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OCULAR MANIFESTATIONS
DURING ACUTE PHASE OF LEPTOSPIROSIS |
DEEPIKA SINGHAL , MANISHA SHASTRI,
SHAILESH AGRAWAL, DEEPAK SAXENA,
V.K.SHARMA, M.M.PRAKASH, RAKESH TRIVEDI, and RAJESH DIXIT
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ABSTRACT: Leptospirosis is a multi system disease involving
the eye in different phase of disease and manifesting in a varied pattern.Meticulous
examination of eye in suspected cases of leptospirosis should be done not only to
prevent ocular morbidity but also should be watched for development of leptospiral
uveities a very well known complication of Leptospirosis.The present study was under
taken with an aim to document the ocular manifestations in Acute phase of Leptospirosis
admitted in teaching hospital with a high clinical suspicion of Leptospirosis following
flood and to establish significance between these symtoms and sera report. |
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INTRODUCTION |
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Surat city witnessed floods during
the month of August 2006 due to heavy rainfall in catchments of Tapi river in Maharashtra
and Madhya Pradesh.Almost 85-90%of th ecity remained submerged for more than five
to six days. There was an upsurge in fever cases during post flood,presenting with
organ involvement and were suspected to be Leptospirosis, a zoonotic disease known
to occur in South Gujrat since 1994.However ,its occurrence has ben documented so
far only in the rural areas of districts of Surat,Navasri and Valsad(Kumar,2005).It
was for the first time that cases of Leptospirosis were reported in Surat city. |
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Leptospirosis are very thin,spiral-shaped,tightly
coiled,gram-negative aerobic,spirochetes with a unique flexuous type of motility.The
genus is divided into two species:the pathogenic Leptospires interrogans and and
non pathogenic Leptospires biflexa.Infected rodents and other animals pass the bacteria
in their urine,contaminating the soil and water reservoirs.They enter the humans
through an intact mucosa or abraded skin,resulting in a bacteraemia,disseminating
into various organs such as the kidneys,liver,lungs,heart and the central nervous
system.A febrile illness,headache,redness of eye,servere fatigue and muscle pain
may be the clinical features of the leptospiremic acute phase;however the severity
of fever varies from asymptomatic presentation to mild,moderate or servere form
and is not sufficiently characteristic for an early didiagnosis.After 4 to 7 days
of the initial bacteraemia,the Leptospires are rapidly eliminated by the immune
system from all host tissues except from immunologically privileged places like
the brain and eyes. |
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Ocular ininvolvement is seen both
in the systemic bacteraemic phase as well as in the immunological phase.The incidenceof
ocular signs during acute systemic phase varies from 2% to 90%.However ,in some
instances,the ocular manifestations may be sub-clinical or of such low order as
to be overlooked.During this stage conjunctival congestion without any conjunctival
discharge,chemosis,and sub-conjunctival hemorrhage may be seen.Presence of yellow
sclera and circum-corneal congestion is regarded as path gnomic sign of server systemic
Leptospirosis.However the most short tirm suffusion,refering to a conjunctival congestion,has
historically been liked to findings of Leptospirosis normal ophthalmologic evalation
of the eye vduring the acute phase of Leptospirosis may reveal dilation of the conjunctival
vasculture,subconjunctival hemorrhage,and retinal vasculities.
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Confirmation of clinical dignosis
of Leptospirosis relies on laboratory testing.MAT is currently Considered a gold
standard test.However,methodological complexities,including the requirement for
a continous supplyof live organisms,high specificity for individual sero-groups
leading to false negativity and subjective errors in the reading limit its use.Analysis
of paired serum is recommended, either sero-conversion or a four fold or greater
rise in antibody titer is considered diagnostic for systemic Leptospirosis,whereas
in the chronic stage or in ocular Leptospirosis,a titer above 1:100 dilutions is
taken as significant. |
The present study was undertaken
to study the ocular involvement in acute phase of Leptospirosis and to study the
various ophthamic manifestations in serologically positive and negative cases of
Leptospirosis admitted in the hospital.
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MATERIALS
AND METHODS |
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The present study was carried out
in teaching hospital of SMIMER between August and 2nd week of September.Inclusion
criteria included all haspitalized cases in SMIMER,,who were clinically suspected
with Leptospirosis as per the suspected case defination by NICD.The patients were
examined and their details were collected in a pre tested and pre designed performa
to record demographic characteristics,history and duration of exposure along with
clinical feature with an emphasis on specific ocular complaints like pain,discharge,redness
and other ocular complaints. |
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Rapid Test status and or First ELISA
status (a titer above 1:100 dilutions) or sero-conversion or a four fold or greater
rise in antibody titer after second sera(which was collected after 14 days of first
sera) was considered diagnostic for systemic Leptospirosis to classify a patient
serologically as positive or negative.The data was collected and analyzed by help
of EPI info version 6.01 using Chi-square test to estimate the statistical significance. |
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RESULTS
AND DISCUSSION |
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Out of 81 cases,more cases were
of males (82.7%)than females (17.3%).Age group of 21-40 years accounted of more
than 50% of the total cases.Reasons that can be attributed for this high percentage
of infection in this group was history of exposure to flood water(90%);most people
in affected areas gave history of moving in flooded water to secure relief supplies,rescue
or shifting to safer places- |
Table. 1 Age sex distribution of the study population- |
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Age groupe |
Male |
Female
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Total |
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<20
21-30
31-40
41-50
51-60
61 and more
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16(19.75)
27(33.3)
10(12.3)
7(8.6)
5(6.1)
2(2.4)
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4 (4.9)
4 (4.9)
2 (2.5)
2 (2.5)
2 (2.5)
0(0)
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20 (24.69)
31 (38.27)
12 (14.8)
9 (11.1)
7 (8.6)
2(2.5)
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Total |
67(82.7) |
14(17.3) |
81(100) |
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Values in parenthesis are
contribution.
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Cases that showed either first ELISA
as positive increased titer in second ELISA (first one may be negative) were considered
as ELISA positive. Proportion of such cases was 61.72 percent; rest were ELISA-ve
(25.9). In 12.4 percent cases only rapid test was available for interpretation labeled
Lepto +ve. Over all Cases fatality rate (CFR) WAS 13.5 Percent, however, in those
who were ELISA+ve CFR was 12 percent compared to a CFR OF 23.8% cases (Table, 2).
Out of 81 cases studied most common presenting symptom was Fever present in 61 (87.6%)
cases. However, 18.26 per cent of the cases had pulmonary involvement followed by
Renal involvement in 12.5% cases (Table. 3).
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Table. 2 Distribution study
population according to the sera report and their outcome
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Test Result |
Expired
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Discharged
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Total
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ELISA+ve
Rapid+ve
ELISA+ve
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6
0
5
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44
10
16
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50 (61.7)
10 (12.4)
21(25.9)
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Total |
11 |
70
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81 (100) |
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Values in parenthesis are
contribution.
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Table. 3 Distribution study population
according to the presenting sysmpotms and major organ nvolvement
(other than Ophthalmic involvement)
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Sysmptoms / Organ Involved |
N%
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71 (68.26)
19 (18.26)
13 (12.5)
11 (10.5)
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Total |
104 |
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33out of 81 cases presented with
one or more than one type of ocular manifestations. Most common ocular manifestation
was Conjunctival Suffusion in 23.7 percent followed by Sub conjuntival
hemorrhage in 21.6 percent population (Table. 4) 33cases out of 81 presented with
one or more ocular manifestations, however, 69.6 per cent (23out of 33) presented
with Conjuntival suffusion, most sensitive predictor of Leptospirosis in a patient
with fever and history of occupational exposure. The difference in serum status
and the ocular manifestations was found significant statistically (Table. 5).
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Table. 4 distribution according
to the various ocular manifestation (n=33)
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Sysmptoms
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N%
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Conjuntival suffiusion
Icterus
Venous Fullness
Sub conjuntival Hemorrhage
Other
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23 (23.7)
19 (19.5)
15 (15.5)
21 (21.6)
19 (19.5)
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Total |
97 (100) |
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Table. 5 Distribution of study population as per
Sera report and ocular manifestation(n=33) |
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Sera Report
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Ocular Manifestations
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P Value
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df
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Persent
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Absent
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ELISA+ve
ELISA –ve
Rapid +ve
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27
4
2
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23
17
8
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0.02 at a X2
Value of 7.41
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2
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Values in parenthesis are percent contribution
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Ophthalmic
diagnosis of systemic Leptospirosis is often missed at peripheral centres; subsequently
patients may develop uneitis, which may be misinterpreted as idiopathic uveitis
by the ophthalmologists. There exists a definite possibility of underestimating
the incidence of uneitis associated with Leptospiroses. If the diagnosis is
misinterpreted, young patients with hypopyon uveites with a history of joint
pain (during systemic Leptospirosis ) may mislead the ophthalmologist to diagnose
other uveitic entities that are associated with arthralgia such as
Behcet’s syndrome or HLAB27 related uveitis. There is a definite need for development
of clinical prediction rules to detect the initial ocular presentation of leptospiral
and its complications. Thus urgently required more specific and accessible molecular
methods to confirm the clinical of leptospirosis.
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