Department of Internal Medicine, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka.
Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka.
PLoS Negl Trop Dis. 2023 Oct 16;17(10):e0011352. doi: 10.1371/journal.pntd.0011352. eCollection 2023 Oct.
Leptospirosis is a tropical disease associated with life threatening complications. Identifying clinical and investigation-based parameters that predict mortality and morbidity is vital to provide optimal supportive care.
We conducted an observational study in an endemic setting, in the southern Sri Lanka. Consecutive patients having complicated leptospirosis were recruited over 18 months. Clinical, investigational and treatment data were collected and the predictors of mortality were analysed.
Out of 88 patients having complicated leptospirosis, 89% were male. Mean age was 47yrs (±16.0). Among the total major complications 94.3% had acute kidney injury, 38.6% pulmonary haemorrhages, 12.5% fulminant hepatic failure, 60.2% hemodynamic instability and 33% myocarditis. An acute significant reduction of haemoglobin (Hb) was observed in 79.4% of patients with pulmonary haemorrhage. The mean of the highest haemoglobin reduction in patients with pulmonary haemorrhage was 3.1g/dL. The presence of pulmonary haemorrhage (PH) and hemodynamic instability within first 48 hours of admission significantly predicted mortality (p<0.05) in severe leptospirosis. Additionally, within first 48 hours of admission, elevated SGOT (AST), presence of atrial fibrillation, presence of significant haemoglobin reduction, higher number of inotropes used, prolonged shock, invasive ventilation and admission to ICU significantly predicted mortality. Out of major complications during the first week after admission, pulmonary haemorrhage and fulminant hepatic failure (FHF) combination had significant adjusted odds of mortality (OR = 6.5 and 4.8, p<0.05). Six patients with severe respiratory failure due to PH underwent ECMO and four survived. The overall mortality in complicated leptospirosis was 17%. In PH and FHF, the mortality rate was higher reaching 35.4% and 54.5%, respectively.
Within first 48 hours of admission, major complications such as pulmonary haemorrhage and haemodynamic instability and other parameters such as atrial fibrillation, acute haemoglobin reduction, elevated SGOT level could be used as early parameters predictive of mortality in severe leptospirosis. PH and FHF during the first week of admission in leptospirosis are associated with high morbidity and mortality requiring prolonged ICU care and hospitalisation. Above parameters could be used as parameters indicating severity for triaging and intensifying treatment. Using ECMO is a plausible treatment option in patients with severe pulmonary haemorrhage.
钩端螺旋体病是一种与危及生命的并发症相关的热带病。确定预测死亡率和发病率的临床和基于调查的参数对于提供最佳支持治疗至关重要。
我们在斯里兰卡南部的一个流行地区进行了一项观察性研究。在 18 个月的时间里，连续招募了患有复杂钩端螺旋体病的患者。收集了临床、检查和治疗数据，并分析了死亡率的预测因素。
在 88 名患有复杂钩端螺旋体病的患者中，94.3%为男性，平均年龄为 47 岁（±16.0）。在所有主要并发症中，94.3%有急性肾损伤，38.6%有肺出血，12.5%有暴发性肝衰竭，60.2%有血液动力学不稳定，33%有心肌炎。38.6%的患者有肺出血，血红蛋白（Hb）明显急性下降。肺出血患者中 Hb 下降最高平均值为 3.1g/dL。在严重钩端螺旋体病中，入院后 48 小时内出现肺出血（PH）和血液动力学不稳定显著预测死亡率（p<0.05）。此外，入院后 48 小时内，SGOT（AST）升高、心房颤动、血红蛋白显著下降、使用更多的正性肌力药、休克延长、有创通气和入住 ICU 显著预测死亡率。在入院后第一周的主要并发症中，肺出血和暴发性肝衰竭（FHF）的组合具有显著的死亡调整比值比（OR = 6.5 和 4.8，p<0.05）。6 名因 PH 导致严重呼吸衰竭的患者接受 ECMO 治疗，其中 4 名存活。复杂钩端螺旋体病的总死亡率为 17%。在 PH 和 FHF 中，死亡率更高，分别为 35.4%和 54.5%。
入院后 48 小时内，肺出血和血液动力学不稳定等主要并发症以及心房颤动、急性血红蛋白下降、AST 水平升高等其他参数可作为严重钩端螺旋体病死亡的早期预测参数。在钩端螺旋体病入院后第一周出现 PH 和 FHF 与高发病率和死亡率相关，需要延长 ICU 护理和住院时间。上述参数可作为分诊和强化治疗的严重程度参数。在严重肺出血患者中，使用 ECMO 是一种可行的治疗选择。
