LEPTOSPIROSIS AND PREGNANCY
Shailesh Kore*, Ranjit Akolekar**,Nishchal Vaidya**, V R Ambiye***, V R Badhwar****
*Associate Professor; **Registrar; ***Hon. Professor and Head of Unit; ****Professor and Head of Dept. Department of Obstetrics and Gynaecology, LTMG Hospital, Sion, Mumbai.
Leptospirosis may mimic hepatorenal failure following PIH or septicaemia or malaria. Subconjunctival haemorrhage can be a clue to clinical diagnosis, so this case is reported.
Leptospirosis, a unique and unusual spirochaetal infection, is one of the uncommon causes of hepatorenal failure. Many times, it may remain undiagnosed unless it is specifically looked for and investigated. In pregnancy, it can mimic puerperal septicaemia or hepatorenal failure associated with severe pregnancy induced hypertension.
Mrs. XYZ, second para residing at Dharavi in Mumbai, presented with high grade fever with chills, with nausea and vomiting and severe bodyache for last 24 days. Patient had a full term normal home delivery, five days back. There was also a history of oliguria with passing dark coloured urine. There was no history of PIH or any other high risk factor during antenatal period.
On examination, general condition was unsatisfactory. The patient was conscious but rowdy and irritable. She was febrile (39oC) with pulse of 136/min and BP of 96/70 mm of Hg. She was pale and icteric with subconjunctival haemorrhages. Patient had desquamation of skin over extremities and there was marked muscular tenderness. Her respiratory and cardiovascular examination revealed no abnormal findings. There was no neck rigidity and no flaps were demonstrable.
On abdominal examination, liver was two fingers palpable and tender. The uterus was palpable below umbilicus. On vaginal examination, there was minimal lochia, which was not foul smelling. The uterus was well retracted. On catheterization, there was 30 ml dark coloured urine.
Differential count revealed polymorphonuclear leucocytosis. BUN was 16 mg%, and serum creatinine was 1.7 mg%. Though total bilirubin was 10 mg% with a direct of 8 mg%, SGOT and SGPT were minimally raised. Ultrasound showed moderate hepatomegaly with dilatation of the biliary canaliculi. The kidneys and spleen were normal. The uterus was normal, involuting and bulky without any collection.
Thus, the patient had obstructive type of jaundice with decreased renal function, severe myalgia and subconjunctival haemorrhage; the classical features of leptospirosis - Weil’s disease. Hence, blood and urine was sent for examination, which came positive, confirming the clinical diagnosis.
The patient was treated with penicillin and metronidazole. Her condition improved fast and her hepatorenal profile returned to normal by tenth day of treatment. Baby’s test for leptospirosis was negative. The patient was discharged in good condition on day 16th. On follow up, after one month, blood and urine test for leptospirosis were negative.
DISCUSSION AND CONCLUSION
Leptospirosis is a term applied to disease caused by all leptospiras regardless of specific serotype. The genus Leptospira contains only one species L. interrogans which may be divided into two complexes, interrogans and biflexa. Leptospirosis is thought to be the most widespread zoonosis in the world. Infection in humans is an incidental occurrence and is not essential to the maintenance of leptospirosis. Human infections can occur either by direct contact with urine or tissue of an infected animal or indirectly through contaminated water, soil or vegetation. The incubation period ranges from 7 to 13 days and the average being ten days. Leptospirosis is a typically biphasic illness. In the first phase, onset is abrupt with symptoms like severe headache, myalgia, cutaneous hyperaesthesia. Chills followed by a rapidly rising temperature are prominent. The most characteristic sign is conjunctival suffusion which usually appears on the third or the fourth day. The second phase has been characterized as the immune phase with the appearance of circulating IgM antibodies. Leucocytosis may be present. Urinalysis reveals mild proteinuria, casts and an increase in the cellular elements. Increases in the liver enzymes are very slight. During the first phase of illness some patients have a raised serum creatine phosphokinase (CK) levels.
Diagnosis is based upon culture of the organism or serologic proof of its existence. Penicillin, streptomycin, choramphenicoal and erythromycin have been effective in treating these patients.
This case was treated with penicillin and was very effective. Niyogi GM had reported a similar case of leptospirosis in pregnancy.
The purpose of reporting this case is that clinical picture of leptospirosis may mimic hepatorenal failure following PIH or septicaemia or even other infections like malaria. Subconjunctival haemorrhage and marked muscle tenderness can be clinical features in the diagnosis, but the final diagnosis can be made only after blood and serological tests. Hence, in any pregnant/puerperal patient with hepatorenal disease, possibility of leptospirosis must be kept in mind.
We thank our Head of Department and Dean for allowing us to use and publish the hospital data.
1. Niyogi GM, Pandit S, Patki A. Leptospirosis : A unique spirochaetal infection in pregnancy. J Obst and Gyn India 1992; 42 (4) : 532.
2. Sanford JP. Leptospirosis in : Harrison’s principles of internal medicine, 12th edn. New York; Mc Graw Hill. 1991; 1 : 663.