O objetivo principal foi comparar a letalidade hospitalar da leptospirose entre pacientes pediátricos (< 19 anos) e adultos (> 19 anos), levando em consideração gênero, função renal, duração dos sintomas e icterícia. Prontuários de 1016 pacientes foram revistos. Análise comparativa foi restrita a 840 pacientes (100 pediátricos, 740 adultos) com informações sobre as variáveis incluídas na análise. Entre estes pacientes 81,4% eram do sexo masculino e 91,5% apresentavam icterícia à admissão. A letalidade da leptospirose foi 14,4%. A razão entre número de pacientes que morreram e número de pacientes que sobreviveram, ajustada para gênero, icterícia, duração de sintomas, uréia sérica e creatinina sérica foi quase quatro vezes maior no grupo adulto do que no pediátrico (odds ratio (OR) = 3,94; intervalo de confiança de 95% = 1,19-13,03, p = 0,029). Em adultos, idade mais avançada foi também significantemente e independentemente associada com maior risco de morte (p < 0,01). Pacientes mais velhos foram também mais freqüentemente dialisados. Em conclusão, os dados mostram que a letalidade da leptospirose é mais alta em adultos do que em crianças e adolescentes, mesmo após o ajuste para os efeitos de potenciais fatores de risco de morte. Entre adultos, idade avançada mostrou-se também associada fortemente e independentemente com risco mais alto de morte.

The main objective was to compare the in-hospital case-fatality rate of leptospirosis between pediatric (< 19 years) and adult (>19 years) patients, taking into account gender, renal function, duration of symptoms and jaundice. Medical records of 1016 patients were reviewed. Comparative analysis was restricted to 840 patients (100 pediatric, 740 adults) with recorded information on the variables included in the analysis. Among these patients 81.7% were male and 91.5% were icteric. The case-fatality rate of leptospirosis was 14.4%. The odds of death adjusted for gender, jaundice, duration of symptoms, serum urea and serum creatinine were almost four times higher for the adult than for the pediatric group (odds ratio (OR) = 3.94; 95% confidence interval = 1.19-13.03, p = 0.029). Among adults, increased age was also significantly and independently associated with increased risk of death (p < 0.01). Older patients were also more often treated by dialysis. In conclusion, the data suggest that the in-hospital case fatality rate of leptospirosis is higher for adults than for children and adolescents, even after taking into account the effects of several potential risk factors of death. Among adults, older age was also strongly and independently associated with higher risk of death.

Existe evidência de que o início precoce do tratamento com penicilina reduz a letalidade da leptospirose e de que a quimioprofilaxia é eficaz em pessoas expostas às fontes de infecção. Os dados existentes, contudo, são inconsistentes quanto ao benefício de iniciar penicilina na fase tardia da leptospirose. O presente estudo foi desenvolvido para avaliar se a introdução de penicilina após mais de quatro dias de sintomas reduz a letalidade da leptospirose. Um total de 253 pacientes entre 15 e 76 anos de idade, com leptospirose avançada, i.e., mais de quatro dias de sintomas, admitidos em um hospital de doenças infecciosas localizado em Salvador, Brasil, foram selecionados para o estudo. Os pacientes foram randomizados para um dos seguintes grupos de tratamento: com penicilina intravenosa, 6 milhões de unidades/dia (um milhão de unidades cada quatro horas) por 7 dias (n = 125) e sem penicilina (n = 128). O evento principal foi morte durante o período de internamento. A letalidade foi aproximadamente duas vezes maior no grupo tratado com penicilina (12%; 15/125) do que no grupo de comparação (6,3%; 8/128). Esta diferença seguiu direção oposta a da hipótese do estudo, porém não alcançou significância estatística (p = 0,112). A duração do internamento foi similar entre os grupos de tratamento. De acordo com os resultados do presente ensaio clínico randomizado o uso de penicilina não é benéfico em paciente com leptospirose quando iniciado com pelo menos quatro dias após o início dos sintomas. Portanto, maior atenção deve ser dada à prevenção e ao inicio mais precoce do tratamento da leptospirose.

There is evidence that an early start of penicillin reduces the case-fatality rate of leptospirosis and that chemoprophylaxis is efficacious in persons exposed to the sources of leptospira. The existent data, however, are inconsistent regarding the benefit of introducing penicillin at a late stage of leptospirosis. The present study was developed to assess whether the introduction of penicillin after more than four days of symptoms reduces the in-hospital case-fatality rate of leptospirosis. A total of 253 patients aged 15 to 76 years with advanced leptospirosis, i.e., more than four days of symptoms, admitted to an infectious disease hospital located in Salvador, Brazil, were selected for the study. The patients were randomized to one of two treatment groups: with intravenous penicillin, 6 million units day (one million unit every four hours) for seven days (n = 125) and without (n = 128) penicillin. The main outcome was death during hospitalization. The case-fatality rate was approximately twice as high in the group treated with penicillin (12%; 15/125) than in the comparison group (6.3%; 8/128). This difference pointed in the opposite direction of the study hypothesis, but was not statistically significant (p = 0.112). Length of hospital stay was similar between the treatment groups. According to the results of the present randomized clinical trial initiation of penicillin in patients with severe forms of leptospirosis after at least four days of symptomatic leptospirosis is not beneficial. Therefore, more attention should be directed to prevention and earlier initiation of the treatment of leptospirosis.

OBJECTIVE: To report the frequency and types of electrocardiographic alterations in patients with leptospirosis in the first 24 hours of hospitalization. METHODS: We analyzed the electrocardiograms of 157 patients admitted to the Hospital Couto Maia in the city of Salvador, in the State of Bahia, Brazil, from March 1998 to June 1999. The electrocardiograms were performed in the first 24 hours after hospital admission, independent of the clinical manifestations of the patients. RESULTS: The mean ± SD for patients' age was 35.5± 13.7 (median = 32) years, and jaundice was present in 95.5% of them. Alterations in the electrocardiogram were detected in 68.2% (107/157) of the patients (95% confidence interval = 60.6% - 75.1%). Atrial fibrillation was the most frequent arrhythmia, occurring in 10.8% (17/157) of the patients. Other frequent findings were alterations in ventricular repolarization detected in 38.9% (61/157) of patients and first-degree atrioventricular block in 10.2% (16/157). The patients with atrial fibrillation were older and had higher levels of creatinine and aminotransferases. CONCLUSION: In this sample, approximately 2/3 of the patients had electrocardiographic alterations after hospital admission. Of the major arrhythmias, atrial fibrillation was the most frequent, and the patients with this arrhythmia had evidence of more severe disease. The relation between the presence and type of electrocardiographic alteration and the prognosis of leptospirosis is yet to be assessed.

Evaluating tetanus immune status is not yet the usual clinical practice regarding patients with chronic ulcers or myasis. However, of 858 tetanus patients at Hospital Couto Maia (Salvador, Bahia, Brazil) aged 1 year or above, 2 had pressure ulcers and 17 had chronic ulceration of the lower limbs where these skin lesions were the ports of entry for Clostridium tetani. In these 19 cases, the following predisposing factors were described: venous insufficiency (n=6), sickle cell anemia (n=2), Hansen's disease (n=1), malnutrition (n=1), diabetes mellitus (n=1), trauma (n=1) and unknown factors (n=7). In 6 other cases, in addition to the Hansen's disease patient, the port of entry for tetanus was the site of extraction of Tunga penetrans larvae. In these 25 cases, the majority of patients (68%) were over 40 years old (17/25) and all of these patients stated that they had either not followed a tetanus toxoid vaccination regimen (19/25), or had partially completed such a regimen, or did not give precise information (6/25). Among the same series studied, over half (52%) of the patients died (13/25). We conclude that tetanus prevention must be included in the treatment of chronic skin ulcer patients, vaccination coverage should be increased among older people, and strategies aimed at improving coverage for all age groups must be reviewed.

Leptospirose grave afeta predominantemente os homens e apresenta alta susceptibilidade para insuficiência renal aguda com hipocalemia. Como hipocalemia e hipercalemia induzem complicações graves, é importante avaliar se o potássio sérico é um independente fator de risco de morte na leptospirose. Foram revistos os prontuários de 1016 pacientes internados com o diagnóstico de leptospirose. A análise foi restrita a 442, obedecendo os seguintes critérios: sexo masculino, idade igual ou superior a 18 anos, informação sobre morte ou alta hospitalar e registro dos valores do potássio sérico, da creatinina sérica e da duração dos sintomas. Valores de potássio menor do que 3,5 mEq/l (hipoK), 3,5-5 mEq/L (normoK) e superior a 5 mEq/L (hiperK) foram detectados em 180, 245 e 17 pacientes, respectivamente. A mortalidade aumentou com a elevação do potássio: 11,1% no grupo hipoK, 14,7% no normoK e 47,1% no hiperK (p = 0,002). Em um modelo de regressão logística (normoK como referência), incluindo idade, creatinina e duração de sintomas, hipoK não se associou com aumento da mortalidade (odds ratio (OR) = 0,72; p > 0,1). Contrariamente, hiperK foi significantemente associado com risco aumentado de morte (OR = 3,95; p = 0,021). Em conclusão, nesta amostra de homens com leptospirose o potássio sérico inicial foi positivamente e independentemente correlacionado com risco de morte hospitalar.

Severe leptospirosis affects predominantly males and presents a high susceptibility to hypokalemic acute renal failure. As hypokalemia and hyperkalemia induce severe complications, it is important to evaluate if the initial serum potassium is an independent risk factor for death in leptospirosis. The medical records of 1016 patients hospitalized with the diagnosis of leptospirosis were reviewed. The analysis was restricted to 442, according to the following criteria: male, 18 years or older, information about death or hospital discharge and recorded values of serum potassium, serum creatinine and duration of symptoms at admission. Potassium values lower than 3.5 mEq/L (hypoK), 3.5-5 mEq/L (normoK) and above 5 mEq/L (hyperK) were detected in 180, 245 and 17 patients, respectively. The death rate increased with serum potassium: 11.1% in the hypoK, 14.7% in the normoK and 47.1% in the hyperK group (p = 0.002). In a logistic regression model (normoK as referent), including age, creatinine and duration of symptoms, hypoK was not associated with increased death rate (odds ratio (OR) = 0.80; p > 0.1). On the other hand, hyperK showed a significant association with increased risk of death (OR = 3.95, p = 0.021). In conclusion, in this sample of men with leptospirosis initial serum potassium was positively and independently correlated with the risk of in-hospital death.

São descritas as características de 1.016 pacientes internados com leptospirose no Hospital Couto Maia, Salvador, BA, entre 1993 e 1997. Aumento na precipitação pluviométrica mostrou relação com aumento do número de internamentos no mês subsequente. Sexo masculino correspondeu a 81,1% (824/1.016); a média da idade foi 35,7±15,4 anos. Quase 94% (778/829) dos 829 com informação sobre raça eram negros ou mulatos. Para idade igual ou superior a 18 anos, quase 93% não cursaram o segundo grau. A média do período de incubação foi estimado em 6,3±3,9 dias. A duração dos sintomas foi em média 6,1±2,4 dias. Episódios hemorrágicos corresponderam a 14,3% (145/1.016). A letalidade entre 1.009 pacientes não transferidos foi de 14,2% (143/1.009). Insuficiência renal foi a causa atribuída de morte em 76,2% (109/143). Os dados indicam que leptospirose é estreitamente relacionada com baixos níveis socioeconômicos e que aumento da precipitação pluviométrica precede surtos epidêmicos.

Characteristics of 1,016 patients hospitalized with leptospirosis in the Hospital Couto Maia, Salvador, BA, Brazil, between 1993 and 1997 are described. Higher pluviometric precipitation was related to an increase in the number of hospitalizations during the following month. Males corresponded to 81.1% (824/1,016) of these; mean age was 35.7±15.4 years. Almost 94% (778/829) of the 829 patients with information about race were black or mulatto (mixed race). For ages 18 years or above, almost 93% had not completed high school level. The mean incubation period was estimated as 6.3±3.9 days. Average duration of symptoms was 6.1±2.4 days. Hemorrhagic events corresponded to 14.3% (145/1,016). The case-fatality rate among 1,009 patients that were not transferred was 14.2% (143/1,009). Renal failure was the attributable cause of death in 76.2% (109/143). The data indicate that leptospirosis is closely related to lower socioeconomic levels, and that higher pluviometric precipitation antecedes the outbreaks.

Este relato de caso descreve os achados de um homem de 27 anos, residente na Bahia, Brasil, que desenvolveu paralisia facial durante a fase de convalescença da leptospirose. O paciente se recuperou sem sequela neurológica. Este trabalho chama atenção para uma possível associação entre leptospirose e paralisia facial.

This case report describes the findings of a 27-year-old black male from Bahia, Brazil, who developed facial palsy during the convalescence phase of leptospirosis. The patient recovered without neurological sequel. This work calls attention to a possible association between leptospirosis and facial palsy.

This study was designed to estimate the prevalence of pulmonary radiograph abnormalities and describe the distribution of the patterns of radiographic alterations among patients hospitalized with leptospirosis. Chest radiographs of 139 patients hospitalized with leptospirosis in Couto Maia Hospital, in Salvador, Bahia, Brazil, between July, 1997, and July, 1999, were analyzed. The radiographs were requested soon after hospital admission, independent of the clinical manifestations of the patients. Only the first radiograph was considered. Pulmonary radiograph alterations were recorded in 35/139 patients (25.2%); 95% mid-point confidence interval = 18.5% to 32.9%. Among the patients with radiograph alterations, alveolar infiltrate was seen in 26/35 (74.3%). The lesions were bilateral in 54.3% and located in the inferior lobes in 45.5%. Pleural effusion, represented by blunting of the costo-phrenic angle, was detected in 8.6% of the patients. The pattern of the pulmonary alterations, predominantly bilateral alveolar infiltrates, is consistent with the evidence that the basic pulmonary alteration in leptospirosis is a generalized capillaritis.

Este relato de caso descreve os achados em homem negro com 18 anos de idade, da Bahia, estado do nordeste do Brasil, com estigma falciforme que desenvolveu hifema bilateral e hemorragia vítrea com cegueira no curso de leptospirose. O paciente começou a se queixar de visão embaçada quatro dias após o início da febre e da dor muscular e aproximadamente 12 horas após o início da penicilina. A gravidade da leptospirose em conjunto com o estigma falciforme foi considerada a mais provável explicação para esta complicação ocular.

This case report describes the findings of a 18 year-old black male from Bahia, a Northeastern state in Brazil, with the sickle cell trait, who developed bilateral hyphema and vitreous hemorrhage with blindness in the course of leptospirosis. The patient started to complain of blurred vision four days after the start of fever and muscular pain and approximately twelve hours after the introduction of penicillin. The severity of the leptospirosis in conjunction with sickle cell trait was considered to be the most likely explanation for this ocular complication.