Leptospira Disease

Leptospira disease is a disease caused by spiral-shaped bacterium Leptospira infection that attacks humans and animals and can live in fresh water for about 1 month. But in sea water, sewer and water is not diluted urine would quickly die.

II. Source of Infection

Animals are a source of transmission is the rat (rodent), pigs, goats, sheep, horses, dogs, cats, insects, birds, bats, squirrels and hedgehogs. While direct transmission from human to human is rare.

III. Modes of Transmission

Humans infected with leptospires through contact with water, soil or plants that have been contaminated by the urine of animals suffering from leptospirosis. The bacteria enter the body through mucous membranes (mucosa) of eyes, nose, or skin abrasions or food contaminated by infected animal urine leptospires. Incubation period of 4-19 days.

IV. Clinical symptoms of

First Stage
? Fever, chills
? Headache
? Malaise
? Throw up
? Conjunctivitis
? Calf muscle pain and back
? The above symptoms will appear between 4-9 days

Symptoms Kharakteristik
? Conjunctivitis without serous exudates / porulen (redness of the eyes)
? Pain in the muscles of the Second Stage
? Formed antibodies in the patient's body
? The symptoms are more variable than the first stage
? If fever with other symptoms arise is likely to occur meningitis.
? This stage usually occurs between the second and fourth weeks.

Complications of Leptospirosis
At the heart: yellow occurred on day 4 and 6
The kidney: renal failure that can cause death.
At the heart: palpitations, irregular heart swell and heart failure that can mengikabatkan sudden death.
In the lungs: coughing up blood, chest pain, shortness of breath.
Hemorrhage because of damage to blood vessels of the respiratory tract, gastrointestinal tract, kidney, genital tract, and eye (conjunctiva).
On the pregnancy: miscarriage, prematurity, birth defects and stillbirth.

V. Prevention

Familiarize yourself with the Clean and Healthy Behavior (PHBs)
Store food and drink well to avoid mice.
Washing hands with soap before eating.
Washing the hands, feet and other body parts with soap after working in the field / garden / litter / ground / sewers and polluted places others.
Protect workers who are at high risk of leptospirosis (cleaners, farmers, veterinary officer cutters, etc.) with boots and gloves.
Keeping the environment clean
Places clean water and swimming pool.
Avoid the presence of rats in the house / building.
Avoid contamination by rodents.
Disinfection of places contaminated by mice
Increase the capture of mice.

VI. Treatment

Early treatment is very helpful because the Leptospira bacteria are easily killed by antibiotics encountered in many markets such as penicillin and its derivatives (Amoxylline)
Streptomycine, Tetracycline, Erithtromycine.
When complications occur lematian figure can reach 20%.
Immediately went to the nearest doctor.

VII. Kewaspadan by Kader / Community.

When the cadre / community with the above symptoms immediately brought to a health center / UPK nearest to receive treatment

VIII. Early Alert System

Data analysis of patients with leptospirosis were reported by the Hospital (SARS) to the DKI Jakarta Provincial Health Office

IX. Outbreak prevention

Performed on the prevention of outbreaks of leptospirosis patients tend to increase (per hour / day / week / month) with blood sampling for patients with symptoms of fever, about 20 homes of index cases.


Leptospirosis

Leptospirosis is an acute infectious disease that can infect humans and animals caused by bacteria pathogenic leptospires and is classified as a zoonosis.
Clinical symptoms of leptospirosis are similar to other infectious diseases such as influenza, meningitis, hepatitis, dengue fever, dengue fever and other viral fever, which often goes undiagnosed. Typical complaints that can be found, namely: sudden fever, general state of helpless weakness, nausea, vomiting, decreased appetite and feel the eyes of the longer growing yellow and severe muscle pain, especially the calves and thighs. It remains a public health problem, especially in the tropics and subtropics, with high rainfall (humidity), especially in developing countries, where less attention, especially environmental health. waste disposal. International Leptospirosis Society declared Indonesia as the country's high incidence of leptospirosis (Table 1) and ranked third in the world for mortality


Leptospira Infection Cycle

Based on data from Semarang in 1998? Of 2000. Major flooding in Jakarta in 2002, provisional data from 113 leptospirosis patients,
of which 20 people died. The possibility of leptospirosis infection is quite large in the rainy season over? More with the transmission of leptospirosis in humans is transmitted by infected animals leptospires bacteria. The main reservoir host is the Roden / mice with leptospires bacteria live in the kidneys and excreted in urine during urination. Humans are infected incidentally hospes directly or indirectly (Fig. 1).

Direct transmission occurs:
Through blood, urine or other body fluids that contain germs leptospires into the host body
From animals to humans is a disease of occupational injuries, occur in people who are caring for animals or handling animal organs such as abattoir workers, or someone who is infected from pets.
From human to human, although rare, can occur through sexual intercourse during the convalescent patients with leptospirosis or from mother to fetus through the placental barrier and breast milk.
Indirect transmission occurs through puddles, rivers, lakes, drainage ditches and mud contaminated with urine of animals such as mice, generally occurs during a flood. Outbreaks of leptospirosis may also occur in the dry season because the same water sources used by humans and animals.

Risk factors

Factor? leptospires bacteria infection risk factors, if direct contact / exposure to contaminated water and wetlands are:
Activities that allow contact with contaminated environmental keptospira germs, such as floods, work as gardeners, farmers, abattoir workers, sewer cleaners, miners, wash or bathe in the river / lake, and recreational activities in the wild and laboratory workers.
Breeders and veterinarians. exposed for dealing with cattle, especially during milking, touching dead animals, help animals give birth, or contact with other materials such as placenta, amniotic fluid and splash when in contact with infectious animals while urinating.
Leptospires germs enter the body through the wound host iris / abrasion wounds on the skin, conjunctiva or mucous that coats the whole mouth, pharynx, osofagus, bronchi, alveoli, and may enter through inhalation of infectious droplets and contaminated drinking water.
Infection through the mucous membrane of the stomach, rarely happens, because there is stomach acid kill germs leptospires.

Patients sign Leptospirosis:

Sclera jaundice = yellow eyes.
Symptoms of leptospirosis include:
or high-grade fever that generally remittances
headache
shiver
myalgia
nausea, vomiting and anorexia
headache can be severe, like that occurs in dengue infection, accompanied by retro-orbital pain and photophobia
muscle pain especially in the calf so that the patient is difficult to walk, back and thighs.
Jaundiced sclera (Figure 2) and conjunctival suffusion (Fig. 3) or red eyes, and enlarged lymph nodes, spleen and liver.
disorders of the eye of uveitis and iridosiklitis.
The most important clinical manifestations of meningitis or leptospirosis anikterik is aseptic meningitis is not specific so it often goes undiagnosed.

Clinical symptoms resemble the acute febrile diseases other, therefore in each case with symptoms of fever, leptospirosis must always be considered as one of differential diagnosis, especially in endemic areas.
Mild or anikterik Leptospirosis is a major cause of fever of unknown origin in some Asian countries like Thailand and Malaysia. Mortality in leptospirosis anikterik almost zero, although cases of leptospirosis have been reported who died from massive pulmonary hemorrhage in an outbreak in China. Sometimes damming test positive, so that anikterik leptospirosis patients initially diagnosed as patients with dengue infection.
On leptospirosis jaundice, patients continued in a state of fever accompanied by jaundice sclera, the state of severe acute renal failure, jaundice and bleeding manifestations that are typical clinical picture of Weil's disease.
Routine clinical laboratory tests are not specific for leptospirosis, and only shows the severity of complications that have occurred.


CASE MANAGEMENT GUIDELINES AND LABORATORY DIAGNOSIS IN HOSPITAL leptospirosis

Leptospirosis is an infectious disease caused by bacteria pathogenic leptospires. This zoonosis is one of the emerging infectious diseases. and a public health problem, especially in the tropics and subtropics, with high rainfall such as Indonesia.
Clinical symptoms of leptospirosis are nonspecific and difficult laboratory tests to confirm the diagnosis of this disease often lead to undiagnosed.
Leptospires reservoir host bacteria are Roden and pets, with humans as incidental hospes. Transmission occurs directly from animal infectious body fluids or contaminated with germs directly from environmental leptospires. Transmission from humans to humans is rare but can occur through sexual contact, breast milk and placental barrier.
According to the severity of the disease, leptospirosis is divided into light and heavy, but for the approach to clinical diagnosis and treatment, divided into anikterik leptospirosis and leptospirosis jaundice.
The majority of cases anikterik leptopirosis is composed of two phases / stages of the phase leptospiremia / phase and phase immune septicemia, which are separated by asymptomatic periods.
On leptospirosis jaundice, fever can be persistent and immune phases appear to be unclear or overlapping phases of septicemia. The presence of an immune phase is affected by the type and number of germ serovar infecting leptospires, immunological status, nutritional status of patients and the speed of obtaining the appropriate therapy.
Clinical manifestations include fever is mild or high remittances, especially in the calf muscle myalgia, conjungtival suffusion (red eyes), headache, chills, nausea, vomiting and anorexia, non-specific aseptic meningitis.
Clinical symptoms of jaundice is more severe leptospirosis, which is acute renal failure, jaundice and bleeding manifestations (Weil's disease). Moreover, it can happen Adult Respiratory Distress Syndromes (ARDS), uremia coma, shock, septicemia, cardiorespiratory failure and hemorrhagic shock as a cause of death in patients leptospirosis jaundice.
Prognostic factors associated with mortality in patients with leptospirosis is primarily oliguric renal oliguria, hyperkalemia, hypotension, ronkhi wet lungs, shortness of breath, leukocytosis> 12,900 / mm3, abnormal electrocardiogram (ECG) showed repolarization, and the presence of pulmonary infiltrates on pecitraan photo.

Leptospirosis cases are rarely reported in children, due to undiagnosed or clinical manifestations are different from adults.
Laboratory tests are absolutely necessary to confirm the diagnosis of leptospirosis, consisting of direct examination to detect the presence of leptospires or antigenic bacteria (culture, microscopy, animal inoculation, immunostaining, polymerase chain reaction), and indirectly through the examination of antibody against leptospires bacteria (MAT, ELISA, the test filter).
Serology is the gold standard MAT, an examination of the microscopic agglutination to detect the agglutination antibody titer, and can identify the type serovar.
Screening is often done in Indonesia is the Lepto Tek Dri Dot and LeptoTek Lateral Flow.
Diagnosis of leptospirosis can be divided into three classifications, namely:
Suspect, if there are clinical symptoms, without the support of laboratory tests.
Probable, if the clinical symptoms of leptospirosis and appropriate filters serologic test results that dipstick, lateral flow, or dri dot positive.
Definitive, when laboratory results are positive directly, or in accordance with the clinical symptoms of leptospirosis and the test results MAT / serial ELISA showed a seroconversion or increase in titer 4 times or more.
Therapeutic aspects of leptospirosis include causative aspects of therapy, with antibiotics Procaine Penicillin, Amoxicillin, Ampicillin, Doxycycline in the first week infekasi, as well as in symptomatic and supportive with antipyretics administration, nutrition, etc..
All cases of mild leptospirosis can be healed completely, in contrast to severe leptospirosis that have a high CFR rate, between 5? 40%. Prognosis is determined by various factors such as the virulence of the bacteria leptospires, the physical condition of the patient, patient age, presence of jaundice, presence of acute renal failure, severe liver dysfunction and rapid than handling by the medical team.
Prevention of transmission of leptospires bacteria can be carried out through three lines of intervention that includes the source of infection intervention, intervention on the routes of transmission and intervention on the human host.


OBSERVATIONS MOVEMENT IN URINE Spira
SIMPLE WAY

A. Billy Lawrence Halim Mubin * **
* Sub-Division of Infectious Diseases / Infectious
Department of Internal Medicine UNHAS FK;
The UNHAS FK ** Pathology; Petri Ujungpandang

ABSTRACT
Simple examination with an ordinary microscope can be detected in the urine of Leptospira with or without staining.
Preparations can be seen live on the movement forward, backward or rotational movements ranging from slow to fast. Generally difficult to form the spiral look with magnification 10 x 40 times. Spira a fast moving eventually stop moving by itself. In part appears to divide by transverse cut, so that separate a mother and daughter leptospires. Only a small Part of the move to form a clear spiral.
Leptospires morphology of straight or curved, spiral shape hard look and so did the end of the hook (hook). Its size varies in length between short, medium and long term. Some look like streptococcus.
With Giemsa staining reddish color, and with a bluish red gram (gram negative). Further research is needed to establish the diagnosis of leptospires in person.

ABSTRACT
Simple diagnostic method by using light microscopy can be used for detecting leptospires in the urine with or without staining. In a living specimen we can Observe the movement ie forward, backward and rotating, as well as slow and fast. The morphology of leptospires is spiral and difficult, to be observed under magnification 10x40. The fast moving leptospires usually stop by Itself. Some of them have a segmented body and evetually separated. Thereby a mother and daughter leptospires can be seen. The morphology usually straight, with hook ending spiral. The size varied from short, intermediate, and long. Some of them look like streptococcus. With Giemsa staining the germ looks pink, and Gram staining it will look blue (Gram negative). Further study is needed to evaluate the characteristic and diagnostic approach of leptospires in human (Nus J Med 1996; 17:72-76).

Spira is a group of bacteria which can cause leptospirosis, including zoonotic diseases, a pathogen called Leptospira interrogans and Leptospira biflexa not petogen called. Interrogans called because its shape resembles a question mark (?) (Interrogative: questioning) (Sanford, 1984). There are three serovar frequently causes human infection in mice is ictrerohaemorrhagiae Leptospira, Leptospira canicola in dogs and Leptospira Pomona in cattle and pigs. The most frequent cause severe disease (Weil's disease) is ictreromorrhagiae Spira. Leptospira enters the body through food or water contaminated with urine containing Leptospira. Besides, it can also through skin abrasions or through konyuktiva (RA Jacobs, 1995). Leptospira that enter the human body is pathogenic (Leptospira interrogans).
To observe the movement of Leptospira used dark field microscope (darkfield microscope). This tool is difficult to be prepared in the peripheral regions, so that diagnosis is very difficult to trace, although the clinical prevalence of Leptospira adults is increasing.

MATERIALS AND METHOD OF RESEARCH
Materials research
Examination material is fresh urine of patients with suspected Weil's disease.
The inspection:
A. Direct examination of urine

A total of 5 ml of fresh urine is inserted into the centrifuge tube.
Urine dipusing 1000-1500 rpm speed for 5-10 minutes.
Supernatant was discarded sentifus tube, so the sediment left along with as many as 1-2 drops of urine. In practice the tube was poured just over 3 seconds and then the tube is placed in a tube rack that has been provided.
Carefully one drop of urine was aspirated with a pasteur pipes, and then placed onto a glass object is then covered with a glass lid that is rather small (size 22x22 mm). Must be maintained so that the droplets are not too many, so that urine does not overflow after being closed with a cover slip.
Preparations directly examined without staining under microskope with magnification 10 x 40.
Light is set not to be too bright blinding light or too dark it, because in both these circumstances will not be visible leptospires. So, the power light is arranged roughly as strong if you want to see the urine sediment.
Because Leptospira is moving, then watching it closely for any time required to shift the focus.
Leptospira is not moving too fast can be seen more clearly in an enlarged form 10 X 100 with oil emersi.

B. Examination of the staining
Performed as step 1 through 3 above.
Urine dripped on the glass object made preparations a thin, soft and dry.
After drying were fixed with methanol
After drying with methanol were Giemsa or Gram painting.

RESULTS OF OBSERVATIONS
The results can be obtained from the examination without staining or by staining.
A. Examination without staining
On examination without staining Leptospira some circumstances will appear as follows:
Forms of leptospires
Spira is not the same size, varying between 2? - 24?. There are three lengths, namely:
Mini-sized, just like bacteria are rod-shaped, size 4-6? (Width from 0.1 to 0.2).
2-3 medium size mini X
The size of the longest, usually size 2 x size
Leptospires in part shaped like a streptococcus, which is a miniature consists of only two chefs

Spira movement
Found that the stem forms of moving forward in accordance with the lengthwise axis.
Some are moving very swiftly, so fast across the field of vision on enlargement 10x40 enlargement especially on 10x100. (10x100 magnification Leptospira difficult to see). Sometimes nothing seems to move in rotation when taking vertical direction. Generally, a mini-sized moving swiftly.
Some are moving very weak, only with a careful observation of the movement can be observed especially at 10x magnification of 100.
There are not moving. If observed for a long time, then some active Leptospira will eventually stop moving.
Only a small Part of leptospires that moved with a clear spiral shape.
Some forms of leptospires from the urine of patients with Weil's Disease
Spira is a length when the move was quite a pace and far-reaching. They sometimes move toward unity, but often have problems when moving? Back? without changing the bow, but the speed of motion as soon as forward motion. When being observed, then this is the longest size Spira Spira which will divide the two transversely, where? Head? first born. After? Aterm? both are active for secession by the separation between the two? tail?. Apparently the motion? forward? and? back? mentioned above as a result of the first individual movement forward, while the second individual interested in it, and when? back? The second individual means an individual who developed while the first still and follow it. So before they split to form the individual, they may move alternately or simultaneously with the opposite direction.
Movements is what ultimately separates the mother and dauhter Spira. Spiralisasi body movements are not so clear, sometimes it just looks like a vibrate only.
B. With Giemsa and Gram stain
With Giemsa staining Spira will appear as small rods are straight or curved reddish colored, not spiral. By painting Gram bluish red (Gram Negative). We must be careful with hyphe fungi are sometimes also found.

DISCUSSION
Most authors propose that Leptospira can only be seen by dark field microscopy (dark-field microscopy), Kontrast phase (phase contrast) or by imunofluoresens and can not be seen with ordinary microscopes (light microscopy) (Alexander, 1983; McClain, 1985; Kempe , 1987). Spira appears in the urine during the second week of illness and can last a month or more (Kempe, 1987).
No details of Leptospira spiral shape may be due to spiral as it goes very fine (very fine spiral) (Jawetz, 1982). But if the observed number of preparations would seem some of Leptospira move with clear spiral. And rotational motion clearly seen in the Leptospira move vertically. Movement back and forth (move forward and backward) in the urine can be found as raised by Alexander (1983), when Leptospira is in a liquid medium to another.
With dim field inspection on a regular microscope leptospires morphology in general can be seen. Where it will be seen more clearly in a special examination by darkfield microscopy (Jawets, 1982). With a scanning electron micrograph would seem hook and spiral (Boyd and Hoerl, 1986). By using a regular microscope that smaller structures are still difficult to see clearly.
In the state does not move without staining or staining or by staining with Giemsa or Gram sebahagian Leptospira seem like streptococcus, in accordance with the dikemukan potrais (personal approach, a Belgian researcher).
Spira size varies between 4-20? (Sparling and basement, 1980; Joklik, 1984). The same was found in this study there is a mini-sized, medium and long term. Sizes vary from 4? to 25?. With this simple examination allows observing Leptospira in urine routine examination quite easily able to follow her movements.

CONCLUSION
Leptospiruria easily detected with the microscope used to regulate the field of vision dim (dark) at a magnification of at least 10x40 on preparations without staining.
The existence of Leptospiruria considered positive if at least one Leptospira moving in a 10x40 field of vision.
Leptospiruria can not be sure whether or Leptospira biflexa Leptospira interrogans.
With Giemsa and Gram staining is difficult to ensure Leptospira because its shape resembles a mushroom hyphe
Leptospiruria examination without staining to detect Leptospira easier than with Giemsa or Gram staining.
Information about the movements Leptospira in urine can also be seen in Nusantara Medical Journal, 1996, vol 17, pages 72-76.

Weighing LEPTOSPIRURI ARE AS FOLLOWS:
NUMBER OF HEAVY-LIGHT / LP 10X40 positivity
LIGHTWEIGHT <50> 50-100 + +
WEIGHT> 100 + + +

REFERRAL
Alexander AD: Leptospirosis, in infection diseases, Hoeprich PD (Ed), 3rt Ed, Harper & Row Publishers, Philadelphia, 1985, 751-759.
Boys and Hoerl BG RE: Spirochetal and curved rods, In Basic Medical Micribiology, 3rd, Little Brown co, Toronto, 1986, 593-612
Jacobs RA: Spirochetal Disease International, In Current Medical Diagnosis & Treatment, Tierney LM (Eds), 34th Ed, A Lange Medical Book, London 1995, 1197-1214.
Jawetz E, Melnick JL and Adelbergh EA: Spiral & Other spirochetes microorganisms, Review of Medical Microbiology, 15th Ed., Lange Medical Publications, California, 1982, 253-260.
Joklik WK, Willett HP, and Amos DB: Borrelia Treponema, and Leptospira, In Zinsser Microbiology, 18th Ed, Appleton? Century-Crofts, Norwalk, 1984, 728-739.
Kempe CH, Silver HK, O? Brien O, et al: Leptospirosis, In Current Pediatric Diagnosis & Treatment 1987, 9th Ed, Appleton & Lange, Norwalk, 1987, 893-894.
McClaim JB: Leptospirosis, In Cecil Textbook of Medicine, Myngaarden JB and Smith LH (Eds), Vol-2, WB Saunders Co., Tokyo, 1985, 1666-1668.
Sanford JP: Leptospirosis, In Hunter? S Tropical Medicine, 16th Ed, Stricland GT (Ed), WB Saunders Co., Tokyo, 1984, 262-270.
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