Walking in floods could be a cause for hepatic jaundice
Editors:
- Dr. Praful B. Godkar (Ph.D)
Eminent Author, Medical Biochemist and Scientist, Technical Education consultant. AGD Biomedicals (Pvt) LTD. - Dr. Gauri Kulkarni MD (Pathology)
Vice President, AGD Biomedicals (Pvt) LTD.
Walking through flood-logged water could cause leptospirosis, a disease caused by the pathogenic bacteria Leptospira(1,2,3). This bacterial infection spreads through contact with water contaminated by the urine of infected animals, mainly rodents, and it is a significant public health problem in India during the rainy season(4). Leptospirosis manifests as an initial flu-like illness with redness of eyes, headache, fever, muscle aches, and in some cases with skin rashes, diarrhea and vomiting. These symptoms can follow a severe second phase (Weil’s disease), which can lead to meningitis, liver damage, jaundice, kidney and liver failure(5). In severe leptospirosis 5-15% mortality rates have been documented(5). Leptospira can be diagnosed accurately and precisely using urine and serum by Dark-field microscopy, kidney function tests, liver function tests, and results confirmed by fifth generation cutting age ELISA and DNA techniques(6). The newly introduced AGD bilirubinometer can detect jaundice in a few minutes with initial CBC screening by hematology analyzer like AGD HT 340 and Biochemistry analyzer 2020(6).
NOTE:
(A) Leptospira belongs to the family Leptospiraceae. The genus Leptospira is divided into 20 species. Leptos (Greek) means fine and thin and spira (Latin) means coil. The species of medical importance is Leptospira interrogens, which infects humans and wide variety of animals such as rodents, dogs, pigs, cattle and other farm animals.
(B) Leptospira have cell structure like Gram negative bacteria. Due to their specific cell structure, these bacteria are not effectively stained by Gram’s staining method.
(C) Leptospira interrogans cannot be grown on standard bacteriological media due to very difficult maintenance procedures. Hence, for identification, dark-field microscopy, immunofluorescence microscopy and silver staining methods can be used.
(D) Weil’s disease was named after Adolf Weil, who first described the severe, jaundice-causing form of leptospirosis in 1886.
Q1. What is the prevalence of leptospirosis?
ANS: An annual average of 4,753 cases and 83 deaths occurred across 114 districts from 2015 to 2020. Prevalence rate was very high in coastal states such as Tamil Nadu, Andra Pradesh and Kerala, with outbreaks linked to heavy rains and related floods during the monsoon season months(4).
Q2. Which IVD laboratory tests are most commonly prescribed for suspected leptospirosis?
ANS(6) :
(A) Complete hemogram
(B) Examination of urine sediment and drop of serum by Dark-field microcopy
(C) Leptospira antibodies IgM and IgG detection by ELISA
(D) If necessary, RT-PCR test to confirm Leptospira organism.
Additional tests:
(E) Liver function tests
(F) Kidney function tests
NOTE : Complete hemogram report in leptospirosis may show leukocytosis, thrombocytopenia, and anemia in severe cases.
CASE STUDY
A 36-year-old male presented with fever, headache, redness of eyes, diarrhea and vomiting. Case history indicated that he walked through floods during heavy monsoon rains. The following laboratory tests were prescribed: (1) Complete hemogram with malaria parasite detection (2) Routine urine examination (3) COVID 19 RT-PCR test (4) Dengue NS1 test.
His laboratory test reports were as follows:
COMPLETE HEMOGRAM
| PARAMETER | RESULT | NORMAL RANGE |
| Hemoglobin | 13.8 g/dl | 13–18 g/dl |
| Total erythrocyte count | 5.45 X 1012 /l | 5.0 ± 0.5 X 1012 /l |
| Total leukocyte count | 14.3 X 109/l | 7.0 ± 3.0 X 109/l |
| Differential leukocyte count | ||
| Neutrophils | 75% | 40–75% |
| Lymphocytes | 22% | 20–45 % |
| Eosinophils | 3% | 1–4 % |
| PCV | 42% | 36–48% |
| MCV | 88 fL | 82–92 fL |
| MCH | 30 pg | 27–32 pg |
| MCHC | 34 % | 32–36 % |
| RDW- CV | 13.0 | 12–14 |
| Platelet count | 80 X 109/l | 150–400 X 109/l |
| Metzer Index (MI) | 16.14 | < 13 |
Malarial parasites were not detected
STAINED BLOOD SMEAR EXAMINATION OBSERVATIONS:
Abnormal cells were not detected. Malarial parasites were not detected.
INTERPRETATION
Increased neutrophils and total white blood cells with decreased platelets indicate severe bacterial infection
ROUTINE URINE EXAMINATION:
Significant findings:
Bile pigments: Present ++ (Normally absent),
Bile salts: Present (Normally absent) and
Urobilinogen: increased (Normally undetected).
INTERPRETATION
Hepatic jaundice
COVID 19 RT-PCR: Negative
Dengue NS1 Antigen: Not detected
NOTE:
Since the following infections were ruled out: COVID 19, Malaria, Dengue, and to find out cause of Hepatic Jaundice, The following additional tests were prescribed:
(A) HAV IgM and IgG antibodies
(B) HBV surface antigen
(C) Leptospira antibodies IgM and IgG (ELISA)
(D) Urine sediment examination by Dark-field microscopy
(E) Liver function tests
(F) Kidney function tests
HAV IgM antibodies: Absent
HBV IgG antibodies: Absent
Leptospira IgM antibodies: Present
Leptospira IgG antibodies: Present
Urine sediment smear: Dark-field microscopy: Presence of Leptospira
INTERPRETATION
The patient was suffering from Leptospirosis (Weil’s disease).
NOTE:
Presence of IgM antibodies indicate ongoing infection and presence of IgG antibodies indicate the body has developed these to fight the ongoing infection.
LIVER FUNCTION TESTS
| PARAMETER | RESULT | NORMAL RANGE |
| Serum total bilirubin | 4.6 mg/dl | Up to 1.0 mg/dl |
| Serum direct bilirubin | 2.8 mg/dl | Up to 0.5 mg/dl |
| Serum indirect bilirubin | 1.8 mg/dl | Up to 1.0 mg/dl |
| SGPT | 410 IU | 5-35 IU |
| SGOT | 260 IU | 8-40 IU |
| Alkaline phosphatase | 76 IU | 20-80 IU |
NOTE:
Increased serum total, direct (water soluble) and indirect (water insoluble) bilirubin and elevated SGPT and SGOT confirmed Hepatic condition caused due to Leptospira infection.
KIDNEY FUNCTION TESTS
| PARAMETER | RESULT | NORMAL RANGE |
| Serum urea nitrogen | 18 mg/dl | 7.0 – 21.0 mg/dl |
| Serum creatinine | 1.2 mg/dl | 0.7 – 1.5 mg/dl |
| Serum total proteins | 7.4 g/dl | 6.0 – 8.0 g/dl |
| Serum albumin | 4.5 g/dl | 3.3-4.8 g/dl |
| Serum globulins | 2.9 g/dl | 1.8-3.6 g/dl |
| eGFR | 115 ml/min | >90 ml/min |
NOTE:
Kidney function tests indicate normal kidney functions.
Q3. What is the recommended treatment protocol for Leptospirosis?
ANS: Antibiotics such as Doxycycline, or ampicillin, or amoxycillin as prescribed by a physician.
References
(1) CDC. Leptospirosis | CDC . [cited 2023 Feb 10]. Available from: https://www.cdc.gov/leptospirosis/index.html
(2) Costa F, Hagan JE, Calcagno J, Kane M, Torgerson P, Martinez-Silveira MS, Stein C, Abela-Ridder B, Ko AI. Global Morbidity and Mortality of Leptospirosis: A Systematic Review. PLoS Negl Trop Dis. 2015;9(9): e0003898. https://doi.org/10.1371/journal.pntd.0003898. (PMID:26379143 PMCID:PMC4574773).
(3) Bharti AR, Nally JE, Ricaldi JN, et al. Leptospirosis: a zoonotic disease of global importance. Lancet Infect Dis. 2003;3(12):757-771
(4) Rao RS, Gupta N, Bhalla P, Agarwal SK. Leptospirosis in India and the rest of the world. Braz J Infect Dis. 2003;7(3):178-193.
(5) Spichler A, Mook M, Chapola EG, Vinetz J. Weil’s disease: An unusually fulminant presentation characterized by pulmonary hemorrhage and shock Braz J Infect Dis. 2005;9:336–40
(6) Godkar PB, Godkar DP. Text book of Medical laboratory technology (4th edition, 2024), Bhalani Publishers, Mumbai. India.
