Weil's Disease-Immunopathogenesis, Multiple Organ Failure, and Potential Role of Gut Microbiota.

Leptospirosis is an important zoonotic disease, causing about 60,000 deaths annually. In this review, we have described in detail the immunopathogenesis of leptospirosis, the influence of cytokines, genetic susceptibility on the course of the disease, and the evasion of the immune response. These data are combined with information about immunological and pathomorphological changes in the kidneys, liver, and lungs, which are most affected by Weil's disease. The review also suggests a possible role of the gut microbiota in the clinical course of leptospirosis, the main mechanisms of the influence of gut dysbiosis on damage in the liver, kidneys, and lungs through several axes, i.e., gut-liver, gut-kidney, and gut-lungs. Modulation of gut microbiota by probiotics and/or fecal microbiota transplantation in leptospirosis may become an important area of scientific research.

Reversal of renal tubule transporter downregulation during severe leptospirosis with antimicrobial therapy.

Tubular dysfunction is a hallmark of severe leptospirosis. Antimicrobial therapy is thought to interfere on renal involvement. We evaluated the expression of a proximal tubule type-3 Na+/H+ exchanger (NHE3) and a thick ascending limb Na+-K+-2Cl(-) cotransporter (NKCC2) in controls and treated hamsters. Animals infected by a serovar Copenhageni isolate, were treated or not with ampicillin (AMP) and/or N-acetylcysteine (NAC). Leptospiral antigen(s) and expression of renal transporters were evaluated by immunohistochemistry, and serum thiobarbituric acid (TBARS) was quantified. Infected hamsters had high amounts of detectable leptospiral antigen(s) in target tissues while renal expression of NHE3 and NKCC2 decreased. Ampicillin treatment was associated with minimal or no detection of leptospiral antigens, normal expression of NHE3 and NKCC2 transporters, and reduced levels of TBARS. NAC effect was restricted to lowering TBARS. Early and late AMP treatment rescued tubular defects in severe leptospirosis disease, and there was no evidence of benefit from antioxidant therapy.

Leptospirosis: clinical presentation and correlation with serovars.

A total of 2400 patients with pyrexia of unknown origin and or suspected leptospirosis were included in this study. Dark field microscopy detected Leptospira in 690 cases, Leptospira serological Investigations proved positive in 570 out of these 690 patients. Among them 212 had the classical icteric and the other 358 had anicteric type of presentation. Notably eptospira interrogans serovar ictero haemorrhagiae infection was encountered in 212 patients. In 30 patients, who had multi organ dysfunction which included renal failure, hepatic dysfunction or meningitis was due to Leptospira interrogans Serovar cannicola. Coexsistense of leptospirosis and hepatitis B virus infection were noted in 15 patients. Antibody to Leptospira interrogans was demonstrated by Micro agglutination test (MAT) in addition to dark field microscopy positivity in these cases. Similarly HIV antibody was demonstrated in 30 of the 330 anicteric patients. 554 out of 570 cases responded to intra venous penicillin (216), and oral Doxycycline (182) and Augmentin (156), and the remaining 16 patients succumbed to death.

[Clinicomorphological characteristics of icterohemorrhagic leptospirosis].

Thirty three cases of death from icterohemorrhagic leptospirosis were clinically and morphologically analyzed. The disease is characterized by the affliction of two major target organs: the kidney and liver. Infectious-toxic shock underlies the pathogenesis of specific fetal complications of icterohemorrhagic leptospirosis. In the latter, acute renal-hepatic failure is always followed by the structural damage and dysfunction of other organs, which are less pronounced and, at the same time, presents multiple organ dysfunction.

[Leptospirosis: report of a fulminant fatal case and review]. / Leptospirosis: presentación de una infección fulminante y revisión de la literatura.

In relation to the explosive increase of new and reemerging infectious diseases that threaten the humanity, and as a result of this clinical case, a literature review is done on Leptospirosis stressing out the necessity of having in mind the leptospirosis in the differential diagnostic for fever and jaundice syndrome.

Lung lesions in human leptospirosis: microscopic, immunohistochemical, and ultrastructural features related to thrombocytopenia.

Lung fragments from 12 patients were collected immediately after death and studied by light and electron microscopy and by immunohistochemistry to describe the main morphologic and ultrastructural aspects of the lung and platelets in leptospirosis (Weil's syndrome), to search for the possibility of disseminated intravascular coagulation (DIC), and to assess the relationship between endothelial lesions and local platelet aggregation and the leptospiral antigen distribution, as well as its relationship with the intensity of the lesions. The immunohistochemical results for fibrin aggregates were positive in the lumen and/or on the vascular endothelium in nine cases and on the alveolar surface in seven cases, leading to the diagnosis of the adult respiratory distress syndrome in these seven cases. Test results for leptospiral antigen by immunohistochemistry were positive in eight cases with no direct relationship between antigen deposits in the pulmonary vascular endothelium and intensity of the lesions. The ultrastructural findings were uniform and constant. Capillary lesions were characterized by swelling of endothelial cells, an increase in pinocytotic vesicles, and giant dense bodies in the cytoplasm of these cells. No necrosis, rupture, nor exposed subendothelial collagen was observed outside the hemorrhagic areas, and the intercellular junctions were preserved. The lung involvement in severe human leptospirosis presents as hemorrhagic pneumopathy with septal capillary lesions that are the usual cause of death. The thrombocytopenia that was verified in 11 of 12 patients in our study seems to bear no relationship to DIC and seems to be determined by activation, adhesion, and aggregation of platelets to the stimulated vascular endothelium, with an amorphous electron-dense substance between the endothelial cells and the adherent platelets in places where the subendothelial collagen was not exposed.

Leptospirosis in Chonbuk Province of Korea in 1987: a study of 93 patients.

Leptospirosis is a zoonosis with protean clinical manifestation. Diagnosis requires a high index of suspicion and is confirmed by isolation of the organism or, more commonly, by serologic studies. In the fall of 1987, after severe flooding, we saw 93 patients with leptospirosis, confirmed by a microagglutination test. Thirteen percent of the patients had no clinical or laboratory findings except fever and headache, but the rest had mild to severe manifestations. Jaundice, renal failure, and aseptic meningitis were not common, but pulmonary symptoms, when present, were striking. The mortality rate was 5%. The main cause of death was asphyxiation due to massive hemoptysis from pulmonary hemorrhage and acute respiratory failure.

In vivo apoptosis of hepatocytes in guinea pigs infected with Leptospira interrogans serovar icterohaemorrhagiae.

To investigate the contribution of the previously demonstrated in vitro apoptosis to the pathogenesis of leptospirosis, guinea pigs were infected with Leptospira interrogans serovar icterohaemorrhagiae strain Verdun and sequentially killed to collect target organs involved in the natural history of the disease (liver, kidneys, lungs, spleen and heart). The combination of histopathological procedures and a specific TUNEL assay showed a significant Leptospira-induced programmed cell death of hepatocytes with a peak at 48 h post inoculation. Hepatocyte nuclei showed morphological changes including fragmented and condensed nuclei. This phenomenon occurred early in the course of the disease at a time where infecting leptospires were present at a low density between the liver parenchyma cells.

The route of entry of leptospires into the kidney tubule.

To study the migration of Leptospira interrogans serotype pomona through the kidney, conventionally-reared mice aged 2 or 3 weeks were infected intraperitoneally with this organism. Within the first 4 days, the organisms migrated from the capillary lumina to the interstitial tissue and provoked an interstitial oedema. By the 10th day they were seen between the epithelial cells of the proximal convoluted tubules and by the 14th day many were located within tubular lumina. There was no evidence of viable leptospires within the cells of the proximal tubules, though occasionally structures resembling leptospiral fragments inside lysosomes were observed. At no stage during the study were glomerular lesions seen.

Superoxide dismutase activity and lipid peroxidation in the liver of guinea pig infected with Leptospira interrogans.

Superoxide dismutase (SOD) activity and the degree of lipid peroxidation were studied over a two week period in guinea pigs infected with Leptospira interrogans derived from wild mice. The total SOD activity in infected host liver increased by four-fold two days after infection; this was followed by a 20% decrease resulting in levels comparable to normal, uninfected liver. During the period of decreasing SOD activity after day two, the levels of TBA-reactive material (TBARS) are increased by three-fold in infected guinea pig, liver, compared to uninfected liver. The results indicate that SOD attenuates intracellular superoxide-mediated toxic effects in guinea pigs infected with L. interrogans. In addition, electron microscopy structure demonstrates correlated pathogenic shrinkage of mitochondrial and Kupffer cell structures.

Protective effects of serum thymic factor to Leptospira interrogans serovar Copenhageni infection in Mongolian gerbils.

The susceptibility to Leptospira interrogans serovar copenhageni in Mongolian gerbils treated with 10 micrograms of serum thymic factor (FTS) 1 day before infection was examined. Susceptibility of gerbils treated 5 times with 10 micrograms of FTS was also investigated. Mortality of FTS-treated gerbils was significantly lower than that of controls when small challenge doses were used. To analyse the FTS-induced resistance to leptospiral infection, natural killer (NK) cell activity and macrophage activity were studied. Macrophage activity was unaltered but NK cell activity was enhanced in FTS-treated gerbils, with or without leptospiral infection. Since no side-effects of FTS were observed, this compound should be considered for the treatment of leptospirosis.

Pathology of acute Leptospira interrogans serotype icterohaemorrhagiae infection in the Syrian hamster.

The pathology of acute Leptospira interrogans serotype icterohaemorrhagiae infection in the Syrian hamster was investigated up to 7 days after infection using histology, electron microscopy and an indirect fluorescence test for leptospires. The disease was characterized by the presence of many leptospires in the tissues, jaundice, leukocytosis, haemorrhages, endothelial alteration and thrombotic glomerulopathy. The leptospires were present intravascularly, in the interstitium penetrating between liver cells and tubular epithelial cells and in the tubular lumina. The presence of leptospires was not necessarily associated with lesions. These findings support both pathogenetic mechanisms suggested in the literature, namely: the ability of leptospires to penetrate actively between cells with detachment of tight junctions, without obvious lesions to the cells, and an immune-mediated process with immune complex formation and binding and activation of complement resulting in leukocytosis, thrombotic glomerulopathy, endothelial alteration and haemorrhages.

Incidence of leptospiral abortion in Brazilian dairy cattle.

We examined dams' paired serum samples and foetal kidneys (histopathologically and attempting leptospiral cultures) from 120 Brazilian Holstein abortions from 10 herds near Sao Paulo, Brazil, in 1996. Leptospiras was isolated from 15 foetuses. The Leptospira interrogans serovar hardjo was obtained from four, pomona from three and wolffi from eight foetuses. Ten of these 15 foetuses showed a four-fold rise in titres between the day of abortion and the second samples taken 15 days later. Fifty-seven other foetuses had histologic evidence of leptospires; 27 of their dams (47%) had four-fold rises in titres. In total, 72 of 120 aborted foetuses had evidence of leptospiral infection.

Ocular manifestations in the acute phase of leptospirosis.

OBJECTIVES: To study the ocular manifestations during the acute phase of leptospirosis and their incidence in hospitalized patients due to systemic complications, and to verify the importance of routine ophthalmologic care in these cases. METHODS: Twenty-one patients, 20 males and 1 female, with clinical and laboratory (ELISA IgM) diagnoses of leptospirosis were subjected to ophthalmologic examination. RESULTS: We observed conjunctival hyperemia in 18 patients (85.7%), increased retinal venous caliber in 12 patients (57.1%), optic disc redness in 12 patients (57.1%), subconjunctival hemorrhage in four patients (19.0%), optic disc edema in one patient (4.8%), retinal vasculitis in one patient (4.8%), retinal hemorrhage in one patient (4.8%), hard exudates in one patient (4.8%), and papillitis in one patient (4.8%). No anterior chamber reaction was found. CONCLUSIONS: We observed a high incidence of several ocular manifestations in the acute phase of leptospirosis. Despite the systemic severity and high incidence of ocular disorders in the acute phase of leptospirosis, the short-term visual outcome of these patients was good.

Retinal immunopathology in horses with uveitis.

BACKGROUND: Equine uveitis is a spontaneous disorder of horses that can serve as a model for the study of human uveitis. Although the initial presentation is that of an anterior uveitis, retinal involvement has been noted in some cases. We report here the immunohistopathology of retinas from horses with uveitis. METHODS: Sections of eyes recovered from horses with naturally occurring uveitis and from Shetland ponies with experimental leptospira-induced uveitis were stained by hematoxylin and eosin for histopathological evaluation. Immunohistochemistry was used to evaluate retinas for MHC Class II antigen expression and infiltration of T and B lymphocytes. RESULTS: Histopathological abnormalities in retinas from horses with uveitis ranged from minimal to total loss of retinal tissue. MHC Class II antigen-positive round and dendritiform cells were seen in these retinas, but were not seen in retinas from horses without uveitis. There was no significant reactivity noted in the retinal pigment epithelial cells or Muller cells. Numbers of MHC Class II antigen-expressing cells and T lymphocytes correlated with the extent of retinal histopathology. B lymphocytes were seen primarily in retinas from horses that were seroreactive for Leptospira interrogans serovar pomona. Retinas from ponies with experimental uveitis had changes similar to those from horses with spontaneous uveitis. CONCLUSIONS: These results suggest that retinal pathology may be a primary immunological event in equine uveitis, provide evidence that leptospira-associated uveitis may be a distinct subset of equine uveitides, underscore the relevance of the study of equine uveitis to human uveitis, and support the plausibility of a post-infectious immunopathogenesis of some naturally occurring uveitides in both humans and horses.

Pathogenesis of renal lesions in haemoglobinaemic and non-haemoglobinaemic leptospirosis.

Hamsters were infected with Leptospira interrogans serovar ballum or Leptospira interrogans serovar pomona and the kidney lesions were compared by light and electron microscopy. Ballum and pomona both caused severe clinical signs and death within 6 days in some animals, although only ballum was associated with red blood cell destruction and haemoglobinaemic nephrosis. With ballum infections it is difficult to distinguish degenerate changes resulting from leptospiral "toxins" from those resulting from hypoxia and haemoglobinaemic nephrosis because large numbers of organisms and haemoglobinaemia coincide shortly before death. Although large numbers of leptospires were seen within the renal interstitium and blood vessels in animals dying shortly after infection, organisms were seen only in the proximal convoluted tubules of those surviving until 14 days. It is thought that leptospires are carried by the bloodstream and migrate at random throughout all body tissues. When antibody develops, only those in the renal tubules remain. The random migration results in some leptospires entering tubules at all levels of the nephron but there are good grounds for believing that the normal changes in composition of the glomerular filtrate as it passes through the nephron are increasingly deleterious to leptospiral survival. This probably explains why leptospires are found predominantly in the proximal convoluted tubules of animals after the development of specific immunity.

Demonstration of leptospiral antigens on tissues using monoclonal antibodies and avidin-biotin peroxidase staining.

Glycolipoprotein (GLP) cytotoxin was extracted from Leptospira interrogans serovar canicola. The silver staining profile of GLP subjected to SDS-PAGE under denaturing conditions showed a number of bands in the mol. weight range of 14-66 kDa. Mouse Monoclonal Antibodies (MAbs) IgG3 recognizing a band near to 24 kDa of leptospiral GLP were produced (clone number MGLP-01). The agglutinating property of MAbs was established by microscopic agglutination test (MAT) using 25 different serovars as antigens. Only the homologous serovar was agglutinated by MAbs suggesting that the recognized epitope is a specific surface-exposed antigen. The MAbs were applied to demonstration of leptospiral antigens in tissue damage by avidin-biotin immunoperoxidase staining. Golden hamsters were experimentally infected with a virulent strain of L. interrogans serovar canicola. Histologically kidneys stained by routine hematoxylin and eosin showed changes characterized by injury of tubular epithelial cells leading to acute tubular necrosis (ATN). Typical, well-defined morphologic leptospires or finely granular deposits were found by immunoperoxidase staining near to blood vessels, within inflammatory infiltrates and intraluminal in proximal and distal parts of the nephron. Binding of leptospiral antigens to capillary endothelial cells, tubular epithelial cells and macrophages were also demonstrated. This entails a basis for further studies either in research or in diagnostic histopathology.

Preliminary evaluation of antimicrobial agents for treatment of Leptospira interrogans serovar pomona infection in hamsters and swine.

OBJECTIVE: To evaluate antimicrobial agents for treatment of models of acute and persistent leptospirosis caused by Leptospira interrogans serovar pomona. DESIGN: Randomized trials comparing dosages and regimens of various antimicrobial agents for treatment of acute and persistent leptospirosis. ANIMALS: 245 Golden hamsters to model acute leptospirosis and 121 mixed-breed swine to model persistent leptospirosis. PROCEDURE: Hamsters and swine were inoculated with L interrogans serovar pomona. Antimicrobial agents were given to hamsters for 3 or 5 days after inoculation, with necropsy at 14 days after inoculation. Swine were treated for 1, 3, or 5 days beginning at 3 weeks after inoculation, and were necropsied 7 to 10 days after completion of antimicrobial agent treatment. Hamster tissue and swine tissue and urine specimens were examined by culture, fluorescent antibody testing, and histologic examination for presence of leptospires. RESULTS: All untreated control hamsters became infected and manifested clinical signs and lesions of acute leptospirosis. Leptospires were not detected in hamsters treated with dihydrostreptomycin/penicillin G (25 mg/kg of body weight). Administration of ampicillin at all dosages reduced the number of hamsters infected, as confirmed at necropsy; the other agents tested required dosages greater than label recommendations to reduce the number infected. All untreated control swine became infected and shed leptospires in urine through the time of necropsy. Leptospires were not detected in kidneys or urine of swine treated with dihydrostreptomycin/penicillin G (25 mg/kg) for 1, 3, or 5 days, or in swine treated with oxytetracycline (40 mg/kg for 3 or 5 days), tylosin (44 mg/kg for 5 days), or erythromycin (25 mg/kg for 5 days). Treatment with ceftiofur and ampicillin was not effective in elimination of L interrogans serovar pomona in swine. CONCLUSIONS: Dihydrostreptomycin/penicillin G is effective for treatment of acute and persistent leptospirosis. Differences between the effectiveness of antimicrobial agents in the acute and persistent model of leptospirosis emphasize the importance of using the appropriate model for treatment evaluation. Antimicrobial agents evaluated for treatment of persistent leptospirosis in swine required the use of dosages above those recommended by the manufacturer. CLINICAL RELEVANCE: Use of antimicrobial agents at extra-label dosages for treatment of persistent leptospirosis may cause residue problems in food animals; however, these regimens may be useful for treatment of breeding stock or animals destined for import/export.

[The early diagnosis of leptospirosis by demonstrating antigens via an immunohistochemical exam of the hamstring muscle]. / Diagnóstico precoce da leptospirose por demonstração de antígenos através de exame imuno-histoquímico em músculo da panturrilha.

Establishing an early and certain diagnosis of leptospirosis has been a difficult task. So, we analysed the histopathological alterations of the gastrocnemius muscle, and studied, for the first time, the usefulness of the immune histochemical method of peroxidase-antiperoxidase for the demonstration of the spirochete and of its products in this tissue. Histopathological observations have shown a picture of myositis, characterized by interstitial inflammatory infiltrate and necrotic-degenerative abnormalities of muscle fibers. The lesions were considered minimal in 69.45% of the patients, moderate in 19.45%, severe in 5.55% and absent in the remaining. On the other hand, the immune histochemical method identified the etiology in 94.45% what was considered very expressive.

Leptospirosis in rehabilitated Pacific harbor seals from California.

Renal disease was observed in two rehabilitated Pacific harbor seals (Phoca vitulina richardsii) from a facility in California (USA). The seals had leukocytosis and high serum phosphorus, blood urea nitrogen and creatinine concentrations. A retrospective study of leptospiral antibody serum titers indicated both seals had elevated titers to Leptospira interrogans serovar grippotyphosa. A third seal, which died about the time when the index cases occurred, also had elevated titers to L. interrogans serovar grippotyphosa. Post mortem histopathologic examination of all three seals showed tubular necrosis consistent with interstitial nephritis; spirochetes were seen within the kidney parenchyma of the third seal. Sea lions (Zalophus californianus) or elephant seals (Mirounga angustirostris) housed near the harbor seals were possible sources of exposure, but local wildlife also could have been responsible.