Emergency management of the leptospirosis pa3ent. Jus3ne A. Lee, DVM, DACVECC, DABT CEO, VetGirl
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1 Emergency management of the leptospirosis pa3ent Jus3ne A. Lee, DVM, DACVECC, DABT CEO, VetGirl
2 Financial disclosure Jus3ne A. Lee, DVM, DACVECC, DABT CEO, VetGirl Consultant, Merck
3 Goals of this lecture Leptospirosis Pathophysiology: Why do we care? Clinical signs Treatment Preven3on Zoono3c risk
4 Leptospirosis Leptospira spp. Gram- nega3ve spirochete with hook ends Saprophy3c vs. pathogenic Saprophy3c: don t infect animals Pathogenic: Over 250 serovars Geographic regional differences
5 htp://wwwnc.cdc.gov/eid/ar3cle/12/3/ htm
6 Leptospirsosis: E3ology in dogs Species Serogroup Serovar Leptospira interrogans Icterohaemorrhagiae Canicola Pomona Australis Sejroe Autumnalis Icterohaemorrhagiae Canicola Pomona* Bra3slava Autumnalis? Leptospira kirschneri Grippotyphosa Grippotyphosa
7 Hosts Serovar L. grippotyphosa Reservoir Host Raccoons, voles, skunks L. canicola L. Pomona L. icterohaemorrhagiae Dogs Raccoons (?), skunks, pigs, catle (?) Rats, raccoons (?)
8 Leptospirsosis Prior to vaccines, most common serovars infec3ng dogs: L. Icterohaemorrhagiae and L. Canicola Now: more L. Grippotyphosa, Pomona, Bra9slava, and Autumnalis(?)
9 Geographic distribu3on High rainfall; warm tropical loca3ons Humans: Caribbean, La3n America, India, Asia North America: Hawaii Dogs: (based on 3ters > 1,600) Hawaii West coast (CA, OR, WA) Upper midwest TX, CO, Northeast, mid- Atlan3c, SE
10 Increasing incidence? Chronic healthy carriers 8-20% Urban areas (Ward JAVMA 2004) Smaller dogs < 15 pounds! (Lee JVIM 2013) Past decade Male dogs
11 How does it spread? Shed from renal tubules of domes3c & wild animals Infec3on through intact mm or abraded skin from urine Rarely: via bite wound, inges3on of infected 3ssue, venereal, placental transfer Can remain viable in soil for weeks to months
12 Leptospirosis Likes warm (>30 C) Inac3vated by UV radia3on & freezing Risk factors: Slow- moving or stagnant water exposure Outbreaks seen aper higher rainfall Late fall Roaming dogs (rural) Urbanized wild animal exposure Rodent exposure
13 Why are we seeing more lepto? Global warming? Warmer WeTer Flooding Urban growth: Invasion of humans into wildlife s environment
14 Incuba3on Several days Replicates rapidly within 1 day of infec3on Incuba3on period: 7 days, but dependent on dose, strain, geographical loca3on, host immune response
15 Malaise, lethargy Anorexia Vomi3ng Febrile Dehydra3on PU/PD Weight loss? Clinical signs RENAL + HEPATIC SIGNS = LEPTOSPIROSIS!
16 Clinical signs: Renal Renal: 90% of the 3me! Inappetance Vomi3ng Diarrhea Malaise PU/PD Dehydra3on Abdominal pain Oliguric/anuria CKD
17 Clinical signs: Hepa3c Hepa3c: 10-20% Inappetance Malaise Vomi3ng Melena Icterus Hepa3c failure Chronic ac3ve hepa33s
18 Less common clinical signs Fever Shivering, mm tenderness, not moving Ocular Uvei3s, conjunc3vi3s Pulmonary Pulmonary hemorrhage Leptospiral pulmonary hemorrhage syndrome (LPHS) Tachypnea Dyspnea ARDS Vasculi3s
19 Less common clinical signs Coagulopathy à hepa3c failure, DIC, vascular damage by spirochetes? Hemoptysis Melena Epistaxis Petechial hemorrhage Hematochezia Hematemesis
20 Less common clinical signs Miscellaneous Hematuria Vasculi3s à Peripheral edema, pleural effusion, peritoneal effusion ECG altera3ons à myocardial damage (humans?) Abor3on (catle)
21 What about cats? Yes but rare Serologic evidence of exposure Canicola Grippotyphosa Pomona Can cause histopathologic changes Exposure through rodent contact?
22 Prognosis for Leptospirosis Acute 80% survival Fair to good with immediate treatment $$$ Chronic Predisposed to chronic kidney disease Chronic renal inflamma3on
23 Darby, 5 yo, MC Papillion, 5 kgs PC: 2 day history of vomi3ng and anorexia, ADR X 3 days; pu/pd X 2 days PMHX: UTD; on seasonal preventa3ve Diet: On The Honest Kitchen diet Lives in St. Paul, MN
24 Darby, 5 yo, MC Papillion, 5 kgs: Physical Examina3on 7% dehydrated Equivocally icteric mm Moderate pulse quality CRT = 2 seconds HR 160 Splints on abdominal palpa3on Moderate bladder
25 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
26 Darby, 5 yo, MC Papillion, 5 kg: Plan CBC Chemistry UA Urine culture - hold
27 Darby: Plan Start 150 mls Plyte148 over 30 minutes ml/kg bolus Why not LRS? Fluid plan?
28 Darby: Clinicopathologic findings CBC WBC 18,500 Platelets: 150,000 PCV: 55% Chemistry: BUN: 88 Crea3nine 4.2 TBILI: 2.6 AST: 800 ALT: 1200 ALP: 522 TP: 8
29 Leptospirosis: Clinicopathologic findings Neutrophilia Lep ship Lymphopenia Hemoconcentra3on Non- regenera3ve anemia Hemolysis (catle) Thrombocytopenia (58%) Azotemia (> 80-90%) é ALT, AST, ALP, TBILI (almost always seen with azotemia) Hypokalemia é CK
30 Leptospirosis: Clinicopathologic findings Isosthenuria Bilirubinuria Hematuria Glucosuria Proteinuria? é fibrinogen, D- dimers, FDP Prolonged PT/PTT (6-50%)
31 Any other diagnos3cs? Coagula3on panel: R/O DIC Chest radiographs Nodular inters33al to alveolar paterns Abdominal ultrasound Renomegaly Perirenal fluid accumula3on Pylectasia Medullary band of increased echogenicity Increased cor3cal echogenicity Mild abdominal lymphadenopathy
32 DIAGNOSING LEPTOSPIROSIS
33 Microscopic agglu3na3on test (MAT) Standard test, most frequently used Looks for presence of an3bodies to leptospiral an3gens Tests for highest serum dilu3on causing agglu3na3on of 50% of the leptospires Tests for typically: canicola, icterohaemorrhagiae, pomona, grippotyphosa, hardjo, bra9slava Highest an3body 3ter = infec3ng serovar Some cross- reac3vity? Poor laboratory quality control
34 MAT Interpret results based on: Dura3on of disease Vaccine status of pa3ent 1:100-1:400, occasionally as high as 1:3200 Persist for 6 months May cross- react with other serovars (<1:100) Prior an3bio3c therapy? à blunt rise of an3body 3ter Titer of > 1:800 with compa3ble clinical signs and lab tests = Leptospirosis Nega3ve 3ters early in course of disease Typically in 1 st week of illness Doing convalescent 3ters 2-4 weeks later? 4 fold increase = recent infec3on
35 Other diagnos3c tests for leptospirosis? Darkfield microscopy (dark ages) Low specificity Technically difficult Silver staining renal biopsy 3ssue Low sensi3vity & specificity False nega3ves Fluorescent an3body tes3ng & PCR: urine or 3ssue PCR: affected by an3bio3c therapy! Idexx leptospirosis PCR & an3body ELISA in- clinic test
36
37 Darby s fluid plan 5 kgs X 60 ml/kg/day = 300 mls/day = 13 mls/ hr 7% dehydra3on X 5 kgs = 350 mls Replace dehydra3on over 12 hours: 30 ml/hr Ongoing pu/pd?
38 Plyte- 148 at 50 mls/hr Treatment Goal of assessing hydra3on Hemodilu3on (PCV/TS 35/5) Isosthenuria (aim for ) Drinking water in the cage Weight gain à weigh q. 6 Why is weight so important? 5 kgs mls of dehydra3on = 5.4 kgs
39 Normal: 1-2 ml/kg/hour URINE OUTPUT Oliguric: 0.5 ml/kg/hour Decreased renal func3on or your fault? sp. gr. > Solve with IVF not furosemide (yet!) Anuric: < 0.5 ml/kg/hour Blood- 3nged urine
40 Calcula3ng ins and outs Simple! If FUO urinates 160 mls over 4 hours UOP è 160/4 = 40 ml/hour If you gave 80 mls of IV fluids over 4 hours 80/4 = 20 ml/hour In vs. out?
41 Treatment: Darby Blood pressure monitoring UOP monitoring (UCS) Polyuric at 6 ml/kg/hour BUN mg/dl Creat mg/dl UOP Fluid rate PCV TS kg Day Polyuric 50 ml/hr Day 1 Polyuric 50 ml/hr Day Polyuric 50 ml/hr Day Polyuric 30 ml/hr
42 Treatment: GI support Suspect uremic ulcers Omeprazole or pantoprazole 1 mg/kg q 24 or Famo3dine 1 mg/kg IV q 12 Phosphate binder PO q. 6-8 Sucralfate 250 mg PO q. 8 An3- eme3cs (e.g., maropitant 1 mg/kg IV q 24)
43 Treatment: An3bio3c therapy Goals: Eliminate leptospiremia Eliminate organisms from the renal tubular cells and renal carrier state An3bio3cs: 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)
44 Symptoma3c suppor3ve care Monitoring UOP Blood pressure Baseline renal panel/pcv/ts/elytes Nutri3onal support
45 Prognosis Fair to good, but risk for CRF Treat aggressively Why preven3on is impera3ve Small dogs: 90% rats trapped in inner ci3es were carrying leptospirosis (PCR, Vinetz et al, 1996)
46 Zoono3c risk Start appropriate an3bio3cs immediately Pre- treatment blood work! Gloves/proper hygiene when handling bodily fluids (e.g., blood, urine, 3ssue) Wash hands aper handling pets Disinfect with iodine- based solu3ons Vaccinate other pets in the house
47 Preven3on! Discuss zoono3c risk with owners Rodent control/fencing from wild animals Decrease access to swampy, marshy areas
48 Preven3on: Vaccines To vaccinate or not to vaccinate? Leptospirosis endemic yes! 2- way (old) vs. 4- way (new!) Leptospira Canicola, Grippotyphosa, Icterohaemorrhagiae, Pomona
49 Vaccines Annual vaccina3on with 4- serovar vaccines Regardless of breed At- risk (e.g., urban, backyard, roaming, swimmer, hunters, etc.) Wide margin of safety; adequate protec3on and coverage Ideally, use a vaccine that: Protects against disease and mortality Prevents shedding of leptospires in urine to prevent zoono3c risk and exposure
50 Special thank you! To Merck! Free Merck webinars on VetGirl! Download Leptospirosis proceedings at: htp://vetgirlontherun.com/proceedings- publica3ons- veterinary- con3nuing- educa3on- podcasts- webinars/page/2/
51 Dr Jus3ne Lee This material is copyrighted by VetGirl, LLC. None of the materials provided may be used, reproduced or transmited, in whole or in part, in any form or by any means, electronic or otherwise, including photocopying, recording or the use of any informa3on storage and retrieval system, without the consent of VetGirl, LLC. Unless expressly stated otherwise, the findings, interpreta3ons and conclusions expressed do not necessarily represent the views of VetGirl, LLC. Medical informa3on here should be references by the prac33oner 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 informa3on provided including, without limita3on, any fault, error, omission, interrup3on or delay with respect thereto. If you have any ques3ons regarding the informa3on provided, please contact
Thanks to Merck Animal Health!
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