Case Report: Fatal Human Leptospirosis Caused by Leptospira interrogans Genotype ST149

Mohan Rao Leptospirosis Reference Laboratory, Bacteriology Unit, Infectious Disease Research Centre, Institute for Medical Research, Jalan Pahang, Kuala Lumpur, Malaysia;

Search for other papers by Mohan Rao in
Current site
Google Scholar
PubMed
Close
,
Fairuz Amran Leptospirosis Reference Laboratory, Bacteriology Unit, Infectious Disease Research Centre, Institute for Medical Research, Jalan Pahang, Kuala Lumpur, Malaysia;

Search for other papers by Fairuz Amran in
Current site
Google Scholar
PubMed
Close
,
Ameera Ashyila Kamaruzaman Department of Pathology, Selayang Hospital, Lebuhraya Selayang, Kepong, Batu Caves, Selangor, Malaysia

Search for other papers by Ameera Ashyila Kamaruzaman in
Current site
Google Scholar
PubMed
Close
,
Habib Abdul Hakim Esa Department of Pathology, Selayang Hospital, Lebuhraya Selayang, Kepong, Batu Caves, Selangor, Malaysia

Search for other papers by Habib Abdul Hakim Esa in
Current site
Google Scholar
PubMed
Close
,
Ahneez Abdul Hameed Department of Pathology, Selayang Hospital, Lebuhraya Selayang, Kepong, Batu Caves, Selangor, Malaysia

Search for other papers by Ahneez Abdul Hameed in
Current site
Google Scholar
PubMed
Close
, and
Noor Afidah Mohamed Shabery Department of Pathology, Selayang Hospital, Lebuhraya Selayang, Kepong, Batu Caves, Selangor, Malaysia

Search for other papers by Noor Afidah Mohamed Shabery in
Current site
Google Scholar
PubMed
Close

ABSTRACT

Leptospirosis is an important zoonotic disease with worldwide distribution and nonspecific clinical manifestation. We report a case of fatal leptospirosis in a previously healthy woman with a causative agent. A young adult Indian woman was brought in dead to the forensic department. Ten days before, she developed fever, dizziness with headache, myalgia, diarrhea, and vomiting. Routine inquest and autopsy were performed on the deceased, revealing hemorrhagic lungs with extensive intra-alveolar hemorrhages, pale liver with dissociation and separation of hepatocyte plates, and edematous brain with histiocyte and lymphocyte infiltration in the parenchyma and meninges. Heart tissue depicts myocarditis and pericarditis inflammatory changes. Cerebrospinal fluid (CSF) was turbid in appearance with mildly elevated leukocytes, predominantly lymphocytes. Real-time PCR targeting lipL32 gene of pathogenic Leptospira was detected in the blood, CSF, brain, kidney, heart, and liver. The genetic profile of the causative agent was ST149 (multi-locus sequence typing Scheme 3). This study illustrates the usefulness of Leptospira PCR assay in postmortem diagnosis and addresses the need for further surveillance to identify the epidemiological link of the disease.

INTRODUCTION

Leptospirosis is a re-emerging zoonotic disease caused by Leptospira species, a group of spirochete bacteria with 29 described serogroups and more than 200 different Leptospira serovars. 1 This disease occurs in diverse epidemiological settings but highly prevalent in tropical and subtropical areas. The worldwide incidences of leptospirosis were reported to be 0.1–1 per 100,000 inhabitants. However, the increase in incidence is likely during seasonal breaks, heavy rainfalls, and among high-risk populations. 2 Leptospira species infect a wide range of hosts such as mammals, fish, birds, and reptiles as well as humans. Rodents constitute as an essential reservoir for several pathogenic Leptospira. 3 In this report, we describe a fatal case of leptospirosis in a young woman infected by pathogenic Leptospira genotype ST149.

CASE PRESENTATION

An unemployed 41-year-old woman of Indian descent with an unremarkable medical history was brought in dead to the forensic department of Selayang Hospital. The deceased had a history of fever, mild flu-like symptoms, dizziness with headache, myalgia, diarrhea, and vomiting that began 10 days before. On day 3 of her illness, she had visited a general practitioner for being sick, where antibiotics were prescribed and no further blood investigation was made. She had no recent history of traveling, jungle trekking, or swimming in a lake or pool. She is a divorcee, living with her family (eight of them), and owned two healthy dogs. Her body was shifted to the mortuary for routine inquest and autopsy.

Autopsy findings.

Autopsy revealed pale liver with no enlargement, hemorrhagic lungs, and edematous brain without sign of bleeding. Microscopic examination of tissue specimens revealed dissociation and separation of the hepatocyte plate prominent at the perivenular area (zone 3) with macro-vesicular steatosis of the liver (Figure 1B), diffuse congestion with extensive intra-alveolar hemorrhages mixed with fibrins and macrophages of the lungs (Figure 1A), mild perivascular histiocyte and lymphocyte infiltration within brain parenchyma and meninges suggestive of mild meningoencephalitis changes (Figure 1C), mild myocarditis, and pericarditis morphologies. At the same time, diffuse autolysis of the gallbladder and mild hypertensive vascular changes of the kidneys were observed. No significant pathological changes were seen in the pancreas, stomach, and small intestine. Because of histopathological findings and epidemiology of hemorrhagic fever in Malaysia, the deceased was screened for dengue fever and leptospirosis (Table 1).

Figure 1.
Figure 1.

Histopathologic evaluation of tissue specimens collected postmortem from the deceased. Tissue specimens were taken from the lung (A), liver (B), and brain (C) stained with hematoxylin–eosin (AC: original magnification ×20). Picture (D1, D2, and D3) is probed CD68 and leukocyte common antigen immunohistochemistry stain to identify histiocytes and lymphocytes, respectively.

Citation: The American Journal of Tropical Medicine and Hygiene 104, 1; 10.4269/ajtmh.20-0267

Table 1

Laboratory and microbiological investigation performed on the deceased

Investigation Result
Vitreous fluid analysis
 Appearance Clear
 Urea, Ur (mmol/L) 17.3
 Creatinine, Cr (μmol/L) 251
 Sodium, Na (mmol/L) 134
 Potassium, K (mmol/L) 7.7
 Glucose (mmol/L) < 0.6
CSF analysis
 Appearance Turbid
 White blood cell count (cells/mm3) 25 cells, predominantly lymphocytes
 Glucose (mmol/L) < 0.6
 Protein (g/dL) 2.48
Dengue screening
 NS1 Ag Nonreactive
 IgM Nonreactive
 IgG Reactive
 PCR assay (targeting DENV1-4 genes) Not detected
Leptospirosis screening
 Microscopic agglutination test Nonreactive (titer < 1:50)
Specimen for Leptospira PCR assay, Ct-value
 Blood 29.70
 CSF 36.50
 Lung 35.28
 Liver 32.78
 Kidney 31.70
 Heart 34.45
Conventional culture
 Blood culture Clostridium limosum
 Lung tissue culture Mixed growth
 CSF culture No growth
Leptospira culture No growth

CSF = cerebrospinal fluid.

Laboratory findings.

A multi-locus sequence typing (MLST Scheme 3) was performed on extracted blood DNA targeting six housekeeping genes (adk-icdA-lipL32-lipL41-rrs2-secY). The allelic profile was 5-1-2-3-1-5 which was assigned to ST149 in the Leptospira MLST Scheme 3 database. 4 Table 1 summarizes laboratory investigations performed on the deceased.

DISCUSSION

Leptospirosis is an important emerging zoonotic disease with global distribution. Malaysia is known to be endemic for leptospirosis partly because of the tropical weather with a humid environment that prolongs the survival period of pathogenic Leptospira in the environment. 5 Reservoir animals play a critical role in the continued persistence of Leptospira in the environment, causing outbreaks by direct or indirect exposure. Humans are an accidental host, and risk of infection is commonly associated with the nature of occupation. 6

Although, the deceased is not associated with any occupational risk groups as described by Jalii and Bahaman, 7 environmental exposure cannot be excluded. Nevertheless, the deceased companion dogs can transmit this infection, but to no avail for serological study or leptospiral isolation. On the other hand, ST149 is not a frequently reported genotype among dogs. 8 However, Leptospira genotype ST149 obtained from the deceased shared similar sequence typing (ST) with Leptospira interrogans serovar Bataviae strain LepIMR 22, 9 a persistently found serovar in the urban rat populations in Malaysia. Rattus rattus, Rattus norvegicus, and Rattus exulans were the common host reservoirs of this serovar in Malaysia. 10,11 It can be assumed that the deceased was directly or indirectly in contact with rodents carrying Leptospira ST149. However, this assumption cannot be demonstrated as culture isolation of infecting serovars from the deceased or the companion dogs was not performed to illustrate the existence of epidemiological linkage.

Common targeted organs in leptospirosis are lungs, liver, kidney, and brain. Despite lack of laboratory investigation in our case report, the severity of illness can be appreciated by the histopathology findings of the involved organs. Pulmonary hemorrhage secondary to severe leptospirosis was the likely cause of death in this case report. Other typical pathological changes in this case study was observed in the liver, heart, kidney, and brain which may suggest high leptospiral load. 5 Leptospira DNA was detected in all the tissue samples and body fluid of the deceased, with PCR cycle threshold-value ranging from 29 to 37 (Table 1). However, Agampodi et al. 12 have demonstrated that leptospiral load is not a predictive factor of severity of illness. On the contrary, although not studied in larger scale, it is presumed that the virulence factor of Leptospira species/serovar/strain may be associated with severity of the illness.

In conclusion, Leptospira PCR assay is valuable in postmortem diagnosis of acute illness because Leptospira culture is laborious, tedious, and less sensitive. Leptospirosis serology assay is not helpful as it requires paired sera to confirm a diagnosis with certainty, and many patients succumbed to death during the acute phase of illness. 5 At the same time, this case report demonstrates the need for surveillance on the deceased companion dogs and housing ecosystems by leptospiral isolation or serological study to identify the epidemiological link and mitigate the risk and exposure to the fatal disease.

ACKNOWLEDGMENTS

We are grateful to the Institute for Medical Research, Kuala Lumpur, and the pathology department of Selayang Hospital for their support and facilities. We would like to thank the Director General of Health Malaysia for allowing us to publish our findings.

REFERENCES

  • 1.

    Levett PN , Vinetz JM , 2001. Leptospirosis. Curr Opin Infect Dis 14: 296326.

  • 2.

    World Health Organization , 2010. Report of the First Meeting of the Leptospirosis Burden Epidemiology Reference Group. Geneva, Switzerland: WHO, 134.

  • 3.

    Gomes-Solecki M , Santecchia I , Werts C , 2017. Animal models of leptospirosis: of mice and hamsters. Front Immunol 8: 58.

  • 4.

    Ahmed N , Manjulata Devi S , de los Á Valverde M , Vijayachari P , Machang’u RS , Ellis WA , Hartskeerl RA , 2006. Multilocus sequence typing method for identification and genotypic classification of pathogenic Leptospira species. Ann Clin Microbiol Antimicrob 5: 28.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Haake DA , Levett PN , 2015. Leptospirosis in humans. Curr Top Microbiol Immunol 387: 6597.

  • 6.

    Barcellos C , Sabroza PC , 2001. The place behind the case: leptospirosis risks and associated environmental conditions in a flood-related outbreak in Rio de Janeiro. Cad Saude Publica 17 (Suppl): 5967.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Jalii IM , Bahaman AR , 2004. A review of human leptospirosis in Malaysia. Trop Biomed 21: 113119.

  • 8.

    López MC , Vila A , Rodón J , Roura X , 2019. Leptospira seroprevalence in owned dogs from Spain. Heliyon 5: e02373.

  • 9.

    Amran F , Khairul M , Khalid M , Mohamad S , Ripen AM , Ahmad N , Goris MGA , Muhammad AH , Halim NAN , 2016. Draft genome sequence of Leptospira interrogans serovar Bataviae strain LepIMR 22 isolated from a Rodent in Johor, Malaysia. Genome Announc 4: e00956-16.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Garba B , Bahaman AR , Khairani-Bejo S , Zakaria Z , Mutalib AR , 2017. Retrospective study of leptospirosis in Malaysia. Ecohealth 14: 389398.

  • 11.

    Benacer D , Mohd Zain SN , Sim SZ , Khalid MKNM , Galloway RL , Souris M , Thong KL , 2016. Determination of Leptospira borgpetersenii serovar Javanica and Leptospira interrogans serovar Bataviae as the persistent Leptospira serovars circulating in the urban rat populations in Peninsular Malaysia. Parasit Vectors 9: 1.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Agampodi SB , Matthias MA , Moreno AC , Vinetz JM , 2012. Utility of quantitative polymerase chain reaction in leptospirosis diagnosis: association of level of leptospiremia and clinical manifestations in Sri Lanka. Clin Infect Dis 54: 12491255.

    • PubMed
    • Search Google Scholar
    • Export Citation

Author Notes

Address correspondence to Mohan Rao, Leptospirosis Reference Laboratory, Bacteriology Unit, Infectious Disease Research Centre, Institute for Medical Research, Jalan Pahang, 50588 Kuala Lumpur, Malaysia. E-mail: rao.mohan@moh.gov.my

Disclosure: This study did not involve any type of intervention in diagnosis and treatment; thus, written informed consent was not considered necessary for the study.

Financial support: This study was funded by the Diagnostic Operational Budget from the Leptospirosis Reference Laboratory of Bacteriology Unit, Institute for Medical Research, Ministry of Health Malaysia, 50588 Jalan Pahang, Kuala Lumpur.

Authors’ addresses: Mohan Rao and Fairuz Amran, Bacteriology Unit, Infectious Disease Research Department, Leptospirosis Reference Laboratory, Institute for Medical Research, Jalan Pahang, Malaysia, E-mails: rao.mohan@moh.gov.my and fairuz.a@moh.gov.my. Ameera Ashyila Kamaruzaman, Habib Abdul Hakim Esa, Ahneez Abdul Hameed, and Noor Afidah Mohamed Shabery, Department of Pathology, Selayang Hospital, Kepong, Malaysia, E-mails: ameera@moh.gov.my, habix87@gmail.com, drahneez@gmail.com, and noorafidah@selayanghospital.gov.my.

  • Figure 1.

    Histopathologic evaluation of tissue specimens collected postmortem from the deceased. Tissue specimens were taken from the lung (A), liver (B), and brain (C) stained with hematoxylin–eosin (AC: original magnification ×20). Picture (D1, D2, and D3) is probed CD68 and leukocyte common antigen immunohistochemistry stain to identify histiocytes and lymphocytes, respectively.

  • 1.

    Levett PN , Vinetz JM , 2001. Leptospirosis. Curr Opin Infect Dis 14: 296326.

  • 2.

    World Health Organization , 2010. Report of the First Meeting of the Leptospirosis Burden Epidemiology Reference Group. Geneva, Switzerland: WHO, 134.

  • 3.

    Gomes-Solecki M , Santecchia I , Werts C , 2017. Animal models of leptospirosis: of mice and hamsters. Front Immunol 8: 58.

  • 4.

    Ahmed N , Manjulata Devi S , de los Á Valverde M , Vijayachari P , Machang’u RS , Ellis WA , Hartskeerl RA , 2006. Multilocus sequence typing method for identification and genotypic classification of pathogenic Leptospira species. Ann Clin Microbiol Antimicrob 5: 28.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Haake DA , Levett PN , 2015. Leptospirosis in humans. Curr Top Microbiol Immunol 387: 6597.

  • 6.

    Barcellos C , Sabroza PC , 2001. The place behind the case: leptospirosis risks and associated environmental conditions in a flood-related outbreak in Rio de Janeiro. Cad Saude Publica 17 (Suppl): 5967.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Jalii IM , Bahaman AR , 2004. A review of human leptospirosis in Malaysia. Trop Biomed 21: 113119.

  • 8.

    López MC , Vila A , Rodón J , Roura X , 2019. Leptospira seroprevalence in owned dogs from Spain. Heliyon 5: e02373.

  • 9.

    Amran F , Khairul M , Khalid M , Mohamad S , Ripen AM , Ahmad N , Goris MGA , Muhammad AH , Halim NAN , 2016. Draft genome sequence of Leptospira interrogans serovar Bataviae strain LepIMR 22 isolated from a Rodent in Johor, Malaysia. Genome Announc 4: e00956-16.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Garba B , Bahaman AR , Khairani-Bejo S , Zakaria Z , Mutalib AR , 2017. Retrospective study of leptospirosis in Malaysia. Ecohealth 14: 389398.

  • 11.

    Benacer D , Mohd Zain SN , Sim SZ , Khalid MKNM , Galloway RL , Souris M , Thong KL , 2016. Determination of Leptospira borgpetersenii serovar Javanica and Leptospira interrogans serovar Bataviae as the persistent Leptospira serovars circulating in the urban rat populations in Peninsular Malaysia. Parasit Vectors 9: 1.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Agampodi SB , Matthias MA , Moreno AC , Vinetz JM , 2012. Utility of quantitative polymerase chain reaction in leptospirosis diagnosis: association of level of leptospiremia and clinical manifestations in Sri Lanka. Clin Infect Dis 54: 12491255.

    • PubMed
    • Search Google Scholar
    • Export Citation
Past two years Past Year Past 30 Days
Abstract Views 571 0 0
Full Text Views 1845 553 50
PDF Downloads 1276 337 33
 

 

 

 
 
Affiliate Membership Banner
 
 
Research for Health Information Banner
 
 
CLOCKSS
 
 
 
Society Publishers Coalition Banner
Save