Annals of Tropical Medicine and Public Health

CASE REPORT
Year
: 2013  |  Volume : 6  |  Issue : 2  |  Page : 261--262

Mild self resolving acute leptospirosis in an HIV infected patient in south India


Anand Pai 
 Department of General Medicine, Aarupadai Veedu Medical College and Hospital, Puducherry, Tamil Nadu, India

Correspondence Address:
Anand Pai
Old No 19; New No 2, Third Street Habibullah Road, Tnagar, Chennai, Tamil Nadu
India

Abstract

Leptospirosis is a zoonotic disease that occurs throughout the world. Clinical manifestations range from asymptomatic serological conversion to acute undifferentiated fever to malignant presentation with jaundice, renal failure in human immunodeficiency virus (HIV) patients. Here with we report a case of mild self resolving form of acute leptospirosis in a HIV patient as such cases are very sparse and reported in India.



How to cite this article:
Pai A. Mild self resolving acute leptospirosis in an HIV infected patient in south India.Ann Trop Med Public Health 2013;6:261-262


How to cite this URL:
Pai A. Mild self resolving acute leptospirosis in an HIV infected patient in south India. Ann Trop Med Public Health [serial online] 2013 [cited 2020 Apr 8 ];6:261-262
Available from: http://www.atmph.org/text.asp?2013/6/2/261/116511


Full Text

 Introduction



Leptospirosis is a zoonotic disease caused by spirochetes from the genus Leptospira and is typically transmitted via contact with urine from infected animals. The clinical presentation of the disease is an acute biphasic febrile illness with or without jaundice. Unusual clinical manifestations may result from involvement of pulmonary, cardiovascular, neural, gastrointestinal, ocular, and other systems. Immunological phenomena secondary to antigenic mimicry may also be an important component of many clinical features and may be responsible for reactive arthritis. There are only few cases reported of leptospirosis in human immunodeficiency virus (HIV) infected individuals [1],[2],[3] but no generalization can be made due to paucity of data.

 Case Report



A 45-year-old male patient presented with the history of low grade intermittent fever, vomiting, loose stools, and high colored urine since 4 days. Patient was married since 15 years and had three children. On detailed history patient was found to be a promisquous individual and gave history of extramarital unprotected contact with a commercial sex workers. Patient was a chronic smoker and was an occasional alcoholic. On examination, he had anemia and bilateral pedal edema. Respiratory tract examination revealed scattered crepitations while abdomen was soft, distended. Liver was palpable 4 cm below right diaphragm, tender and smooth in consistency. Other systems were clinically normal. His platelet count was 40,000, creatinine was 1.4, and urea was 90 mg. Liver function test showed that serum alkaline phosphate was 230 units/L, direct bilirubin 1.7 mg, indirect bilirubin 2.2 mg, and total bilirubin 3.9 mg. His serology for microscopic agglutination test (MAT) was positive for leptospirosis and was confirmed by high concentration of leptospira in urine sample by Taqman-based real-time polymerase chain reaction (PCR). His widal and dengue serology was negative. Ultrasound abdomen showed hepatosplenomegaly with fatty infiltration of liver. Chest X-ray showed bilateral bronchectatic changes. He tested positive for HIV and CD4 count done was in the lower margin. Patient was treated with Inj. crystalline penicillin and other supportive drugs. After one week, patient's symptom had improved significantly and was nonicteric and a repeat liver function tests were normal. Patient was referred to antiretroviral therapy (ART) center for further treatment of retroviral disease.

 Discussion



Worldwide there is high prevalence of leptospirosis in tropical areas both in rural and urban settings. [4] Leptospirosis is not an acquired immune deficiency syndrome (AIDS) defining illness. In contrast to the usual exaggerated course of various infective diseases in patients with HIV, our patient had only mild icteric form of leptospirosis. The reason may be that the patient's humoral immunity, which is primarily against leptospirosis lipopolysaccharide (LPS) mediates recovery from acute leptospirosis and protects against re-infection. [5] As a T-cell independent antigen, leptospiral LPS would be predicted to induce antibody in the absence of CD4 helper T cell. [6] This T cell independency explains the milder course and high modified agglutination test (MAT) titer during acute infection despite likely advanced HIV immunodeficiency states. In natural course of leptospirosis there is an immunological response to the infection during the later immune phase of leptosirosis. In HIV patients, during later immune phase of leptosirosis there is a misregulation and aberration in antigen antibody reactions so thatthere is an exaggerated end organ failure leading to severe forms of leptospirosis in patients with HIV. It is understood that acute leptospirosis in HIV coinfections not inevitably severe and clinical manifestation may be mild as in immunocompetent hosts. [1],[2],[3] Clinical presentation and complications likely depend on a combination of virulency potential difference that vary between pathogenic leptospira and host genetic non T-cell dependent innate immunity.

 Conclusion



We conclude that acute leptospirosis in HIV coinfection is not inevitably severe and that there is probably wide variation in clinical manifestations similar to what occurs in immuno-competent hosts. Clinical presentations and complications likely depend on a combination of virulence potential differences that vary between pathogenic Leptospira and host genetics of non T-cell-dependent innate immune responses. A prospective cohort study in an HIV and leptospirosis dually endemic area would be necessary to establish definitively whether HIV infection alters the course of leptospiral infection, either acutely or in chronic infection, as it does for Treponema pallidum, the agent of another spirochetal disease, syphilis, which lacks the T-independent LPS antigen. [7]

References

1Jones S, Kim T. Fulminant leptospirosis in a patient with human immunodeficiency virus infection: Case report and review of the literature. Clin Infect Dis 2001;33:E31-3.
2Neves Ede S, Pereira MM, Galhardo MC, Caroli A, Andrade J, Morgado MG, et al. Leptospirosis patient with AIDS: The first case reported. Rev Soc Bras Med Trop 1994;27:39-42.
3Ganoza CA, Segura ER, Swancutt MA, Gotuzzo E, Vinetz JM. Mild, self-resolving acute leptospirosis in an HIV-infected patient in the Peruvian Amazon. Am J Trop Med Hyg 2005;73:67-8.
4Bharti AR, Nally JE, Ricaldi JN, Matthias MA, Diaz MM, Lovett MA, et al. Peru-United States leptospirosis consortium. Leptospirosis: A zoonotic disease of global importance. Lancet Infect Dis 2003;12:757-71.
5da Silva MV, Batista L, Camargo ED, Leitao PA, Szalkay VG, Rosenthal C, et al. Leptospirosis in patients with anti-HIV antibodies: Report of 2 cases. Rev Soc Bras Med Trop 1990;23:229-31.
6Shih TA, Roederer M, Nussenzweig MC. Role of antigen receptor affinity in T cell-independent antibody responses in vivo. Nat Immunol 2002;3:399-406.
7Lynn WA, Lightman S. Syphilis and HIV; a dangerous combination. Lancet Infect Dis 2004;4:456-66.