Leptospirosis differential diagnosis: Difference between revisions

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__NOTOC__
__NOTOC__
{{Leptospirosis}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Leptospirosis]]


{{CMG}};{{AE}}{{VSKP}}
{{CMG}};{{AE}}{{VSKP}}
==Overview==
==Overview==
Leptospirosis must be differentiated from other diseases that cause [[fever]], [[diarrhea]], [[nausea]] and [[vomiting]], such as [[ebola]], [[typhoid fever]], [[malaria]], [[yellow fever]], [[shigellosis]], and other enteric bacterial infections.  Moderate to severe leptospirosis must be differentiated from [[dengue fever]].
Leptospirosis must be differentiated from other [[diseases]] that cause [[fever]], [[diarrhea]], [[nausea]] and [[vomiting]], such as [[ebola]], [[typhoid fever]], [[malaria]], [[yellow fever]], and other [[enteric]] [[bacterial]] [[infections]].  Moderate to severe leptospirosis must be differentiated from [[dengue fever]].


==Differential diagnosis==
==Differential diagnosis==


[[Differential diagnosis]] list for leptospirosis is very large due to diverse symptomatics. For forms with middle to high severity, the list includes [[dengue fever]] and other hemorrhagic [[fever]]s, [[hepatitis]] of various [[etiology|etiologies]], viral [[meningitis]], [[malaria]] and [[typhoid fever]]. Light forms should be distinguished from [[influenza]] and other related viral diseases. Specific tests are a must for proper diagnosis of leptospirosis. Under circumstances of limited access (e.g., developing countries) to specific diagnostic means, close attention must be paid to [[Anamnesis (medicine)|anamnesis]] of the patient. Factors like  certain dwelling areas, seasonality, contact with [[stagnant water]] (swimming, working on flooded meadows, etc) and/or rodents in the medical history support the leptospirosis hypothesis  and serve as indications for specific tests (if available).
[[Differential diagnosis]] list for leptospirosis is very large due to diverse symptomatics. For forms with middle to high severity, the list includes [[dengue fever]] and other hemorrhagic [[fever]]s, [[hepatitis]] of various [[etiology|etiologies]], viral [[meningitis]], [[malaria]] and [[typhoid fever]]. Light forms should be distinguished from [[influenza]] and other related [[viral]] [[diseases]]. Specific tests are a must for proper diagnosis of leptospirosis. Under circumstances of limited access (e.g., developing countries) to specific diagnostic means, close attention must be paid to [[Anamnesis (medicine)|anamnesis]] of the patient. Factors like  certain dwelling areas, seasonality, contact with [[stagnant water]] (swimming, working on flooded meadows, etc) and/or rodents in the medical history support the leptospirosis hypothesis  and serve as indications for specific tests (if available).
 
=== Differential Diagnosis for Hemorrhagic fever ===
The table below summarizes the findings that differentiate [[Leptospirosis]] from other conditions that cause [[fever]], [[diarrhea]], [[nausea]] and [[vomiting]]:
<small><small>
 
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
|+
! style="background: #4479BA; width: 120px;" | {{fontcolor|#FFF|Disease}}
! style="background: #4479BA; width: 550px;" | {{fontcolor|#FFF|Findings}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Ebola]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with [[fever]], [[chills]] [[vomiting]], [[diarrhea]], generalized [[pain]] or [[malaise]], and sometimes [[Internal bleeding|internal]] and external [[bleeding]], that follow an [[incubation period]] of 2-21 days.
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Typhoid fever]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with [[fever]], [[headache]], [[rash]], gastrointestinal symptoms, with [[lymphadenopathy]], relative [[bradycardia]], [[cough]] and [[leucopenia]] and sometimes [[sore throat]]. [[Blood]] and [[stool culture]] can confirm the presence of the causative bacteria.
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''[[Malaria]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |Presents with acute [[fever]], [[headache]] and sometimes [[diarrhea]] (children). A [[blood smear]]s must be examined for malaria parasites. The presence of [[parasites]] does not exclude a concurrent viral infection. An [[antimalarial]] should be prescribed as an [[empiric therapy]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Lassa fever]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |Disease onset is usually gradual, with [[fever]], [[sore throat]], [[cough]], [[pharyngitis]], and [[facial edema]] in the later stages. [[Inflammation]] and exudation of the [[pharynx]] and [[conjunctiva]] are common.
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Yellow fever]] and other [[Flaviviridae]] '''
| style="padding: 5px 5px; background: #F5F5F5;" | Present with [[hemorrhage|hemorrhagic]] complications. [[Epidemiological]] investigation may reveal a pattern of disease [[transmission]] by an insect vector. Virus isolation and serological investigation serves to distinguish these [[viruses]]. Confirmed history of previous [[yellow fever]] [[vaccination]] will rule out [[yellow fever]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Shigellosis]] & other bacterial enteric infections'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with [[diarrhea]], possibly [[Dysentery|bloody]], accompanied by [[fever]], [[nausea]], and sometimes [[toxemia]], [[vomiting]], [[cramps]], and [[tenesmus]]. [[Stool]]s contain [[blood]] and mucous in a typical case. A search for possible sites of bacterial infection, together with cultures and [[blood smear]]s, should be made. Presence of [[leucocytosis]] distinguishes bacterial infections from [[viral infections]].
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Dengue'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presence of atypical lymphocytosis in blood differentiate it from leptospirosis.<ref name="Levett2001">{{cite journal|last1=Levett|first1=P. N.|title=Leptospirosis|journal=Clinical Microbiology Reviews|volume=14|issue=2|year=2001|pages=296–326|issn=0893-8512|doi=10.1128/CMR.14.2.296-326.2001}}</ref>
 
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Others'''
| style="padding: 5px 5px; background: #F5F5F5;" |[[Viral Hepatitis]], [[rheumatic fever]], [[typhus]], and [[mononucleosis]]
|-
|}
{| class="wikitable"
{| class="wikitable"
! rowspan="2" |Disease
! rowspan="2" |Disease
Line 49: Line 17:
! colspan="7" |Symptoms
! colspan="7" |Symptoms
! colspan="2" |Physical signs
! colspan="2" |Physical signs
! colspan="4" |Lab findings
! colspan="2" |Lab findings
! rowspan="2" |Other findings
! rowspan="2" |Other findings
! rowspan="2" |Treatment
! rowspan="2" |Treatment
|-
|-
!Fever characterestic
!Fever  
!Cough
!Cough
!Rash
!Rash
Line 62: Line 30:
!Characterestic physical finding
!Characterestic physical finding
!Icterus
!Icterus
!Characteristic lab finding
!Leukocyte count
!Plasma Creatine kinase
!Plasma Creatine kinase
!Confirmatory test
!Confirmatory test
|-
|-
!Leptospirosis
![[Leptospirosis]]
|
| align="center" |2 to 30 days
|
| align="center" |Rodents
* Rodents
 
* Domestic animals
Domestic animals
|Fever last for 4-7 days, remission for 1-2 days and then relapse  
| align="center" |[[Fever]] last for 4-7 days, remission for 1-2 days and then relapse  
|
| align="center" | +
|Present over legs, Hemorrhagic rash
| align="center" |Present over legs [[Hemorrhagic]] [[rash]]
|
| align="center" | +
|
| align="center" | +
(Severe myalgia is characteristic of  leptospirosis)
(Severe [[myalgia]] is characteristic of  leptospirosis typically localized to the [[Calf muscle|calf]] and [[lumbar]] areas)
|
| align="center" | +
|
| align="center" |[[Conjunctival hemorrhage]],
|
[[Hemoptysis]]
* Conjunctival suffusion
| align="center" |[[Conjunctival hemorrhage|Conjunctival suffusion]]
|
| align="center" | +
|
| align="center" |Elevated
|High
| align="center" |[[Agglutination|Microscopic agglutination test]] of urine
|Elevated
| align="center" |History of exposure to soil or water  
|Microscopic agglutination test of urine
contaminated by [[infected]] rodents
|
 
* History of exposure to soil or water contaminated by infected rodents
Recent history travel to tropical,  
* Recent history travel to tropical, sub tropical areas or humid areas
sub tropical areas or humid areas
|
| align="center" |[[NSAIDs]]
* NSAIDs
|-
|-
!'''Dengue'''
!'''[[Dengue fever|Dengue]]'''
|4 to 10 days
| align="center" |4 to 10 days
|
| align="center" |''[[Aedes]]'' [[Aedes|mosquito]]
* ''Aedes'' mosquito
| align="center" |[[Fever]] last for 1-2 days,  
|Fever last for 1-2 days, remission for 1-2 days and then relapse for 1-2 days
remission for 1-2 days and then relapse for 1-2 days
(Biphasic fever pattern)
(Biphasic [[fever]] pattern)
|
| align="center" | -
|Over legs and trunk
| align="center" |Over legs and [[trunk]]


Pruritic rash May be hemorrhagic  
pruritic [[rash]] May be [[hemorrhagic]]
|
| align="center" | +
|
| align="center" | +
|
| align="center" | -
|
| align="center" |[[Upper gastrointestinal bleeding]]
|
| align="center" |[[Lymphadenopathy|Painful lymphadenopathy]]
|X
| align="center" | -
|
| align="center" |Normal
* Elevated hematocrit
| align="center" |Serology showing positive [[IgM]] or [[IgG]]
* Drop in platelet count
| align="center" |Recent travel to South America, Africa, Southeast Asia
* Atypical lymphocytes
| align="center" |Supportive care
|
Avoid aspirin and other [[NSAIDs]]
* Low
|
|Serology showing positive IgM or IgG
|
* Recent travel to South America, Africa, Southeast Asia
|
* Supportive care
* Avoid aspirin and other NSAIDs
|-
|-
!'''Malaria'''
!'''[[Malaria]]'''
|
| align="center" |
* ''Plasmodium falciparum: 9-14 days''
* ''[[Plasmodium falciparum]]: 9-14 days''
* ''Plasmodium vivax: 12-18 days''
* ''[[Plasmodium vivax]]: 12-18 days''
* ''Plasmodium ovale: 18-40 days''
* ''[[Plasmodium ovale]]: 18-40 days''
|
| align="center" |[[Anopheles|Female Anopheles]]
* Female Anopheles
| align="center" |[[Fever]] present daily or on alternate day or every 3 days depending on [[Plasmodium|Plasmodium sps]].
|Fever present daily or on alternate day or every 3 days depending on Plasmodium sps.
| align="center" | -
|X
| align="center" |No rash
|No rash
| align="center" | -
|X
| align="center" | +
|
| align="center" | -
|
| align="center" |[[Hematuria|Bloody urine]]
|
| align="center" |[[Hepatosplenomegaly]]
|
| align="center" | +
* Hepatosplenomegaly
| align="center" |Normal
|
| align="center" |[[Giemsa stain|Giemsa]] stained thick and thin [[blood]] smears  
|Hemolytic anemia showing
| align="center" |Recent travel to South America, Africa, Southeast Asia
* Hemoglobinuria
| align="center" |[[Antimalarial medication|Anti malarial regimen]]
* Elevated indirect bilurubin
* Low [[hepcidin]]
|
|
|Giemsa stained thick and thin blood smears  
|
|
|-
|-
!'''Ebola'''
!'''[[Ebola]]'''
|
| align="center" |2 to 21 days.
|
| align="center" |No vector
|
 
|
Human to human transmission
|
 
* [[Maculopapular]], non-pruritic [[rash]] with [[erythema]]
[[Airborne transmission|Air born disease]]
* Centripetal distribution
| align="center" | +
|
| align="center" | +
|
| align="center" |[[Maculopapular]]  
|
non-pruritic [[rash]] with [[erythema]]
 
Centripetal distribution
| align="center" | +
| align="center" | +
| align="center" | +


May be bloody in the early phase
May be bloody in the early phase
|
| align="center" |[[Epistaxis]]
* Epistaxis
 
* Mucosal bleeding
[[Mucosal bleeding]]
|
| align="center" |Sudden onset of high [[fever]] with [[conjunctival injection]] and early [[gastrointestinal]] symptoms
|
| align="center" | -
| align="center" |Normal
| align="center" |[[RT-PCR]]
| align="center" |Recent visit to endemic area especially African countries
| align="center" |Isolation of the patient,
 
supportive therapy
|-
!'''[[Influenza]]'''
| align="center" |1-4 days
| align="center" |No vector
 
[[Airborne transmission|Air born disease]]
| align="center" | +
| align="center" | +
| align="center" | +/-
| align="center" | +
| align="center" | +
| align="center" | +
| align="center" | -
| align="center" |[[Fever]] and upper [[respiratory]] symptoms
| align="center" | -
| align="center" |Normal
| align="center" |[[Viral culture]] or [[PCR]]
| align="center" |Health care workers
Patients with co-morbid conditions
| align="center" |Symptomatic treatment
 
[[Oseltamivir]] or [[zanamivir]]
|-
!'''[[Yellow fever]]'''
| align="center" |3 to 6 days
| align="center" |[[Aedes]] or [[Aedes|Haemagogus]] species mosquitoes
| align="center" | +
| align="center" | +
| align="center" | -
| align="center" | -
| align="center" | +
| align="center" | -
| align="center" |[[Conjunctival hemorrhage]],
 
[[Hemoptysis]]
| align="center" |Relative [[bradycardia]]
([[Faget's sign]])
| align="center" | +
| align="center" |Normal
| align="center" |[[RT-PCR]],
 
[[Nucleic acid amplification technique|Nucleic acid amplification test]],
 
[[Immunohistochemical staining|Immuno-histochemical staining]]
| align="center" |Recent travel to  Africa, South and Central America, and the Caribbean.
 
Tropical rain forests of south America
| align="center" |Symptomatic treatment,
 
[[Anti inflammatory medications|Anti-inflammatory drugs]]
|-
!'''[[Typhoid fever]]'''
| align="center" |6 to 30 days
| align="center" |No vector
 
[[Airborne transmission|Air born disease]]
| align="center" | +
| align="center" | -
| align="center" |Blanching [[erythematous]] 
[[maculopapular]][[lesions]] on the
lower chest and abdomen
| align="center" | +
| align="center" | +
| align="center" | +
| align="center" |[[Intestinal bleeding]]
| align="center" |[[Rose spots]]
| align="center" | -
| align="center" |Normal
| align="center" |[[Blood]] or [[stool]] [[Culture medium|culture]] showing ''[[Salmonella typhi|salmonella typhi sps]].''
| align="center" |Residence in [[endemic]] area
 
Recent travel to [[endemic]] area
| align="center" |[[Fluoroquinolones]],
 
[[Cephalosporin|Third generation cephalosporins]],
 
[[Azithromycin]]
|}
 
'''Differentiating psittacosis from other diseases'''
 
{| class="wikitable"
!Clinical feature
![[Cough]]
![[Sputum]]
![[Dyspnea]]
![[Sore throat]]
![[Headache]]
![[Confusion]]
![[Diarrhea]]
!Chest radiograph changes
!Hyponatremia
![[Leukopenia]]
!Abnormal Liver function tests
!Treatment
|-
|Psittacosis
| ++
| -
| +
| -
| +++
| +
|Minimal
|
|
* No changes seen
| -
| +
| -
|[[Doxycycline]]
|-
|[[Chlamydia pneumoniae|''C.pneumoniae'']] pneumonia
| +
| +
| +
| +++
| ++
| +
| -
|
|
* Minimal changes observed
| -
| -
| -
|[[Doxycycline]], [[Azithromycin]]
|-
|[[Mycoplasma pneumoniae|''M. pneumoniae'']] pneumonia
| ++
| ++
| ++
| -
| -
| -
| -
|
|
* Bronchial wall thickening
* Centrilobular nodules
* [[Ground glass opacification on CT|Ground-glass attenuation]]
* [[Consolidation (medicine)|Consolidation]]
| -
| -
| +
|[[Doxycycline]]
|-
|[[Legionella pneumophila|''L. Pneumophila'']] infection
| +
| +++
| +++
| -
| +
| ++
| +
|Often Multifocal
| ++
| +
| ++
|[[Doxycycline]]
|-
|[[Influenza (Flu) (For Patients)|Influenza]]
| ++
| ++
| ++
| ++
| ++
| +/-
| +/-
|
|
* Bi-basal air-space opacities
* Perihilar [[reticular]] and [[Alveolar|alveolar infiltrates]]
| -
| -
| -
|[[zanamivir]], [[oseltamivir]],
|-
|[[Endocarditis]]
| ++
| ++
| +
| -
| -
| -
| -
|
|
* Hazy opacities at [[lung]]
bases bilaterally
| -
| +/-
| +/-
|[[Vancomycin]]
|-
|[[Coxiella burnetii infection|''Coxiella burnetii'' infection]]
| ++
| -
| +
| +/-
| -
| +/-
|Minimal
|
|
* [[Segmental analysis (biology)|Segmental]] or [[Lobar pneumonia|lobar]] opacification
* Occasional [[pleural effusions]]
| -
| +/-
|=/-
|[[Doxycycline]]
|-
|-
!'''Influenza'''
|[[Leptospirosis]]
| ++
| +
| ++
| +
| +
| ++
| -
|
|
|
* Multiple  ill-defined  [[Nodule (medicine)|nodules]]  in  both  lungs.
|
| +++
|✔
|
|
|
|
|[[Doxycycline]], [[azithromycin]], [[amoxicillin]]
|-
|[[Brucellosis]]
| ++
| -
| +
| -
| ++
| +
| -
|
|
* Soft [[Miliary TB|miliary]] mottling
* [[Parenchymal lung disease|Parenchymal nodules]]
* [[Consolidation (medicine)|Consolidation]]
* [[Chronic (medical)|Chronic]] [[diffuse]] changes
* [[Hilar]] or [[Paratracheal lymph nodes|paratracheal]] [[lymphadenopathy]]
* [[Pneumothorax]].
| -/+
| +/-
| +/-
|[[Doxycycline]], [[rifampin]]
|}
</small></small>
Key;
+, occurs in some cases
++, occurs in many cases,
+++, occurs frequently
Leptospirosis must be differentiated from other diseases that cause [[atypical pneumonia]] such as Q fever and legionella pneumonia:
{| class="wikitable"
!Disease
!Prominent clinical features
!Lab findings
!Chest X-ray
|-
|Q fever
|
|
* Q fever is characterized by abrupt onset of [[fever]], [[myalgia]], [[headache]], and other constitutional symptoms.
* [[Cough]] is the most prominent respiratory symptom and it is usually dry.<ref name="pmid23422417">{{cite journal |vauthors=Irfan M, Farooqi J, Hasan R |title=Community-acquired pneumonia |journal=Curr Opin Pulm Med |volume=19 |issue=3 |pages=198–208 |year=2013 |pmid=23422417 |doi=10.1097/MCP.0b013e32835f1d12 |url=}}</ref>
* [[Cough]] is associated with [[dyspnea]] and [[pleuritic chest pain]].
|
|
* [[Antibody]] detection using [[Immunofluorescence|indirect immunofluorescence]] (IIF) is the preferred method for diagnosis.
* [[Polymerase chain reaction|PCR]] can be used if IIF is negative, or very early once disease is suspected.
* [[Coxiella burnetii|''C. burnetii'']] does not grow on ordinary blood cultures, but can be cultivated on special media such as embryonated eggs or cell culture.
* A two-to-three fold increase in [[Aspartate transaminase|AST]] and [[ALT]] is seen in most patients.
|
|
[[Image:Q fever.gif|center|300px|thumb|Q fever pneumonia - - Case courtesy of Royal Melbourne Hospital Respiratory, Radiopaedia.org, rID 21993 ]]
|-
|[[mycoplasma pneumonia|''Mycoplasma'' pneumonia]]
|
|
* [[mycoplasma pneumonia|''Mycoplasma'' pneumonia]] can be [[asymptomatic]].
* [[Headache]], [[Nausea and vomiting|nausea]], and [[malaise]] usually precede the onset of symptoms.<ref name="pmid23422417">{{cite journal |vauthors=Irfan M, Farooqi J, Hasan R |title=Community-acquired pneumonia |journal=Curr Opin Pulm Med |volume=19 |issue=3 |pages=198–208 |year=2013 |pmid=23422417 |doi=10.1097/MCP.0b013e32835f1d12 |url=}}</ref>
* [[Cough]] is intractable and nonproductive.
|
|
* Postitve [[Coombs test]]
* [[Leukocytosis]]
* [[Thrombocytosis]]
|
|
|
[[Image:Atypical-pneumonia-mycoplasma - Case courtesy of Dr Alborz Jahangiri, Radiopaedia.org, rID 45781.jpg|center|300px|thumb|Mycoplasma pneumonia - Case courtesy of Dr Alborz Jahangiri, Radiopaedia.org, rID 45781]]
|Viral culture or PCR
|
|
|-
|-
!'''Yellow fever'''
|[[Legionellosis]]
|
|
|✔
|
|
|
|
|
|
|
|
|
|
|
|
|
* [[Legionellosis]] is characterized by cough that is slightly productive.<ref name="pmid23422417">{{cite journal |vauthors=Irfan M, Farooqi J, Hasan R |title=Community-acquired pneumonia |journal=Curr Opin Pulm Med |volume=19 |issue=3 |pages=198–208 |year=2013 |pmid=23422417 |doi=10.1097/MCP.0b013e32835f1d12 |url=}}</ref>
* Constitutional symptoms such as [[chills]], [[myalgia]], and [[arthralgia]].
* Gastrointestinal symptoms such as [[diarrhea]], [[nausea]], and [[vomiting]].
|
|
* Labs are nonspecific for diagnosing [[legionellosis]]
* [[Renal dysfunction|Renal]] and [[hepatic dysfunction]]
* [[Thrombocytopenia]] and [[leukocytosis]]
* [[Hyponatremia]]
|
|
[[Image:Legionella-pneumonia - Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID 31816.jpg|center|300px|thumb|Legionella pneumonia - Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID 31816 ]]
|-
|-
!'''Typhoid fever'''
|[[Chlamydia pneumonia]]
|
|
* There are no specific clinical features of [[chlamydia pneumonia]].
* Symptoms appear gradually.
* [[Chlamydia infection]] is usually associated with [[upper respiratory tract]] symptoms ([[pharyngitis]], [[sinusitis]], etc).
* It might be associated with extrapulmonary maifestations such as [[meningitis]] and [[Guillain-Barre syndrome]].<ref name="pmid23422417">{{cite journal |vauthors=Irfan M, Farooqi J, Hasan R |title=Community-acquired pneumonia |journal=Curr Opin Pulm Med |volume=19 |issue=3 |pages=198–208 |year=2013 |pmid=23422417 |doi=10.1097/MCP.0b013e32835f1d12 |url=}}</ref>
|
|
|✔
* [[Chlamydia pneumonia]] is usually associated with normal [[WBC|WBC count.]]
|X
* Diagnosed with the presence of [[Antibody|antichlamydial antibody]] (through [[complement fixation]] or direct immunofluoroscence) or direct antigen detection.
|Blanching [[erythematous]] [[maculopapular]][[lesions]] on the lower chest and abdomen 
|✔
|✔
|✔
|
|
* Intestinal bleeding
[[Image:Chlamydia-pneumonia - Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID 14567.jpg|center|300px|thumb|Chlamydia-pneumonia - Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID 14567]]
|
* Rose spots
|X
|
|
|
|Blood or stool culture showing ''salmonella typhi sps.''
|
* Residence in [[endemic]] area
* Recent travel to [[endemic]] area
|
|-
!Ricketsial fever
!
!
!
!
!✔
!
!✔
!✔
!
!
!
!
!
!
!
!
* Recent history of tick bite
!
|-
!Viral hepatitis
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!Positive serology
!
!
|}
|}


Line 280: Line 441:


[[Category:Disease]]
[[Category:Disease]]
[[Category:Emergency mdicine]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Infectious disease]]
[[Category:Pulmonology]]
[[Category:Gastroenterology]]
[[Category:Otolaryngology]]
[[Category:Neurology]]

Latest revision as of 22:29, 29 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [2]

Overview

Leptospirosis must be differentiated from other diseases that cause fever, diarrhea, nausea and vomiting, such as ebola, typhoid fever, malaria, yellow fever, and other enteric bacterial infections. Moderate to severe leptospirosis must be differentiated from dengue fever.

Differential diagnosis

Differential diagnosis list for leptospirosis is very large due to diverse symptomatics. For forms with middle to high severity, the list includes dengue fever and other hemorrhagic fevers, hepatitis of various etiologies, viral meningitis, malaria and typhoid fever. Light forms should be distinguished from influenza and other related viral diseases. Specific tests are a must for proper diagnosis of leptospirosis. Under circumstances of limited access (e.g., developing countries) to specific diagnostic means, close attention must be paid to anamnesis of the patient. Factors like certain dwelling areas, seasonality, contact with stagnant water (swimming, working on flooded meadows, etc) and/or rodents in the medical history support the leptospirosis hypothesis and serve as indications for specific tests (if available).

Differential Diagnosis for Hemorrhagic fever

Disease Incubation period Vector Symptoms Physical signs Lab findings Other findings Treatment
Fever Cough Rash Joint pain Myalgia Diarrhea Common hemorrhagic symptoms Characterestic physical finding Icterus Plasma Creatine kinase Confirmatory test
Leptospirosis 2 to 30 days Rodents

Domestic animals

Fever last for 4-7 days, remission for 1-2 days and then relapse + Present over legs Hemorrhagic rash + +

(Severe myalgia is characteristic of leptospirosis typically localized to the calf and lumbar areas)

+ Conjunctival hemorrhage,

Hemoptysis

Conjunctival suffusion + Elevated Microscopic agglutination test of urine History of exposure to soil or water

contaminated by infected rodents

Recent history travel to tropical, sub tropical areas or humid areas

NSAIDs
Dengue 4 to 10 days Aedes mosquito Fever last for 1-2 days,

remission for 1-2 days and then relapse for 1-2 days (Biphasic fever pattern)

- Over legs and trunk

pruritic rash May be hemorrhagic

+ + - Upper gastrointestinal bleeding Painful lymphadenopathy - Normal Serology showing positive IgM or IgG Recent travel to South America, Africa, Southeast Asia Supportive care

Avoid aspirin and other NSAIDs

Malaria Female Anopheles Fever present daily or on alternate day or every 3 days depending on Plasmodium sps. - No rash - + - Bloody urine Hepatosplenomegaly + Normal Giemsa stained thick and thin blood smears Recent travel to South America, Africa, Southeast Asia Anti malarial regimen
Ebola 2 to 21 days. No vector

Human to human transmission

Air born disease

+ + Maculopapular

non-pruritic rash with erythema

Centripetal distribution

+ + +

May be bloody in the early phase

Epistaxis

Mucosal bleeding

Sudden onset of high fever with conjunctival injection and early gastrointestinal symptoms - Normal RT-PCR Recent visit to endemic area especially African countries Isolation of the patient,

supportive therapy

Influenza 1-4 days No vector

Air born disease

+ + +/- + + + - Fever and upper respiratory symptoms - Normal Viral culture or PCR Health care workers

Patients with co-morbid conditions

Symptomatic treatment

Oseltamivir or zanamivir

Yellow fever 3 to 6 days Aedes or Haemagogus species mosquitoes + + - - + - Conjunctival hemorrhage,

Hemoptysis

Relative bradycardia

(Faget's sign)

+ Normal RT-PCR,

Nucleic acid amplification test,

Immuno-histochemical staining

Recent travel to  Africa, South and Central America, and the Caribbean.

Tropical rain forests of south America

Symptomatic treatment,

Anti-inflammatory drugs

Typhoid fever 6 to 30 days No vector

Air born disease

+ - Blanching erythematous 

maculopapularlesions on the lower chest and abdomen

+ + + Intestinal bleeding Rose spots - Normal Blood or stool culture showing salmonella typhi sps. Residence in endemic area

Recent travel to endemic area

Fluoroquinolones,

Third generation cephalosporins,

Azithromycin

Differentiating psittacosis from other diseases

Clinical feature Cough Sputum Dyspnea Sore throat Headache Confusion Diarrhea Chest radiograph changes Hyponatremia Leukopenia Abnormal Liver function tests Treatment
Psittacosis ++ - + - +++ + Minimal
  • No changes seen
- + - Doxycycline
C.pneumoniae pneumonia + + + +++ ++ + -
  • Minimal changes observed
- - - Doxycycline, Azithromycin
M. pneumoniae pneumonia ++ ++ ++ - - - - - - + Doxycycline
L. Pneumophila infection + +++ +++ - + ++ + Often Multifocal ++ + ++ Doxycycline
Influenza ++ ++ ++ ++ ++ +/- +/- - - - zanamivir, oseltamivir,
Endocarditis ++ ++ + - - - -
  • Hazy opacities at lung

bases bilaterally

- +/- +/- Vancomycin
Coxiella burnetii infection ++ - + +/- - +/- Minimal - +/- =/- Doxycycline
Leptospirosis ++ + ++ + + ++ -
  • Multiple ill-defined nodules in both lungs.
+++ Doxycycline, azithromycin, amoxicillin
Brucellosis ++ - + - ++ + - -/+ +/- +/- Doxycycline, rifampin

Key;

+, occurs in some cases

++, occurs in many cases,

+++, occurs frequently

Leptospirosis must be differentiated from other diseases that cause atypical pneumonia such as Q fever and legionella pneumonia:

Disease Prominent clinical features Lab findings Chest X-ray
Q fever
  • Antibody detection using indirect immunofluorescence (IIF) is the preferred method for diagnosis.
  • PCR can be used if IIF is negative, or very early once disease is suspected.
  • C. burnetii does not grow on ordinary blood cultures, but can be cultivated on special media such as embryonated eggs or cell culture.
  • A two-to-three fold increase in AST and ALT is seen in most patients.
Q fever pneumonia - - Case courtesy of Royal Melbourne Hospital Respiratory, Radiopaedia.org, rID 21993
Mycoplasma pneumonia
Mycoplasma pneumonia - Case courtesy of Dr Alborz Jahangiri, Radiopaedia.org, rID 45781
Legionellosis
Legionella pneumonia - Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID 31816
Chlamydia pneumonia
Chlamydia-pneumonia - Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID 14567

References

  1. 1.0 1.1 1.2 1.3 Irfan M, Farooqi J, Hasan R (2013). "Community-acquired pneumonia". Curr Opin Pulm Med. 19 (3): 198–208. doi:10.1097/MCP.0b013e32835f1d12. PMID 23422417.