Early Indicators of Fatal Leptospirosis during the 2010 Epidemic in Puerto Rico.
Early Indicators of Fatal Leptospirosis during the 2010 Epidemic in Puerto Rico.
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2010年波多黎各流行病期间致命的钩端螺旋体病的早期指标。
DOI：
10.1371/journal.pntd.0004482
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发表时间：
2016-02
影响因子：
3.8
通讯作者：
Bower WA
中科院分区：
文献类型：
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作者：
Sharp TM;Rivera García B;Pérez-Padilla J;Galloway RL;Guerra M;Ryff KR;Haberling D;Ramakrishnan S;Shadomy S;Blau D;Tomashek KM;Bower WA
钩端螺旋体病是一种潜在致命的细菌性人畜共患病，在整个热带地区流行，可能被误诊为登革热。钩端螺旋体病患者延迟住院与死亡率增加有关。2010年在波多黎各同时发生登革热/钩端螺旋体病流行期间，对登革热检测呈阴性的登革热疑似患者进行了钩端螺旋体病检测。致死性和非致死性住院钩端螺旋体病患者按年龄1:1-3匹配。评估了所有就诊记录中与死亡结果相关的因素。在175例确诊的钩端螺旋体病患者中（每10万居民4.7例），26例（15%）死亡。多数患者为老年男性，发病时间为雨季。死亡病例患者首次就诊时间早于非死亡对照患者（发病后2.5天vs. 5天[DPO]， p < 0.01），但首次就诊频率低于非死亡对照患者（52.4% vs. 92.2%, p < 0.01）。虽然死亡病例在首次就诊时诊断为钩端螺旋体病的比例更高（43.9%比9.6%,p = 0.01），但他们入院的时间并不早于非致命对照组（4.5比6，p = 0.31）。发热发生率较低（p = 0.03），而黄疸、水肿、腿痛、咯血、癫痫发作发生率较高（p≤0.03）。首次就诊时与致命结果相关的实验室值的多变量分析包括白细胞（WBC）计数增加与肌酐升高（p = 0.001），碳酸氢盐减少与白细胞计数增加、肌酐升高或血小板计数减少（p < 0.001）。致死性钩端螺旋体病患者更早寻求治疗，但不比非致死性患者更早入院治疗。在对疑似钩端螺旋体病患者进行入院决策时，应考虑预测致命结局的常规实验室值组合。钩端螺旋体病是一种常见的热带疾病，由接触感染了钩端螺旋体细菌的动物的尿液引起。由于钩端螺旋体病与登革热等其他常见热带疾病具有相同的体征和症状，因此对钩端螺旋体病患者的识别可能具有挑战性。钩端螺旋体病患者的早期识别是必要的，以便开始抗生素治疗，并在某些情况下提供院内管理。在波多黎各发生的钩端螺旋体病流行与登革热同时流行期间，我们通过筛查疑似登革热患者的标本确定了钩端螺旋体病患者。在175例确诊的钩端螺旋体病患者中，26例（15%）死亡。在将死亡的钩端螺旋体病患者与住院但存活的年龄相仿的患者进行比较后，我们观察到，致命病例在首次就诊后更常被送回家。接下来，我们从患者第一次就诊中确定了与死亡患者相关的几个常规可用的实验室值。临床医生可以使用这些实验室值来诊断和治疗致命风险增加的钩端螺旋体病患者。
Leptospirosis is a potentially fatal bacterial zoonosis that is endemic throughout the tropics and may be misdiagnosed as dengue. Delayed hospital admission of leptospirosis patients is associated with increased mortality. During a concurrent dengue/leptospirosis epidemic in Puerto Rico in 2010, suspected dengue patients that tested dengue-negative were tested for leptospirosis. Fatal and non-fatal hospitalized leptospirosis patients were matched 1:1–3 by age. Records from all medical visits were evaluated for factors associated with fatal outcome. Among 175 leptospirosis patients identified (4.7 per 100,000 residents), 26 (15%) were fatal. Most patients were older males and had illness onset during the rainy season. Fatal case patients first sought medical care earlier than non-fatal control patients (2.5 vs. 5 days post-illness onset [DPO], p < 0.01), but less frequently first sought care at a hospital (52.4% vs. 92.2%, p < 0.01). Although fatal cases were more often diagnosed with leptospirosis at first medical visit (43.9% vs. 9.6%, p = 0.01), they were admitted to the hospital no earlier than non-fatal controls (4.5 vs. 6 DPO, p = 0.31). Cases less often developed fever (p = 0.03), but more often developed jaundice, edema, leg pain, hemoptysis, and had a seizure (p ≤ 0.03). Multivariable analysis of laboratory values from first medical visit associated with fatal outcome included increased white blood cell (WBC) count with increased creatinine (p = 0.001), and decreased bicarbonate with either increased WBC count, increased creatinine, or decreased platelet count (p < 0.001). Patients with fatal leptospirosis sought care earlier, but were not admitted for care any earlier than non-fatal patients. Combinations of routine laboratory values predictive of fatal outcome should be considered in admission decision-making for patients with suspected leptospirosis. Leptospirosis is a common tropical illness that results from exposure to the urine of animals infected with Leptospira bacteria. Because leptospirosis shares signs and symptoms with other common tropical illnesses such as dengue, identification of patients with leptospirosis can be challenging. Early identification of patients with leptospirosis is necessary to initiate antibiotic therapy and in some cases provide in-hospital management. During an epidemic of leptospirosis in Puerto Rico that occurred during a concomitant dengue epidemic, we identified leptospirosis patients by screening specimens from suspected dengue patients. Of 175 leptospirosis patients identified, 26 (15%) died. After comparing leptospirosis patients that died to patients of a similar age that were hospitalized but survived, we observed that fatal cases were more often sent home after their first medical visit. We next identified several routinely available laboratory values from patients’ first medical visit that were associated with patients that died. Clinicians can use such laboratory values to diagnose and hospitalize leptospirosis patients at increased risk for fatal outcome.