Epidemic Leptospirosis Associated with Pulmonary Hemorrhage—Nicaragua, 1995

Abstract

In October 1995, epidemic "hemorrhagic fever," without jaundice or renal manifestations, was reported in rural Nicaragua following heavy flooding; 2259 residents were evaluated for nonmalarial febrile illnesses (cumulative incidence, 6.1%) and 15 (0.7%) died with pulmonary hemorrhage. A case-control study found that case-patients were more likely than controls to have ever walked in creeks (matched odds ratio [MOR], 15.0; 95% confidence interval [CI], 1.7-132.3), have household rodents (MOR, 10.4; 95% CI, 1.1-97.1), or own dogs with titers >/=400 to Leptospira species (MOR, 23.4; 95% CI, 3.6-infinity). Twenty-six of 51 case-patients had serologic or postmortem evidence of acute leptospirosis. Leptospira species were isolated from case-patients and potential animal reservoirs. This leptospirosis epidemic likely resulted from exposure to flood waters contaminated by urine from infected animals, particularly dogs. Leptospirosis should be included in the differential diagnosis for nonmalarial febrile illness, particularly during periods of flooding or when pulmonary hemorrhage occurs.

HLA-DQ6 and ingestion of contaminated water: possible gene–environment interaction in an outbreak of Leptospirosis

“…Most study subjects were homozygous TNF1 or heterozygous at this site; two individuals were TNF2 homozygous (Datasheets A and D, see Supplementary Information). In all, 13 HLA-DR genotypes 1,3,4,[7][8][9][10][11][12][13][14][15][16] were identified within this cohort; the HLA-DR genotype was unambiguous for all 85 specimens. Bivariate analysis of laboratory-confirmed cases showed no TNF-a polymorphism or HLA-DR genotype significantly associated with case-status (Data-sheets A and D, see Supplementary Information).…”

“…However, symptoms can vary widely; while some studies suggest a high prevalence of subclinical infection, [4][5][6][7] 5-10% of symptomatic disease involves severe complications including liver or kidney dysfunction, pulmonary hemorrhage or cardiovascular collapse. [8][9][10][11] Although pathogen virulence factors may contribute to some differences in clinical presentation, 1 the diversity of the disease presentation and course suggests that immune response factors play a role in modulating susceptibility to or severity of leptospirosis.…”

Leptospirosis in the tropics and in travelers

“…An epidemic of leptospirosis in Nicaragua [2] brought pulmonary hemorrhage as a complication to international attention, although this manifestation had been previously well recognized to affect populations in leptospirosis-endemic regions, for example in the Andaman Islands [51]. Curiously, in the epidemic of severe leptospirosis in Salvador, Brazil, originally described by Ko et al [52••], pulmonary hemorrhage was not observed.…”

“…Placement of livestock ranches away from rivers and creeks would help in preventing contamination of suburban and rural water sources. Flooding in other regions (such as Brazil, India, Nicaragua, Andaman Islands) has been strongly associated with leptospirosis transmission [51], likely by mobilizing leptospires from ground sources into flowing water where people walk and swim [2,45,67,68]. Whether leptospirosis will emerge as an important disease in the recent hurricaneassociated flooding along the Gulf Coast remains to be seen.…”

“…It is commonly overlooked as a cause either of undifferentiated fever or fulminant, multisystem disease. The severe pulmonary form of leptospirosis manifesting as hemorrhage has globally emerged as a clinical important form of this disease [1][2][3]4••]. In recent years, leptospirosis has increasingly been recognized as an urban disease in both industrialized and developing countries [5,6], as an endemic disease with substantial morbidity in tropical settings [4••,7,8•], and, increasingly, as a disease associated with exotic exposures, whether among adventure travelers [9][10][11][12][13] or military personnel [14].…”