Thanks to Merck Animal Health!

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1 Emergency management of the leptospirosis pa8ent Sponsorship Thanks to Merck Animal Health! Jus8ne A. Lee, DVM, DACVECC, DABT CEO, VetGirl Introduc8on Financial disclosure Jus8ne A. Lee, DVM, DACVECC, DABT CEO, VetGirl Introduc8on Garret Pach8nger, VMD, DACVECC COO, VetGirl VetGirl on the RUN! The tech- saavy way to get CE credit! A subscrip8on- based podcast and webinar service offering veterinary RACE- approved CE 1

2 Subscrip8on plans itunes Download!!! VetGirl Standard: podcasts/year $99/year 4 hours of RACE- CE VetGirl ELITE: podcasts/year plus 20 hours of webinars! $199/year 20+ hours of RACE- CE Find us on social media Blogs and Social h^p:// Logis8cs: CE Cer8ficates Call in from Smart Phone!! No need to raise your hand!! Type in ques8ons! ed to you 48 hours aber the webinar! Ac8ve par8cipa8on = no quiz! Watching video later, must complete quiz! ELITE members only! / contact with ANY ques8ons! garret@vetgirlontherun.com! jus8ne@vetgirlontherun.com 2

3 Goals of this lecture Leptospirosis Pathophysiology: Why do we care? Clinical signs Treatment Preven8on Zoono8c risk Leptospirosis Leptospira spp. Gram- nega8ve spirochete with hook ends Saprophy8c vs. pathogenic Saprophy8c: don t infect animals Pathogenic: Over 250 serovars Geographic regional differences Leptospirsosis: E8ology in dogs Species Serogroup Serovar Leptospira interrogans Icterohaemorrhagiae Canicola Pomona Australis Sejroe Autumnalis Icterohaemorrhagiae Canicola Pomona* Bra8slava Autumnalis? Leptospira kirschneri Grippotyphosa Grippotyphosa h^p://wwwnc.cdc.gov/eid/ar8cle/12/3/ htm Serovar L. grippotyphosa L. canicola Hosts Reservoir Host Raccoons, voles, skunks Dogs Leptospirsosis Prior to vaccines, most common serovars infec8ng dogs: L. Icterohaemorrhagiae and L. Canicola L. Pomona L. icterohaemorrhagiae Raccoons (?), skunks, pigs, ca^le (?) Rats, raccoons (?) Now: more L. Grippotyphosa, Pomona, Bra:slava, and Autumnalis(?) 3

4 Geographic distribu8on High rainfall; warm tropical loca8ons Humans: Caribbean, La8n America, India, Asia North America: Hawaii Dogs: (based on 8ters > 1,600) Hawaii West coast (CA, OR, WA) Upper midwest TX, CO, Northeast, mid- Atlan8c Increasing incidence? Chronic healthy carriers 8-20% Urban areas (Ward JAVMA 2004) Smaller dogs < 15 lbs! (Lee JVIM 2013) Past decade Male dogs How does it spread? Shed from renal tubules of domes8c & wild animals Infec8on through intact mm or abraded skin from urine Rarely: via bite wound, inges8on of infected 8ssue, venereal, placental transfer Can remain viable in soil for weeks to months Leptospirosis Likes warm (>30 C) Inac8vated by UV radia8on & freezing Risk factors: Slow- moving or stagnant water exposure Outbreaks seen aber higher rainfall Late fall Roaming dogs (rural) Urbanized wild animal exposure Rodent exposure Why are we seeing more lepto? Global warming? Warmer We^er Flooding Incuba8on Several days Replicates rapidly within 1 day of infec8on Urban growth: Invasion of humans into wildlife s environment Incuba8on period: 7 days, but dependent on dose, strain, geographical loca8on, host immune response 4

5 Malaise, lethargy Anorexia Vomi8ng Febrile Dehydra8on PU/PD Weight loss? Clinical signs RENAL + HEPATIC SIGNS = LEPTOSPIROSIS! Clinical signs: Renal Renal: 90% of the 8me! Inappetance Vomi8ng Diarrhea Malaise PU/PD Dehydra8on Abdominal pain Oliguric/anuria CKD Clinical signs: Hepa8c Hepa8c: 10-20% Inappetance Malaise Vomi8ng Melena Icterus Hepa8c failure Chronic ac8ve hepa88s Less common clinical signs Fever Shivering, mm tenderness, not moving Ocular Uvei8s, conjunc8vi8s Pulmonary Pulmonary hemorrhage Leptospiral pulmonary hemorrhage syndrome (LPHS) Tachypnea Dyspnea ARDS Vasculi8s Less common clinical signs Coagulopathy " hepa8c failure, DIC, vascular damage by spirochetes? Hemoptysis Melena Epistaxis Petechial hemorrhage Hematochezia Hematemesis Less common clinical signs Miscellaneous Hematuria Vasculi8s " Peripheral edema, pleural effusion, peritoneal effusion ECG altera8ons " myocardial damage (humans?) Abor8on (ca^le) 5

6 Yes but rare What about cats? Serologic evidence of exposure Canicola Grippotyphosa Pomona Can cause histopathologic changes Exposure through rodent contact? Prognosis for Leptospirosis Acute 80% survival Fair to good with immediate treatment $$$ Chronic Predisposed to chronic kidney disease Chronic renal inflamma8on Darby, 5 yo, MC Papillion, 5 kgs PC: 2 day history of vomi8ng and anorexia, ADR X 3 days; pu/pd X 2 days PMHX: UTD; on seasonal preventa8ve Diet: The Honest Kitchen diet Lives in St. Paul, MN Darby, 5 yo, MC Papillion, 5 kgs: Physical Examina8on 7% dehydrated Equivocally icteric mm Moderate pulse quality CRT = 2 seconds HR 170 Splints on abdominal palpa8on Moderate bladder Darby, 5 yo, MC, 5 kg Papillion: Plan IV catheter BIG 4 PCV/TS: 55%/8 BG: 133 mg/dl AZO: mg/dl Slightly icteric serum Darby, 5 yo, MC Papillion, 5 kg: Plan CBC Chemistry UA Urine culture - hold 6

7 Darby: Plan Darby: Clinicopathologic findings Start 150 mls Plyte148 over 30 minutes ml/kg bolus Why not LRS? Fluid plan? CBC WBC 18,500 Platelets: 150,000 PCV: 55% Chemistry: BUN: 88 Crea8nine 4.2 TBILI: 2.6 AST: 800 ALT: 1200 ALP: 522 TP: 8 Leptospirosis: Clinicopathologic findings Neutrophilia Leb shib Lymphopenia Hemoconcentra8on Non- regenera8ve anemia Hemolysis (ca^le) Thrombocytopenia (58%) Azotemia (> 80-90%) # ALT, AST, ALP, TBILI (almost always seen with azotemia) Hypokalemia Hyperphosphatemia # CK Leptospirosis: Clinicopathologic findings Isosthenuria Bilirubinuria Hematuria Glucosuria Proteinuria? # fibrinogen, D- dimers, FDP Prolonged PT/PTT (6-50%) Any other diagnos8cs? Coagula8on panel: R/O DIC Chest radiographs Nodular inters88al to alveolar pa^erns Abdominal ultrasound Renomegaly Perirenal fluid accumula8on Pylectasia Medullary band of increased echogenicity Increased cor8cal echogenicity Mild abdominal lymphadenopathy DIAGNOSING LEPTOSPIROSIS 7

8 Microscopic agglu8na8on test (MAT) Standard test, most frequently used Looks for presence of an8bodies to leptospiral an8gens Tests for highest serum dilu8on causing agglu8na8on of 50% of the leptospires Tests for typically: canicola, icterohaemorrhagiae, pomona, grippotyphosa, hardjo, bra:slava Highest an8body 8ter = infec8ng serovar Some cross- reac8vity? MAT Interpret results based on: Dura8on of disease Vaccine status of pa8ent 1:100-1:400, occasionally as high as 1:3200 Persist for 6 months May cross- react with other serovars (<1:100) Prior an8bio8c therapy? " blunt rise of an8body 8ter Titer of > 1:800 with compa8ble clinical signs and lab tests = Leptospirosis Nega8ve 8ters early in course of disease Typically in 1 st week of illness Doing convalescent 8ters 2-4 weeks later? 4 fold increase = recent infec8on Poor laboratory quality control Other diagnos8c tests for leptospirosis? Darkfield microscopy (dark ages) Low specificity Technically difficult Silver staining renal biopsy 8ssue Low sensi8vity & specificity False nega8ves Fluorescent an8body tes8ng & PCR: urine or 8ssue PCR: affected by an8bio8c therapy! Idexx leptospirosis PCR & an8body ELISA in- clinic test Darby s fluid plan 5 kgs X 60 ml/kg/day = 300 mls/day = 13 mls/ hr 7% dehydra8on X 5 kgs = 350 mls Replace dehydra8on over 12 hours: 30 ml/hr Ongoing pu/pd? Plyte- 148 at 50 mls/hr Treatment Goal of assessing hydra8on Hemodilu8on (PCV/TS 35/5) Isosthenuria (aim for ) Drinking water in the cage Weight gain " weigh q. 6 Why is weight so important? 5 kgs mls of dehydra8on = 5.4 kgs 8

9 Normal: 1-2 ml/kg/hour URINE OUTPUT Oliguric: 0.5 ml/kg/hour Decreased renal func8on or your fault? sp. gr. > Solve with IVF not furosemide (yet!) Anuric: < 0.5 ml/kg/hour Blood- 8nged urine Simple! Calcula8ng ins and outs If FUO urinates 160 mls over 4 hours UOP $ 160/4 = 40 ml/hour If you gave 80 mls of IV fluids over 4 hours 80/4 = 20 ml/hour In vs. out? Darby Treatment: Blood pressure monitoring UOP monitoring (UCS) Polyuric at 6 ml/kg/hour Treatment: GI support Suspect uremic ulcers Omeprazole or pantoprazole 1 mg/kg q 24 or Famo8dine 1 mg/kg IV q 12 Phosphate binder PO q. 6-8 BUN mg/dl Creat mg/dl UOP Fluid rate PCV TS kg Day Polyuric 50 ml/hr 55 8 Day 1 Polyuric 50 ml/hr 40 7 Day Polyuric 50 ml/hr 35 5 Day Polyuric 30 ml/hr Sucralfate 250 mg PO q. 8 An8- eme8cs (e.g., maropitant 1 mg/kg IV q 24) Treatment: An8bio8c therapy Goals: Eliminate leptospiremia Eliminate organisms from the renal tubular cells and renal carrier state An8bio8cs: Penicillin- type Penicillin 25,000-40,000 U/kg q 12 IV or IM for 14 days) Ampicillin, amoxicillin, amoxicillin/clavulanic acid X 14 days Doxycycline (5-10 mg/kg BID PO X 14 days) Symptoma8c suppor8ve care Monitoring UOP Blood pressure Baseline renal panel/pcv/ts/elytes Nutri8onal support 9

10 Prognosis Fair to good, but risk for CRF Treat aggressively Why preven8on is impera8ve Small dogs: 90% rats trapped in inner ci8es were carrying leptospirosis (PCR, Vinetz et al, 1996) Zoono8c risk Start appropriate an8bio8cs immediately Pre- treatment blood work! Gloves/proper hygiene when handling bodily fluids (e.g., blood, urine, 8ssue) Wash hands aber handling pets Disinfect with iodine- based solu8ons Vaccinate other pets in the house Preven8on! Discuss zoono8c risk with owners Rodent control/fencing from wild animals Decrease access to swampy, marshy areas Preven8on: Vaccines To vaccinate or not to vaccinate? Leptospirosis endemic yes! 2- way (old) vs. 4- way (new!) Leptospira Canicola, Grippotyphosa, Icterohaemorrhagiae, Pomona Vaccines Annual vaccina8on with 4- serovar vaccines Regardless of breed At- risk (e.g., urban, backyard, roaming, swimmer, hunters, etc.) Wide margin of safety; adequate protec8on and coverage Ideally, use a vaccine that: Protects against disease and mortality Prevents shedding of leptospires in urine to prevent zoono8c risk and exposure To Merck! Special thank you! Free Merck webinars on VetGirl! Download Leptospirosis proceedings at: h^p://vetgirlontherun.com/proceedings- publica8ons- veterinary- con8nuing- educa8on- podcasts- webinars/page/2/ 10

11 Check out our upcoming VetGirl appearances! Questions? Dr. Jus=ne Lee Oct 1-3, Asian Pacific Veterinary Conference, Bangkok, Thailand. October 13-16, 2014 Atlan8c Coast Veterinary Conference. Atlan8c City, NJ NAVC 2015 WVC 2015 Dr. Garret Pach=nger October 13-16, 2014 Atlan8c Coast Veterinary Conference. Atlan8c City, NJ NAVC VetGirlOnTheRun Garret@vetgirlontherun.com Jus8ne@vetgirlontherun.com This material is copyrighted by VetGirl, LLC. None of the materials provided may be used, reproduced or transmi^ed, in whole or in part, in any form or by any means, electronic or otherwise, including photocopying, recording or the use of any informa8on storage and retrieval system, without the consent of VetGirl, LLC. Unless expressly stated otherwise, the findings, interpreta8ons and conclusions expressed do not necessarily represent the views of VetGirl, LLC. Medical informa8on here should be references by the prac88oner prior to use. Under no circumstances shall VetGirl, LLC. be liable for any loss, damage, liability or expense incurred or suffered that is claimed to have resulted from the use of the informa8on provided including, without limita8on, any fault, error, omission, interrup8on or delay with respect thereto. If you have any ques8ons regarding the informa8on provided, please contact info@vetgirlontherun.com 11