Mixed infection is a challenge to the treating clinician. Infection like Hepatitis A and Leptospirosis are prevalent in developing countries. The spectrum of clinical severity of both Leptospira and Hepatitis A ranges from mild infection to jaundice. Awareness and appropriate use of investigations can overcome the diagnostic dilemmas.
Keywords: Co infection, Hepatitis A, leptospirosis
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Kumar KJ, Prasad NA, Manjunath VG, Umesh L. Coinfection with hepatitis a and leptospira in jaundice children. Ann Trop Med Public Health 2012;5:523-4
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Kumar KJ, Prasad NA, Manjunath VG, Umesh L. Coinfection with hepatitis a and leptospira in jaundice children. Ann Trop Med Public Health [serial online] 2012 [cited 2020 Nov 26];5:523-4. Available from: https://www.atmph.org/text.asp?2012/5/5/523/105152
Hepatitis A infection occurs throughout the world but occur more frequently in developing countries like India. Hepatitis A accounts for upto 50% of clinically apparent acute viral hepatitis in USA.  Classical presentation of Hepatitis A is that jaundice occurs after prodromal illness like fever and vomiting. However spectrum of leptospirosis ranges from mild infection to severe form of multiorgan dysfunction. Icteric form of leptospirosis occurs in < 10% of cases, and is less common in children.  The majority of leptospira occurs from exposure to water contaminated with rat urine. Spread of Hepatitis A is predominantly by faeco-oral route. The mean incubation period of HAV is about 3-4 weeks whereas it is 2-20days for leptospira. , Similar clinical presentation and simultaneous transmission of these diseases can cause substantial misdiagnosis. We report two febrile jaundiced children in whom Hepatitis A and leptospirosis coexisted.
Eight year female presented with fever, headache, vomiting since five days. On examination child was febrile and vitals were stable. She was dehydrated, had pallor, icterus, bilateral conjunctival suffusion and no rash or bleeding. She had tender hepatomegaly of 6 cm and 1 cm splenomegaly. Rest of the systemic examination was normal. Child was diagnosed to have acute hepatitis and was investigated for Hepatotrophic viruses, malaria, dengue, enteric fever and leptospirosis. Investigations include Hb-9.2gm/ dL, TC-3,900/cu.mm, Platelet-42, 000/ cumm, PCV-25. Blood glucose- 146mg/dL, Serum bilirubin 9.18mg/ dL,Direct bilirubin -7.29mg/dL,AST-1739 U/L, ALT-2002 U/L, Alkaline phosphatase-318 U/L, total protein -7.2gm/dL,Albumin-3.9gm/dL. Blood urea-20mg/ dL, serum creatinine -0.8mg/dL and electrolytes were within normal limits. Her blood culture was sterile, Quntitative Buffy Coat (QBC) smear for malarial parasite and widal test were negative. Child was positive for leptospirosis (IgM by ELISA method, PANBIO, Australia) and for Hepatitis A (IgM by ELISA, Bio-Rad, France). Child was negative for HbsAg, Anti HCV, Anti Hepatitis E, and Dengue fever. Chest x-ray was normal. Ultrasonography of the abdomen showed mild ascitis with enlarged normal echo texture liver. She was started on Inj Crystalline Penicillin 2 lakh units/kg/day. After four days of Crystalline penicillin, she became afebrile, icterus reduced, liver 1 cm and her appetite improved. Her platelets returned to normal (2.2lakhs/cu.mm). After two weeks Liver function tests and ultrasonography were normal. She was followed up for six weeks without complications.
12 year female presented with fever, pain abdomen, vomiting since seven days and jaundice of four days. On examination child was febrile. Her vitals were stable. She was dehydrated, had pallor, icterus and no rash or bleeding. She had tender hepatomegaly of 3cm and just palpable spleen. Rest of the systemic examination was normal. Child was diagnosed to have acute hepatitis and was investigated for Hepatotrophic viruses, malaria, dengue, enteric fever and leptospirosis. Lab findings include Hb-11.2gm/dL, TC-3800/cu.mm, Platelet-1.9 lakhs/cumm, PCV-38. Blood glucose- 102mg/dL, Serum bilirubin 8.4mg/dL,Direct bilirubin -5.5mg/dL, AST-4020 U/L,ALT-3570 U/L, Alkaline phosphatase-340 U/L, PT 26 sec(INR1.79), APTT 47 sec, total Proteins -6.8gm/dL, albumin-3.3 gm/ dL. Blood urea-21mg/dL, serum creatinine -0.8mg/dL and electrolytes were within normal limits. Her blood culture was sterile, QBC negative, Widal test were negative. Child was positive for leptospirosis (IgM by ELISA, PANBIO, Australia) and for Hepatitis A (IgM by ELISA, Bio-Rad, France). Child was negative for HbsAg, Anti HCV, Anti Hepatitis E, and Dengue fever. Chest x-ray was normal. Ultrasonography of the abdomen showed mild ascitis with enlarged normal echo texture liver and enlarged spleen. She was started on Inj Crystalline Penicillin 2 lakh units/kg/day. After seven days she became afebrile, icterus reduced and her appetite improved. After 2 weeks Liver function tests and ultrasonography were normal. She was followed up for six weeks without complications.
Icteric Leptospirosis is a severe form of human leptospirosis occurring in 10% of patients.  Hepatic involvement develops in immune phase, which lasts for 10-30 days. In Hepatitis A by the time jaundice appears fever disappears. Acute fever with jaundice is diagnostic challenge to the clinicians because many infections caused by hepatotrophic viruses, malaria, enteric, leptospira, dengue can present in a similar way. Diagnosis of leptospirosis in our case was confirmed by using modified Faini’s criteria.  Thrombocytopenia occurs in more than 50% of pediatric leptospirosis whereas in 4.1% of acute hepatitis A infection. , Our first case also had thrombocytopenia and it may be because of concurrent involvement by two infections. Our first patient was investigated in detail mainly because of high-grade fever, headache, jaundice and conjunctival suffusion and the second case because of acute fever with jaundice. Spectrum of clinical severity of both Leptospira and Hepatitis A ranges from mild infection to jaundice. Coinfection of leptospira and Hepatitis A could be due to exposure of our patient to water contaminated with both organisms. Rodents and domestic animals harbor leptospira and shed the bacteria in urine. They may disseminate the organism to drinking water source. , Cases with mixed infection in clinical practice are diagnostic dilemma to medical fraternity. Various co-infections with Leptospira have been reported with malaria, dengue, and enteric fever. , Out of 32 leptospirosis patients, five patients also had co infection with other pathogens; including typhoid, malaria, and Hepatitis C.  Even Hepatitis E and Hepatitis B co infection with Leptospira reports are also available. ,, Mixed infection with hepatitis A was observed in one patient out of 86 leptospirosis cases in a study from India; however details regarding jaundice in that mixed infection case were not mentioned.  Because of epidemiological similarieties it is not unusual to see leptospirosis with other infections in tropical countries. Our cases are probably the first report of mixed infection of Hepatitis A and Leptospira in jaundiced children to the best our knowledge. It is imperative to look for leptospira in appropriate setting particularly if jaundice is associated with fever and conjunctival suffusion. It is important that high index of suspicion should be there in endemic areas. Appropriate use of antimicrobials like crystalline penicillin may be lifesaving and decreases the mortality in leptospira. Awareness and optimal use of microbiology lab can overcome such diagnostic dilemmas.
|1.||Azmi P. Leptospira. Yazigi N, Balisteri WF. Viral Hepatitis. In: Kleigman, Behrman, Jensen, Stanton, editors. Nelson Textbook of Pediatrics, 18 th ed., Philadelphia, New York: Saunders Elsevier; 2008. p. 1271-2, 1680-2.|
|2.||Spleelman P, Hartskeerl R. Leptospirosis.Dienstag JL. Acute viral hepatitis. In: Fauci, Braunwald, Kasper, Hauson, Lango, Jameson, Loscalzo, editors. Harrison’s Principles of Internal medicine, 17 th ed, vol 2, USA: McGraw Hill Medical; 2008. p. 1048-51, 1932-48.|
|3.||Shivakumar S, Shareek PS. Diagnosis of Leptospirosis utilizing modified Faine’s Criteria. J Assoc Physicians India 2004;52:678-9.|
|4.||Akarsu S, Erensoy A, Elkiran O, Kurt A, Kurt AN, Aygun AD. Haematological abnormalities in patients with acute viral Hepatitis A and Hepatitis B. J Pediatr Infect 2008;3:90-5.|
|5.||Chaudhry R, Premlatha MM, Mohanty S, Dhawan B, Singh KK, Dey AB. Emerging Leptospirosis, North India. Emerg Infect Dis 2002;8:1526-7.|
|6.||Chaudhary R, Pandey A, Das A, Broor S. Infection potpourri: Are we watching? Indian J Pathol Microbiol 2009;52:125.|
|7.||Cos J, Patel PK, Kumbum K, Fuentes GD, Venkataram S. Coinfection with Hepatitis E and Leptospirosis. Chest 2008;134:c52.|
|8.||Kaushik SP, Yim HB, Tan CC. Weil’s syndrome and Concomitant Hepatitis B Infection. Singapore Med J 1999;40:104-5.|
|9.||Chaudhary R, Suryanarayana BS, Pandey A, Dey AB, Acharya SK. P-19.Co infection of Hepatitis viruses and Leptospira in hepatic failure patients. Indian J Virol 2009;20:39.|
|10.||Sethi S, Sharma N, Kakkar N, Taneja1 J, Chatterjee1 SS, Banga1 SS, et al. Increasing trends of leptospirosis in northern India: A clinico-epidemiological study. PloS Negl Trop Dis 2010;4:e579.|
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