An outbreak of leptospirosis among Peruvian military recruits

Acute undifferentiated febrile illnesses are common in tropical developing countries but are difficult to diagnose on clinical grounds alone. Leptospirosis is rarely diagnosed, despite evidence that sporadic cases and epidemics continue to occur worldwide. The purpose of this study was to diagnose an outbreak of acute undifferentiated febrile illness among Peruvian military recruits that developed after a training exercise in the high jungle rainforest of Peru. Of 193 military recruits, 78 developed an acute febrile illness with varied manifestations. Of these, 72 were found to have acute leptospirosis by a microscopic agglutination test (MAT). An enzyme-linked immunosorbent assay using Leptospira biflexa antigen was insensitive for the detection of anti-leptospiral IgM antibodies compared with the MAT (20 of 72, 28%). This outbreak of acute undifferentiated febrile illness among Peruvian military recruits was due to leptospirosis. High clinical suspicion, initiation of preventative measures, and performance of appropriate diagnostic testing is warranted in similar settings to identify, treat, and prevent leptospirosis.     

Leptospirosis presenting as acute encephalitis syndrome (AES) in Assam,India

ObjectiveTo establish leptospirosis as a new aetiology of the patients presenting acute encephalitis syndrome (AES).MethodsJapanese encephalitis, West Nile, Dengue and Chikungunya negative samples were tested by IgM capture ELISA for leptospira specific IgM. For further confirmation, the IgM positive samples were subjected to Microscopic agglutination test (MAT). The clinical details and laboratory findings of the positive patients were recorded.ResultsWe report 8 cases of leptospirosis presenting as AES, proven on IgM capture ELISA and confirmed by MAT. Fever (100%) and altered sensorium (62.5%) were two most common symptoms. Low haemoglobin (7.5 ± 2.8) g/dL, elevated blood urea (79.16 ± 46.43) mg/dL, serum creatinine (1.5 ±1.2) mg/dL, SGOT (66.5 ± 14.84) U/L and SGPT (70.5 ± 4.9) U/L were observed in positive patients.ConclusionsThis is the maiden study reporting leptospirosis as a new aetiology of the patients presenting AES. Establishing aetiology is very important for a successful therapy at least in treatable conditions like leptospirosis.     

Human leptospirosis in Bulgaria, 1989-2001: epidemiological, clinical, and serological features

A total of 455 confirmed and reported to the Bulgarian Ministry of Health leptospirosis cases between 1989 and 2001 were analysed. Overall incidence of the disease was 0.42/100.000 population (range 0.20-0.64/100.000). The overall fatality rate was 6.6%. Infection was acquired through occupational (30.3%), recreational (45.1%), and accidental (4.6%) exposure or was home contracted (5.1%). A tendency towards the main mode of transmission moving from occupational to recreational exposure was noted. Fishing and livestock farming together accounted for more than half of all leptospirosis cases. Leptospirosis was contracted more frequently through indirect contact with animal excreta and less commonly through direct contact with animal urine or tissue. Serovars belonging to 10 different serogroups caused infection during the 13-year study period. Two serogroups, Icterohaemorrhagiae and Pomona, accounted for more than 87% of all leptospirosis cases. The third main cause was serogroup Australis. The significant change in the infecting serovars has to be related to widely performed vaccinations of cattle and pigs but still inefficient measures for rodent control. The most frequently reported symptoms were fever, myalgia, jaundice, and hepatomegaly. Anicteric cases (40.3%) had milder flu-like course. Acute renal failure was reported in 52 (33.8%) of the patients, all of them with icteric leptospirosis. Knowledge of epidemiological, clinical, and serological features of leptospirosis in Bulgaria during the 13-year study period is an appropriate base to outline measures for successful prevention and early diagnosis of the disease.     

Manifestations and outcomes of leptospirosis during local outbreaks in high endemic districts of Sri Lanka: A retrospective multi-center study

Objective: To determine the clinical presentations and disease outcomes of suspected and confirmed cases of leptospirosis from 3 high endemic districts of Sri Lanka, during outbreaks reported between 2013 and 2017. Methods: The retrospective multi-center study was carried out during 2013-2017 in 5 selected hospitals representing 3 high endemic districts in Sri Lanka. Clinically suspected leptospirosis patients were recruited according to the Communicable Disease Epidemiology Profile Sri Lanka, WHO. Leptospirosis was confirmed by either single microscopic agglutination test titre 1: 400 or by positive polymerase chain reaction(PCR) test result. Results: Out of 372 clinically suspected cases, 29.00% were confirmed as leptospirosis cases by either microscopic agglutination test(50.00%) or positive polymerase chain reaction(52.77%) and 12.90% were presumptively identified as leptospirosis. Clinical symptoms(headache, vomiting, jaundice and dyspnoea) and variations in haematological parameters(haemoglobin, platelet count) and biochemical parameters(serum creatinine, serum urea, serum bilirubin and C-reactive protein) were associated with confirmed leptospirosis(P0.05). Acute kidney injury, meningitis, myocarditis, pulmonary haemorrhage and acute liver failure was seen among 21.30%, 12.04%, 6.48%, 6.48%, 5.56%, respectively with 4.63% fatality among the leptospirosis confirmed patients. The sensitivity, specificity, positive predictive value and negative predictive value of the case definition of Ministry of Health, Sri Lanka were 96.29%, 9.09%, 31.13%and 85.71%, respectively, when benchmarked against either positive polymerase chain reaction or microscopic agglutination test as the gold standard. Conclusions: Acute kidney injury is the predominant complication observed among the leptospirosis confirmed patients. However, pulmonary haemorrhage is predominantly associated with mortality. The case definition of Ministry of Health, Sri Lanka is found to have higher sensitivity and enabled the screening of all probable cases of leptospirosis.     

Virologic and serologic surveillance for dengue fever in Jeddah, Saudi Arabia, 1994-1999.

Dengue fever infection was first documented in Jeddah, Saudi Arabia, by virus isolation of dengue type 2 virus in 1994 at the virology laboratory of Dr. Soliman Fakeeh Hospital. Dengue virus surveillance was established after that time. Blood samples were collected from 985 patients (710 male patients and 275 female patients) with suspected cases of dengue from February 1994 to December 1999. Dengue virus isolates were obtained in 207 patients (21%; 162 male patients and 45 female patients). Dengue type 2 was the predominant serotype (138 of 207 isolates, 66.7%), followed by dengue type 1 with (56 of 207 isolates, 27%) and dengue type 3 (13 of 207 isolates, 6.3%). The largest number of isolates (186 of 207 isolates, 90%) was in 1994, a year during which there was a dengue epidemic. In the next 5 years, 1995-1999, only 21 isolates (10%) were isolated. Immunoglobulin M capture enzyme-linked immunosorbent assay was positive in 160 acute samples; 52 of them were from virus culture-positive cases and 108 (11%) from culture-negative cases. The total number of cases diagnosed by both methods was 315 (32%). The prevalence of dengue immunoglobulin G antibodies, as assessed on the basis of immunofluorescent assay, hemagglutination inhibition titers > or = 1/20, or both, in the acute samples was 314 (32%) of 985, indicating past Flavivirus infection. Two patients died, one man with dengue hemorrhagic fever and one woman with dengue shock syndrome. Both fatal dengue cases were due to infection with type 2 virus. All other cases were simple dengue fever. To our knowledge, this is the first report confirming the circulation of 3 dengue serotypes in Jeddah.     

Referral pattern of leptospirosis cases during a large urban epidemic of dengue.

During heavy seasonal rainfall in 1996, concurrent epidemics of dengue and leptospirosis occurred in an urban center in northeastern Brazil. We interviewed 110 cases of leptospirosis hospitalized a median of seven days after the onset of illness to evaluate the impact of the dengue epidemic on the triage of suspected leptospirosis from ambulatory clinics to the infectious disease reference hospital. Within the first three days of illness, 46 (42%) cases sought their first medical evaluation, and 28 (61% of 46) received a diagnosis of dengue. Dengue diagnoses were associated with a median of five days delay in referral to the infectious disease hospital. Patients who reported initial diagnoses of dengue were more likely than other patients to have required admission to the intensive care unit (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 0.8-9.5) and to have died during hospitalization (OR = 5.1, 95% CI = 0.8-55.0). These findings indicate that diagnostic confusion between the early symptoms of leptospirosis and dengue may have contributed to the high mortality observed during the leptospirosis epidemic.     

Retrospective serosurvey of leptospirosis among patients with acute febrile illness and hepatitis in Egypt

The epidemiologic status of leptospirosis in Egypt has not been well defined because of difficulties in disease diagnosis. A retrospective study was conducted to detect leptospiral antibodies among undiagnosed acute febrile illness (AFI) and hepatitis cases. Approximately 16% of both AFI (141/886) and acute hepatitis (63/392) cases showed seroreactivity to Leptospira IgM by ELISA and microscopic agglutination test (MAT). Canicola, Djasiman, Grippotyphosa, Pyrogenes, Icterohemorrhagiae, and Pomona were the most commonly reactive serovars among patients with AFI. Djasiman, Grippotyphosa and Icterohemorrhagiae were the most reactive among patients with acute hepatitis. This study represents the first systematic report of Leptospira associated with patients with AFI and hepatitis in Egypt. Physicians need to have increased awareness about the importance of leptospirosis in the differential diagnosis of AFI and acute hepatitis in Egypt. In addition, laboratory capacity should be developed at fever hospitals to diagnose leptospirosis.     

Un cas rare de leptospirose révélé par une pancréatite aiguë

Leptospirosis is the most spread anthropozoonosis in the world. Its clinical appearances are highly polymorphic ranging from a pseudo-flu-like syndrome to a potential lethal multivisceral failure. Acute pancreatitis is an exceptional complication of leptospirosis. We report a case of leptospirosis revealed by acute pancreatitis with a good clinical outcome after medical treatment.     

Incidence of Dengue Virus Infection in School-Aged Children in Puerto Rico: A Prospective Seroepidemiologic Study

Dengue is a potentially fatal acute febrile illness caused by the mosquito-borne dengue viruses (DENV-1 to -4). To estimate DENV seroincidence in school-aged children, a 1-year prospective cohort study was conducted in Patillas, Puerto Rico; 10- to 18-year-olds (N = 345) were randomly selected from 13 public schools. At enrollment, 49.8% of the entire cohort had DENV immunoglobulin G (IgG) anti-DENV antibodies, and there were individuals with neutralizing antibodies specific to each of the four DENV. The mean age of participants with incident DENV infection was 13.4 years. The 1-year seroincidence rate was 5.6%, and 61.1% of infections were inapparent. Having IgG anti-DENV at enrollment was associated with seroincidence (risk ratio = 6.8). Acute febrile illnesses during the study period were captured by a fever diary and an enhanced and passive surveillance system in the municipios of Patillas and Guayama. In summary, at enrollment, nearly one-half of the participants had a prior DENV infection, with the highest incidence in the 10- to 11-year-olds, of which most were inapparent infections, and symptomatic infections were considered mild.     

Fiebre Q aguda sintomática: 87 casos en un área de Mallorca

Introduction

Q fever is a widespread zoonotic infection caused by Coxiella burnetii (C. burnetii). Acute infection varies from a self-limited flu-like illness to pneumonia or hepatitis.

Methods

A retrospective case study from March 2003 to December 2011 was conducted in the Hospital Son Llàtzer in Palma de Mallorca. Acute Q-fever was diagnosed in a patient with clinical suspicion and IgM in phase ii positive (≥ 1/40), with a positive IgG (≥1/80), or when IgG seroconversion was observed during convalescence. A total of 87 cases of acute Q fever were diagnosed. The median age was 50 years (range 21-89), and 69 (79.3%) were male. Fever and headache were the most common symptoms. Pneumonia was diagnosed in 39 (44.8%) patients, febrile episode in 21 (24.1%), and acute hepatitis in 23 (25.6%). Increased serum transaminases were observed in 19 (21.8%). Doxycycline was prescribed in 29 cases (33.4%). There were 30 (34.5%) patients lost to follow up after hospital discharge. A favorable outcome was observed in all other cases. Only one new case progressed to chronic Q fever.

Results

A total of 87 cases of acute Q fever were diagnosed. The median age was 50 years (range 21-89), and 69 (79.3%) were male. Fever and headache were the most common symptoms. Pneumonia was diagnosed in 39 (44.8%) patients, febrile episode in 21 (24.1%), and acute hepatitis in 23 (25.6%). Increased serum transaminases were observed in 19 (21.8%). Doxycycline was prescribed in 29 cases (33.4%). There were 30 (34.5%) patients lost to follow up after hospital discharge. A favorable outcome was observed in all other cases. Only one new case progressed to chronic Q fever.

Conclusion

Acute Q fever acute is common our environment. Pneumonia was the most common clinical presentation. Even although doxycycline was prescribed in a small number of patients, a favorable outcome was observed in all cases.     

Acute hepatitis C in a contemporary US cohort: modes of acquisition and factors influencing viral clearance

BACKGROUND: Acute hepatitis C virus (HCV) infection is often asymptomatic; thus, its epidemiology and natural history are difficult to define. METHODS: Acute HCV infection was identified on the basis of HCV seroconversion within 1 year (n=45), new anti-HCV seropositivity with clinical acute hepatitis (n=21), or HCV strain sequencing after an iatrogenic exposure (n=1). Risk factors were assessed with a baseline questionnaire, and participants were followed up prospectively with serial measurement of viral loads. RESULTS: Of 67 persons with acute HCV infection, most were asymptomatic (64%) and injection drug users (66%). Thirteen had an unknown mode of transmission; of these, 11 reported high-risk sexual behavior. Ten acquired acute HCV infection within 3 months of an iatrogenic exposure; 3 had confirmed iatrogenic infection, and 4 had no other risk factors identified. The spontaneous viral clearance rate after 6 months of infection was 18% (95% confidence interval, 11%-31%). The rate of viral clearance varied significantly by sex (34% vs. 3% for women vs. men; P<.001). CONCLUSIONS: High-risk sexual or iatrogenic exposures may be important contemporary risk factors for HCV infection. The spontaneous viral clearance rate (18%) in this contemporary study was similar to that reported for past studies of transfusion-associated HCV infection. Women were more likely to clear acute HCV infection than men.     

Travel-Related Leptospirosis in Israel: A Nationwide Study

Leptospirosis is re-emerging in developed countries as a travel-related infection. In this nationwide study of travel-related leptospirosis in Israel, all cases diagnosed at the Central Reference Laboratory for Leptospirosis, during 2002–2008 were retrospectively reviewed and only travel-related cases were included. During the study years, 20 (42%) of 48 leptospirosis cases in Israel were travel-related. Exposure occurred in Southeast Asia in 15 (75%) of 20 cases. The estimated yearly incidence of travel-related leptospirosis was 1.78/100,000 travelers compared with an incidence of endemic cases of 0.06/100,000 inhabitants (risk ratio = 29.6, 95% confidence interval = 16.7–52.4). Most patients (89%) were infected during water-related activities. Severe disease was present in 10 (55%) of 18 patients; 7 of them were presumptively infected with the Icterohaemorrhagiae serogroup. Thus, travel-related leptospirosis is becoming increasingly important in the epidemiology of leptospirosis in Israel. Leptospirosis should be suspected in any traveler with undifferentiated febrile illness, especially when water exposure is reported.     

Leptospirosis presenting as ascending progressive leg weakness and complicating with acute pancreatitis

Leptospirosis is a spirochetal bacterial infection of great public health importance. It has a broad spectrum of clinical manifestations which goes from subclinical infection and self-limited anicteric febrile illness (80-90% of all cases) to icteric leptospiropirosis known as Weil's disease. This is a severe disease characterized by hemorrhage, acute renal failure and jaundice. It is uncommon for leptospirosis to present itself as a primary neurological disease. Additionally, acute pancreatitis is an unusual gastrointestinal manifestation. We report a case of leptospirosis presenting as ascending progressive leg weakness and complicating with acute pancreatitis in an adult patient treated at Hospital Universitário, Universidade Federal de Santa Catarina. The diagnosis was confirmed through ELISA-IgM antibody testing positive for leptospirosis. After antibiotic therapy and support treatment for a few weeks, total resolution of severe manifestations was achieved. Rare and unusual presentations of leptospirosis should be kept in mind in relevant epidemiological scenario.     

Detection of dengue infection in patients investigated for leptospirosis in Barbados

The annual incidence of leptospirosis in Barbados is approximately 13 severe cases/100,000. The peak incidence occurs in October to December of each year, coinciding with the months of heaviest rainfall. During the second half of 1995, an epidemic of dengue type 1 infection produced almost 1,000 laboratory-confirmed cases. During the same period, leptospirosis mortality was twice the average, suggesting that some cases of leptospirosis were being misdiagnosed and treated inappropriately. Sera from patients investigated for dengue or leptospirosis were analyzed retrospectively to determine the extent of misdiagnosis. During 1995 and 1996, 31 of 139 and 29 of 93 patients, respectively, were confirmed as having leptospirosis. Sera from the remaining leptospirosis-negative patients were tested for IgM antibodies to dengue virus. During 1995 and 1996, 48 of 108 patients and 21 of 64 patients, respectively, were found to have dengue. In 1997, sera from all patients investigated for leptospirosis were also tested prospectively for IgM antibodies to dengue: 38 of 92 leptospirosis-negative patients (41%) were dengue IgM-positive, while 2 of 25 leptospirosis cases also had serologic evidence suggesting acute dengue infection. A second large outbreak of dengue caused by serotype 2 occurred in 1997. During the 1995 and 1997 dengue epidemics in Barbados, dengue cases outnumbered leptospirosis cases investigated in the leptospirosis diagnostic protocol. During 1997, patients investigated but negative for dengue were also tested for anti-leptospiral IgM: 7.3% (19 of 262) were IgM-positive. Substantial misdiagnosis of both dengue and leptospirosis can occur and greater public awareness and clinical suspicion of the similar presentations of these two diseases are necessary.     

Human leptospirosis in Denmark 1970-1996: an epidemiological and clinical study

Epidemiological and clinical aspects of 118 laboratory confirmed cases of human leptospirosis in Denmark from 1970 to 1996 were reviewed. Icterohaemorrhagiae (72%) and sejroe (20%) were the most frequent serovars. The incidence of leptospirosis was 0.09/100,000 inhabitants/y. 93% of the patients were 18-64 y old, 90% were men and 72% of the cases occurred from July to November. Occupational exposure was present in 63% (74/118) of the cases (41% fish farmers, 28%, farmers). Eight percent of the patients had travelled abroad, 7% had been exposed to sewers and 4%, had been exposed through recreational activities (fishing). Initial symptoms were generally non-specific. Weil's disease developed in 63%, of the patients, more often in patients infected with the serovar icterohaemorrhagiae (73%) compared to patients infected with serovars sejroe or saxkoebing (25%). The fatality rate was 7%, all due to icterohaemorrhagiae. Though a rare disease in Denmark, leptospirosis should be considered in certain risk groups as a possible diagnosis in patients with acute febrile illness.     

急性胰周积液和胰腺坏死对急性胰腺炎预后的影响

目的 探讨急性胰周积液和胰腺坏死对急性胰腺炎(AP)预后的影响.方法 回顾分析2003年1月至2007年12月收治的323例AP患者早期CT影像学表现,探讨急性胰周积液、胰腺坏死程度与全身炎症反应综合征(SIRS)、胰腺感染及病死率的关系.结果 发病5 d内出现SIRS并持续2 d或以上者97例(30%),12例(3.7%)在病程中、后期出现胰腺感染;病死14例(4.3%).有急性胰周积液者142例(44.0%).单个部位发生急性胰周积液者76例,其中31例发生SIRS,病死2例;多个部位急性胰周积液者66例,发生SIRS 62例,病死11例.急性胰周积液部位数量与早期SIRS发生及病死率显著相关(P＜0.01).277例(85.8%)无胰腺坏死,均未继发胰腺感染,病死4例;46例(14.2%)有不同程度胰腺坏死.胰腺坏死面积≤30%32例,胰腺感染发生率12.5%,病死率15.6%;＞30%～≤50%7例,感染发生率42.9%,病死率28.6%;＞50%7例,感染发生率为71.4%,病死率42.9%,胰腺坏死的程度与胰腺感染的发生及病死率显著相关(P＜0.05).结论 急性胰周积液和胰腺坏死对AP预后的影响不同.急性胰周积液与病程早期SIRS的发生及病死率相关;胰腺坏死与胰腺继发感染的发生及病死率有关,坏死面积越大,越容易发生胰腺感染,病死率越高.     

Clinical presentation of leptospirosis: a retrospective study of 201 patients in a metropolitan city of Brazil

IntroductionLeptospirosis is a zoonosis of worldwide importance. The disease is endemic in Brazil. This study was conducted to describe the clinical and laboratory presentation of leptospirosis in a metropolitan city of Brazil.MethodsThis is a retrospective study including 201 consecutive patients with leptospirosis admitted to tertiary hospitals in Fortaleza, Brazil, between 1985 and 2006. All patients had clinical and epidemiological data suggestive of leptospirosis, and positive laboratorial test for leptospirosis (microscopic agglutination test, MAT, higher than 1:800).ResultsA total of 201 patients were included, with mean age of 38.9 ± 15.7 years; 79.1% were male. The mean length from onset of symptoms to admission was 7 ± 3 days. The main clinical signs and symptoms at admission were fever (96.5%), jaundice (94.5%), myalgia (92.5%), headache (74.6%), vomiting (71.6%) and dehydration (63.5%). Hemorrhagic manifestations were present in 35.8%. Acute kidney injury was found in 87% of the patients. Platelet count was less than 100,000/mm³ in 74.3%. Hematuria was found in 42.9%. Death occurred in 31 cases (15.4%).ConclusionsLeptospirosis is a globally relevant disease with potential fatal outcome. Signs and symptoms suggestive of leptospirosis must be known by any physician in order to institute early adequate treatment to improve outcome. Early indication and daily hemodialysis seems to be beneficial in this group of patients.     

Respiratory manifestations of leptospirosis. A retrospective study of 91 cases (1978-1984)

Leptospirosis, an ubiquitous zoonotic disease, is a systemic infection usually producing fever with hepatorenal involvement, meningoenephalitis, and hemorrhage. Respiratory manifestations are less well known but have been described in certain regions such as Southeast Asia or the Reunion Island. From January 1978 through December 1994, 154 cases of documented leptospirosis were admitted to the South Reunion Hospital Center. Pulmonary involvement was observed in 91 of these cases (59.1%) with hemoptysis (37.4%) and radiological evidence of bilateral reticulonodular infiltration (40%). Extra-pulmonary manifestations in most cases suggested leptospirosis at admission. Thirteen consecutive patients underwent endoscopy explorations with bronchoalveolar lavage: intra-alveolar hemorrhage was evidenced in all cases. This highly typical pattern of cytolysis would emphasize (20.8%) when the classical extra-pulmonary signs are too discrete to suggest the diagnosis. In this series, 10 patients required ventilatory assistance and 2 were given corticosteroid boluses for massive hemoptysis. Mortality due to leptospirosis is two-fold higher in cases with pulmonary involvement.     

Use of locally isolated saprophytic Leptospira strain for serological testing of human leptospirosis.

A saprophytic Leptospira isolate recovered from tap water was utilized for serological testing. One hundred-twenty Serum samples comprising 55 cases from PUO/febrile jaundice and 65 samples from apparently healthy individuals were tested by MAT and HA using this environmental saprophytic strain and the results compared with that of Leptospira biflexa semaranga patoc, the standard saprophytic strain commonly employed for sero-diagnosis of leptospirosis. The MAT data showed 96.4 per cent correlation between the two strains. Similarly, the HA results were matching to the extent of 94.5 per cent. Results, therefore, suggest that local saprophytic Leptospira strain may serve as a substitute to serovar patoc for serodiagnosis of leptospirosis.     

Anicteric leptospirosis-associated severe pulmonary hemorrhagic syndrome: a case series study

ABSTRACT:: In leptospirosis, severe pulmonary hemorrhagic syndrome has replaced Weil's disease as the main cause of mortality, with rates of up to 75%. Four men, all farmers, were admitted to the intensive care unit between August 2009 and July 2010 with a diagnosis of acute respiratory distress syndrome. All patients presented with fever, hemoptysis, bilateral pulmonary infiltrates in chest radiographs, and thrombocytopenia and had compatible epidemiological history with leptospirosis; 3 patients had anemia, 3 had renal failure, 2 had increased creatine kinase, whereas bilirubin was slightly increased in only 1 patient. Leptospirosis was diagnosed serologically in all cases. Empirical therapy with ceftriaxone was administered immediately to all patients, while implementation of ARDSnet protective mechanical ventilation approach combined with an early goal-directed hemodynamic approach led to a relatively low mortality rate (25%). Acute Physiology and Chronic Health Evaluation II, Simplified Acute Physiology Score II and Sepsis-Related Organ Failure Assessment scoring systems were unable to predict the outcome of the patients with leptospirosis-associated severe pulmonary hemorrhagic syndrome.