Group A

Time

of Interview: 4 P.M.

Informant:

Patient

Reliability:

85%

 General

Data:

AG, 21, Male

Bday: November 10,1994
Birth place: Dagupan
Roman catholic, filipino
Occupation: Miner in Benguet
Date of admission: Aug 20, 2016

CHIEF COMPLAINT: intermittent fever

(unrecorded)

HISTORY OF PRESENT ILLNESS:

5

days PTA> body warm to touch,

generalized body weakness,
frontoparietal headache rated 5/10
> took Phenylephrine
hydrochloride/ chlorphenamine maleate,
paracetamol ( 10 mg/2 mg/500 mg)1 tab
consuming 1 tablet when felt to be
febrile with temporary relief

days PTA- condition persisted,

claimed to have elevated body
temperature merely by palpation,
opted not to go to work and preferred
to stay on bed because of generalized
weakness
- continued medications
consuming 4 tablets with temporary
relief of condition
- no consultations done for
signs and symptoms persisted.

hours PTA perisitent complaints of

weakness and headache, but with
new eruption of maculopapular rash
starting from his upper extremities
going to his and the persistent
elevated body temperature,
prompted for consult thus admission

travelled

to Dagupan for
consultation hence admitted

 PAST

MEDICAL HISTORY: Not

significant

No previous hospitalization

No adult immunization received

ALLERGIES: No known allergies to

food and medication
FAMILY HISTORY:
- Father has asthma

 PERSONAL

AND SOCIAL

HISTORY:

work as miner in a mining company

in Philex, Tuba, Benguet

Wears boots when at work

drinking water is either boiled or

mineral water

non-smoker, occasional drinker

consuming 3-4 bottles of beer

REVIEW OF SYSTEMS

HEAD: dizziness

with colds

RESPIRATORY: (+) cough, nonproductive, (+) night

sweats

CVS: easy fatigability

GI: loss of appetite

MUSCULOSKELETAL: backpain

NEUROLOGIC: insomnia (easily awakened) claims to normally sleep every night prior to the
start of illness

PHYSICAL EXAM
GENERAL SURVEY:
Conscious, Coherent, lying on bed; Vital signs: BP
110/80 mmHg, Temp: 37.9C, Respiratory rate: 23cpm,
Cardiac rate: 78bpm
HEENT:
Pinkish palpebral conjunctivae. Icteric sclerae. No
xanthelasma, no alopecia, no Tonsillopharyngeal
congestion
NECK:

Supple; JVP = 5 cm at 45 degrees. No thyromegaly,

no cervical lymphadenopathy, no carotid bruit.

SKIN:

Has jaundice, maculopapular rash noted at the back

and extremities. Warm to touch

CHEST/LUNGS:
Symmetrical. No retractions, no lag, no spider angiomas.
Equal vocal and tactile fremiti. Equally resonant on both
lung fields. Equal breath sounds. No wheezes.
HEART:
Adynamic precordium; Apex beat at the 4 th or 5th
intercostal space left midclavicular line. No thrills/ heaves.
No loud and palpable P2; normally split S2; S1 > S2 at
apex; S2 > S1 base; (-) S3; (-) S4; normal rate regular
rhythm. No murmurs.
ABDOMEN:
Flat; No caput medusa. Normoactive bowel sounds; soft;
nontender; tymphanitic; Non palpable liver edge.
EXTREMETIES:
No deformities, no clubbing, no cyanosis with the ff. pulses:
DP PT P F

++ ++ ++ ++ ++ ++

++ ++ ++ ++ ++ ++

NEUROLOGIC EXAM:
Cerebrum: conscious; oriented to 3 spheres
Cerebellum: (-) nystagmus; can do heel to shin test;
intact Rombergs test; can do rapid alternating
movements, can do finger to nose test
Cranial Nerves:
I can smell coffee
II, III pupils equally reactive to light
III, IV, VI Intact extraoccular muscles
V Intact corneal reflex, bilateral; intact masseter
muscle contraction
VII (-) facial asymmetry
VIII can hear, bilateral
IX, X intact gag reflex
XI can shrug shoulders
XII tongue midline on protrusion

Salient points
Subjective findings

Objective findings

Body Weakness

Frontoparietal Headache

Miner in Benguet

Colds and non productive

cough

Dizziness

Night Sweats

Fever

Easy Fatigability

Maculopapular rash

Loss of appetite

Cough

Back pain

Jaundice

Insomnia

Impression
Leptospirosis

Differential Diagnosis

Dengue

Typhoid fever

Dengue
Rule in

Rule out

Fever of 5 days

Jaundice

Maculopapular (back and

extremities)

myalgia

Headache

Non productive cough

Lives in Benguet (endemic

area)

Typhoid fever
Rule in

Rule out

Fever 5 days

Rose spots

Generalized body weakness Abdominal pain

Cough (nonspecific)

Constipation/ diarrhea
Abdominal Tenderness
Abdominal distention

Course in the ward

Day 1
Diagnostics

Diagnostics:
Dengue
fever
test(NS1Ag)
CBC
Serum Electrolytes
Serum Creatinine
Urinalysis
SGPT(ALT)
SGPT(AST)

Result:
Negative
Thrombocytopenia
Hyponatremia
Normal
Hematuria,
Glucosuria
Normal
Increase

Proteinuria,

Day 2

Therapeutics:
Hydration and medication continued

Day 3
Diagnostics

Result

Leptospira Test

Positive

Therapeutics:
Penicillin 1-5m Units q6 Hours

Laboratory results

Dengue fever test: NS1Ag: Negative, IgM: Negative, IgG:

Negative

CBC:
RBC: 4.84x1012 g/L(N: 4.00-5.40 x 1012 g/L)
Hemoglobin:146 g/L (N:120-160 g/L)
Hematocrit: 42.3% (N:37.0-47.0 g/L)
WBC: 6.35 x 109/L (N: 4.00-10.00)

Neu%: 78.6% (N: 55.0-65.0)

Lym%: 16.5% (N: 25.0-35.0)

Mon%: 3.3% (N: 3.0-6.0)

Eos%: 1.1% (N: 2.0-4.0)

Bas%: 0.5% (N: 0.0-1.0)

PLT: 95 x 109/L (N: 150-450)

Serum Electrolytes:
Sodium: 129.50 mmol/L (N: 135-148 mmol/L)
Potassium: 3.43 mmol/L (N: 3.5-5.3 mmol/L)
Chloride: 100.40 mmol/L (N: 98.7-107 mmol/L)

Serum Creatinine:
Creatinine: 79.4 umol/L (N:63.6-110.5 umol/L)

Urinalysis:
Physical Examination:
Color: Dark yellow
Transparency: Slightly Turbid

Chemical Analysis:
Blood: Negative
Bilirubin: Negative
Urobilinogen: 1.0
Ketone: Negative
Protein: ++
Nitrite: Negative
Glucose: ++
pH: 5.5
SG: 1.025
Leukocytes: Negative

Urine Flow cytometry

RBC: 4/hpf
Pus Cells: 3/hpf
Epithelial Cells: 2/hpf
Hyaline Casts: 9/lpf
Bacteria: 1/hpf

Final Diagnosis

Leptospirosis
Physical and subjective
Findings

Laboratory

Fever

Dengue fever test: Negative

Headache

Urinalysis: Hematuria,
Proteinuria, Glucosuria

Jaundice

SGPT(AST): Increase

Non-productive cough
(nonspecific)

CBC: Thrombocytopenia

Maculopapular rash

Serum Electrolytes:
Hyponatremia

Myalgia

Pathophysio and
pathogenesis
LEPTOSPIROSIS

http://wiki.ggc.edu/wiki/Leptospirosis_Spring_'14

Leptospires enter the bodythrough:

Cuts, abraded skin; intact mucosa (conjunctiva, oronasopharynx, gut)
Inhalation of droplets of urine
Ingestion of contaminated water or food

Organisms proliferate, cross tissue barriers, and

disseminatehematogenouslyto all organs facilitated by systemic
vasculitis

LeptospiremicPhase/Septicemic Phase
Acute febrile illness
Leptospires isolated in the bloodstream and sometimes in theCSF
Lastsfor 4-7 days
Acute flu-like illness of sudden onset
Fever, chills, headache, nausea, vomiting, abdominal pain, conjunctival suffusion
and myalgia, pretibial rash

Immune system eliminates pathogens, butleptopiresmay persist

for prolonged periods in various organs such as liver, lung,
kidney, heart, and brain.

Leptospiruricphase/Immune phase
Severe multisystem manifestations
Disappearance ofleptospiresin the blood, appearance of IgM antibodies
and isolation ofleptospiresin urine.
Weils syndrome: hemorrhage, jaundice and acute kidney injury
Death due to septic shock with MOF and/or severe bleeding
complications

http://jkt.kpkt.gov.my/resources/index/pdf/Persidangan_20
15/persidangan
%20kesihatan/Leptospirosis_in_Malaysia.pdf

Management

Guidelines

CLINICAL RECOGNITION OF
LEPTOSPIROSIS

acute febrile illness of at least 2 days AND either

residing in a flooded area or has high-risk
exposure AND presenting with at least two of the
following

symptoms: myalgia, calf tenderness, conjunctival

suffusion, chills,abdominal pain, headache,
jaundice, or oliguria should be considered a
suspected leptospirosis case.

Leptospirosis CPG 2010

Which patient will need hospital

admission?

suspected case of leptospirosis presenting with

acute febrile illness

MILD LEPTOSPIROSIS - OUT-PATIENT

SETTING

Plus various manifestations BUT with stable vital

signs, anicteric sclerae, with good urine output,
and no evidence of meningismus / meningeal
irritation, sepsis / septic shock, difficulty of
breathing nor jaundice and cantake oral
medications is considered.

Leptospirosis CPG 2010

MODERATE SEVERE

Plus with unstable vital signs, jaundice/icteric

sclerae, abdominal pain, nausea, vomiting and
diarrhea, oliguria/anuria, meningismus
/meningeal irritation, sepsis / septic shock,
altered mental states or difficulty of breathing
and hemoptysis is considered LEPTOSPIROSIS
and BEST managed in a HEALTHCARE /
HOSPITALSETTING.

eptospirosis CPG 2010

Recommended for
patients suspected
leptospirosis

Leptospirosis CPG 2010

eptospirosis CPG 2010

Algorithm

EBM
DIAGNOSTIC ACCURACY OF RECOMBINANT
IMMUNOGLOBULIN-LIKE PROTEIN A-BASED
IGM ELISA FOR THE EARLY DIAGNOSIS OF
LEPTOSPIROSIS IN THE PHILIPPINES

Authors:
Jessica N. Ricaldi,
Department of Clinical Tropical Medicine, Institute of Tropical Medicine,
Nagasaki University Graduate School of Biomedical Science, Sakamoto,
Nagasaki, Japan
1

Department of Bacteriology I, National Institute of Infectious Diseases,

Toyama, Shinjuku-ku, Tokyo, Japan
2

San Lazaro Hospital, Santa Cruz, Manila, Republic of the Philippines

Department of Community Medicine, Kanazawa Medical University Himi

Municipal Hospital, Himi City, Toyama, Japan
4

Department of Infectious Diseases, Nagasaki University Hospital,

Sakamoto, Nagasaki, Japan
5

Department of Global Health, School of Tropical Medicine and Global

Health, Nagasaki University, Sakamoto, Nagasaki, Japan
6

Department of Clinical Research, London School of Hygiene and Tropical

Medicine, London, United Kingdom
7

Published: 2015 Jun 25

Abstract

Background: to evaluate the diagnostic accuracy

of a recombinant LigA protein based IgM ELISA
during outbreaks in the clinical-setting of a
highly endemic country.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4482399/#__abstr
actid1189167title

Population: 304 hospitalized patients who were

clinically suspected with leptospirosis

Intervention: whole cell-based IgM based ELISA

Method: prospective cohort study

Comparator: newly developed LigA-IgM ELISA

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4482399/#__abstr
actid1189167title

Outcome: The newly developed LigA-IgM ELISA is

more sensitive than the whole cell-based IgM based
ELISA. Although the final diagnosis must be
validated by more specific tests, LigA-IgM ELISA
could be a useful diagnostic test in a real clinicalsetting, where diagnosis is needed in the early
phase of infection.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4482399/#__abstr
actid1189167title

THANK YOU