infection to death of the patient. It may also occur endemically in tropical countries, showing seasonal incidences following heavy rainfall. As the diagnosis is difficult due to vague clinical symptoms, laboratory investigations are essential for the confirmation of the disease. This study was undertaken to correlate the clinical findings, occupation and behavioural pattern in seropositive cases of Leptospirosis. A total of 733 patients suspected of Leptospirosis were tested for specific IgM ELISA and clinical findings, occupation and behavioural pattern were noted.