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BRIEF COMMUNICATION
Year : 2002  |  Volume : 20  |  Issue : 3  |  Page : 153-155
 

An outbreak of leptospirosis in Mumbai


Department of Microbiology (AD, AV, AP, MM), LTM Medical College and General Hospital, Sion, Mumbai - 400 022, India

Correspondence Address:
Department of Microbiology (AD, AV, AP, MM), LTM Medical College and General Hospital, Sion, Mumbai - 400 022, India

 ~ Abstract 

Following prolonged water logging due to heavy rainfall in Mumbai during July 2000, a total of 102 patients clinically suspected of leptospirosis were admitted in our hospital. Blood samples were examined for the presence of leptospires by dark ground microscopy (DGM) and IgM antibodies were detected by ELISA. Out of 102 blood samples, 37 were positive by ELISA giving a positivity rate of 36.27%. Of these, only 24 were positive by DGM. Out of the positive cases, 37.83% had respiratory symptoms, 32.43% each had jaundice and conjunctival suffusion and 16.21% had renal involvement. Mortality amongst the positive cases was 10.81%. Apart from hepatic and renal involvement, respiratory symptoms due to leptospirosis are on the rise.

How to cite this article:
De A, Varaiya A, Mathur M, Bhat M, Karande S, Yeolekar M E. An outbreak of leptospirosis in Mumbai. Indian J Med Microbiol 2002;20:153-5


How to cite this URL:
De A, Varaiya A, Mathur M, Bhat M, Karande S, Yeolekar M E. An outbreak of leptospirosis in Mumbai. Indian J Med Microbiol [serial online] 2002 [cited 2019 Aug 20];20:153-5. Available from: http://www.ijmm.org/text.asp?2002/20/3/153/6941


Leptospirosis is a worldwide zoonotic disease with varied clinical manifestations ranging from fever, myalgia, conjunctival suffusion to severe life threatening illness due to involvement of multiple organ systems, e.g. hepatic, renal, central nervous system, etc.[1] Recently, pulmonary complications occurring early in the disease with high case fatality rate have been reported by Singh et al and others.[2],[3] Since the 1980s, outbreaks are being increasingly reported especially from the states of Tamil Nadu, Kerala and Karnataka.[4],[5] Majority of the cases occur during the monsoons.[2],[4],[6] Recently in the month of July 2000, there was continuous heavy rainfall in the city of Mumbai, following which, within 10-15 days, there was a spurt in leptospirosis cases in and around the city. We present here our experience during this outbreak.

 ~ Materials and Methods Top

From 25th July to 25th August 2000 (one month), 102 patients (51 adults and 51 children) clinically suspected of suffering from leptospirosis were admitted in our hospital.
Criteria for clinical diagnosis
All patients having high grade fever, headache and generalized body aches, associated with at least any one of the following sets of symptoms and signs were included in our study according to criteria laid down by Indian Leptospirosis Society : a) jaundice, b) oliguria, c) cough, hemoptysis and breathlessness, d) neck stiffness with altered sensorium, and e) haemorrhagic tendencies including conjunctival suffusion and others.
Detailed clinical history was taken, especially about their contact with the rain waters. Peripheral blood smears were examined for malarial parasites (MP) and Widal test was also performed. All the sera were processed for qualitative and quantitative estimation of leptospira IgM antibodies by ELISA (Virion Serion, Germany). EDTA plasma of all the patients were processed as per standard procedures and observed under dark ground microscopy (DGM).[8] All the patients were treated with injection crystalline penicillin - two million units intravenously every six hours. The dose was reduced to one million units intramuscularly every six hours when the clinical status of the patients improved. Antibiotics were given for a period of 10-14 days. For children, half of the same dose was used.

 ~ Results Top

Out of 102 patients, both serology and DGM were positive in 24, only serology positive in 13, and only DGM positive in three patients. All the 13 patients with only serology positive had IgM titres > 50 U/mL. Thus total leptospira positive cases in our study were 37 (36.27%). Out of 37 positive patients 16 were children (31.37%) and 21 adults (41.17%). [Table - 1] shows the quantitative IgM titres of these 37 cases. Eighteen patients (48.64%) had IgM antibody titre >100 U/mL. Amongst the 65 negative cases, 3 were positive for malarial parasites on smear and 5 were Widal positive with significant titres.
[Table - 2] highlights the signs and symptoms of 37 positive cases. All the patients presented with fever. Myalgia was the presenting complaint in 51.35% of the cases, respiratory symptoms in 37.83%, jaundice and conjunctival suffusion in 32.43% each, renal failure in 16.21% and altered sensorium in 13.51% of the patients. All the 37 patients received injection crystalline penicillin, and 31 (83.78%) patients responded within 3-6 days of therapy. Two patients (one adult and one child) responded after two weeks and four expired (3 adults and 1 child). Two of the deaths were due to hepatic failure and one each due to renal and respiratory failure. Thus mortality rate amongst the positive cases was 10.81%.

 ~ Discussion Top

IgM ELISA is the test of choice for diagnosing the current infection. It detects genus specific antibodies which tend to be positive by the fifth day onwards.[9] All our patients except two, were in the first week of fever. Three patients had borderline antibody titre of 15-20 U/mL [Table - 1] but all these cases were positive by DGM and had high clinical suspicion, hence were treated with injection crystalline penicillin and all the three responded. Hence these three cases were considered amongst the positive cases. Thus, in our study, IgM ELISA positivity was 36.27%. Chandrasekaran et al reported 41.77% positivity by IgM ELISA.[9] In 1998, Babu et al had reported 88.9% positivity with IgM ELISA in an epidemic in Calicut.[10]
Dark ground microscopy from plasma is a simple, economical, quick and cost effective method for early diagnosis.[7] But, the sensitivity of the test varies from 27-40%. In our study, total 27 were positive by DGM, of which 24 were also positive by ELISA. The remaining three might be false positive. The sensitivity of DGM in our study was 26.47% and had 64.9% correlation with ELISA. Rao et al demonstrated 27.3% positivity by DGM and it was comparable to serology - 96% correlation of DGM with passive haemagglutination and latex agglutination tests.[7]
Due to a variety of clinical manifestations, leptospirosis is often misdiagnosed as viral fever, hepatitis, acute glomerulonephritis, or fever of unknown origin. There are also reports of acute respiratory distress syndrome (ARDS) and central nervous system (CNS) involvement in leptospirosis patients.[1],[2],[3]
Out of 37 patients positive by ELISA in this outbreak, 37.83% had respiratory symptoms, while 32.43% had hepatic involvement and 16.21% had renal involvement. Hepatic involvement was common in adults (47.6%). CNS symptoms were seen only in children (31.3%). None of the children had renal involvement. Two adults had renal failure as well as respiratory symptoms whereas two adults had renal, hepatic and respiratory involvements; one child had hepatic and CNS involvements, which highlights the multi organ failure encountered in leptospirosis.
Pulmonary catastrophies usually develop early in the disease, during the leptospiraemic phase. It is a type of ARDS as a result of disseminated intravascular coagulation (DIC). Mortality in these cases is quite high even if intensive measures like forced ventilation are resorted to.[2] In this outbreak, 47.6% adults and 25% children had respiratory symptoms amongst the positive cases [Table - 2].
Rao et al have reported 25.7% mortality.[7] In this outbreak, 10.8% mortality was encountered of which three were adults and one child. One male adult who died due to renal failure, also had associated respiratory symptoms. One female adult expired due to hepatic failure while another female adult who expired due to respiratory failure had associated renal and hepatic involvement as well. All the deaths among adult patients occurred within 24 hours of admission. One male child died due to hepatic failure after 10 days.
Hepatic and renal involvement due to leptospirosis are well documented. This study highlights that respiratory symptoms due to leptospirosis are on the rise. Therefore, in all patients with acute febrile illness with respiratory and / or hepatorenal involvement, serum for leptospira IgM antibodies should be tested, if possible. Prompt and early diagnosis helps to institute appropriate therapy which leads to a favourable outcome of this potentially life threatening condition. 

 ~ References Top

1.Chaudhry R, Pandey A, Sharma N, Singh YGK, Khanna S, Saraya A. Leptospirosis presenting with hepatic encephalopathy: A case report from Northern India. The Indian Practitioner 1999;52(6):423-425.  Back to cited text no. 1    
2.Singh SS, Vijayachari P, Sinha A, Sugunan AP, Rasheed MA, Sehgal SC. Clinico - epidemiological study of hospitalized cases of severe leptospirosis. Indian J Med Res 1999;109:94-99.  Back to cited text no. 2    
3.Goncalves AJ, de Carvalho JE, Guedes e Silva JB, Rozembaum R, Vieira AR. Hemoptysis and the adult respiratory distress syndrome as the causes of death in leptospirosis. Changes in the clinical and anatomicopathological patterns. Rev Med Trop 1994;25:261-270.  Back to cited text no. 3    
4.Muthusethupathi MA, Shivakumar S, Suguna R, Jayakumar R, Vijayakumar R, Everard COR, Carrington DG. Leptospirosis in Madras - A clinical and serological study. J Assoc Phys India 1995;43(7):456-458.  Back to cited text no. 4    
5.John JT. Emerging and reemerging bacterial pathogens in India. Indian J Med Res 1996;103:4-18.  Back to cited text no. 5    
6.Ratinam S, Sureshbabu L, Natarajaseenivasan K. Leptospiral antibodies in patients with recurrent ophthalmic involvement. Indian J Med Res. 1996;103:66-68.  Back to cited text no. 6    
7.Rao PS, Shashibhushan, Shivananda PG. Comparison of dark ground microscopy with serological tests in the diagnosis of leptospirosis with hepatorenal involvement - a preliminary study. Indian J Pathol Microbiol 1998;41(4):427-429.  Back to cited text no. 7    
8.Faine S. Leptospira and Leptospirosis. (CRC Press Inc. 2000) Corporate Blvd. NW Boca Raton, Florida, 1994; p 69.  Back to cited text no. 8    
9.Chandrasekaran S, Mallika M, Pankajalakshmi VV. Studies on the incidence of leptospirosis and possible transmission of leptospira during leptospiraemia. Indian J Pathol Microbiol 1995;38(2):133-137.  Back to cited text no. 9    
10.Babu SR, Pisharody R. Leptospirosis - experience in an epidemic. In: Abstract book of 2nd Annual Conference of Indian Leptospirosis Society, Cochin 2001:pg 47.  Back to cited text no. 10    
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