Pulmonary haemorrhage as a frequent cause of death among patients with severe complicated Leptospirosis in Southern Sri Lanka
Authors: Fonseka CL , Dahanayake NJ , Mihiran DJD , Mithunika AWK , Nawanjana HLL , Wickramasuriya HS , Wijayaratne WMDGB , Sanjaya K , Bodinayake CK 
Published: May 2023

Background

Leptospirosis is a tropical disease associated with life threatening complications. Identifying clinical and investigation-based parameters that predict mortality and morbidity is vital to provide optimal supportive care.

Methods

We conducted a prospective observational study in an endemic setting, in the southern Sri Lanka. Consecutive patients having complicated leptospirosis were recruited over 18 months. Clinical, investigational and treatment data were collected and the predictors of mortality were analysed.

Results

Out of 88 patients having complicated leptospirosis, 89% were male. Mean age was 47yrs (+16.0). Among the total, 94.3% had acute kidney injury, 38.6% had pulmonary haemorrhages, 12.5% had fulminant hepatic failure, 60.2% had hemodynamic instability and 33% had myocarditis. An acute significant reduction of haemoglobin (Hb) was observed in 79.4% of patients with pulmonary haemorrhage. The mean Hb reduction of patients with pulmonary haemorrhage was 3.1g/dl. The presence of pulmonary haemorrhage (PH) and hemodynamic instability within first 48 hours of admission significantly predicted mortality(p<0.05) in severe Leptospirosis. Additionally, within first 48 hours of admission, elevated SGOT, presence of atrial fibrillation, presence of significant haemoglobin reduction, higher number of inotropes used, prolonged shock, invasive ventilation and admission to ICU significantly predicted morality. Out of organ complications in the first week of illness, pulmonary haemorrhage and fulminant hepatic failure (FHF) combination had significant adjusted odds of mortality (OR=6.5 and 4.8, p<0.05). Six patients with severe respiratory failure due to PH underwent ECMO and four survived. The overall mortality in complicated leptospirosis was 17%. In PH and FHF, the mortality rate was higher reaching 35.4% and 54.5%, respectively.

Conclusions

Within first 48 hours of admission, organ complications such as pulmonary haemorrhage and haemodynamic instability and other parameters such as atrial fibrillation, acute haemoglobin reduction, elevated SGOT level could be used as early parameters predictive of mortality in severe Leptospirosis. PH and FHF within the first week of admission in leptospirosis are associated with high morbidity and mortality requiring prolonged ICU care and hospitalisation. Above parameters could be used as parameters indicating severity for triaging and intensifying treatment. Using ECMO is a plausible treatment option in patients with severe pulmonary haemorrhage.

Author summary

Leptospirosis is a tropical infectious disease predominantly affecting the lower socioeconomic groups in Sri Lanka. It is associated with significant morbidity and mortality, especially in an endemic setting. Hence, it is vital to identify clinical and biochemical parameters that can predict mortality for triaging and for escalation of care. We observed that pulmonary haemorrhage, myocarditis, hemodynamic instability and hepatic dysfunction are frequent complications of leptospirosis in southern Sri Lanka. Additionally, we identified that mortality was associated with the presence of two major complications of leptospirosis: pulmonary haemorrhage and haemodynamic instability. Therefore, early detection of these two complications along with other parameters that predict mortality such as elevated SGOT levels on admission, acute haemoglobin reduction, atrial fibrillation, prolonged shock and need for invasive ventilation would assist to recognise critically ill patients. Within the first week of admission, PH and development of FHF predicted mortality. One-third our population had acute kidney injury in isolation and they had lesser mortality. Other organ complications were almost always detected in combination and were associated with a higher mortality. Pulmonary haemorrhage was detected in one-third of patients and the majority warranted intensive care. Other than usual treatment modalities, ECMO (Extracorporeal Membrane Oxygenation) was used in six patients with critical respiratory failure due to pulmonary haemorrhage, where four survived. Out of the total group of complicated leptospirosis, in excess of one-third required intensive care treatment and 17% succumbed. Additionally, we mapped the leptospirosis prevalence rate in Galle district, and observed that severe cases are detected in specific localities. These features are helpful in early detection of severe disease and proactive management for those who are having predictors of mortality.