Hypotension renal failure and pulmonary complication in leptospirosis

Hypotension, renal failure and pulmonary complication in leptospirosis Kannika Niwattayakul, M. D. , Orawan Khow, M. S. , And Visith Sitprija, M. D. , Ph. D. Department of Medicine, Loei Hospital, Loei Queen Saovabha Memorial Institute, Bangkok, Thailand

Number of patients (deaths) of leptospirosis in Thailand 10, 084 8 2 - - 7 4 1990 1991 1992 1993 1994 1995 19 113 102 266 1997 1998 1999 2000 365 169 20012544

Leptospirosis ���� �� �. �. 2540 ��������� / ������� / ��� ��� (% ������� ) 2334/113 ) (% ������� 2239/109 ) (% ����� 30/2 (4. 8%) (6. 6%) 2541 2226/103 2005/90 (4. 0%) 58/4 (6. 8%) 2542 5926/254 5333/216 382/10 2543 3424/360 11629/286 845/12 2544 11129/180 3673/38 1402/18 (4. 6%) (4. 3%) (2. 7%) (1. 6%) (4. 1%) (2. 5%) (1. 1%) (2. 6%) (1. 4%) (1. 3%)

แนวทางการดแลรกษาผปวย Leptospirosis Diagnosis : CBC, platelet count , U/A VS, BP, Pulse, temp, RR. ����������� Rx OPD case Admit Specific treatment - ������� - BP<90/60 - PGS 2 mu V ทก 6 hr - BP > 90/60 - plt. count<100, 000 - Ceftriaxone 2 gm V ถา BP < 90/60 - plt. >100, 000 Supportive treatment -����� 3 - ����� < 24 ���������� - Lung hemorrhage ����� /���� �� - ��� Doxy 1 x 2 - clinical suspected�� Fu��� - Shock + amoxy 2 x 3 - ��� + ������ + Cr - Acute renal failure ���� pen. V 1 x 4 - ��� + ����- Hyperbilirubinemia - Fu ��� 1 ��� 3 -4 ����� - Thrombocytopenia ����� - ��� + ����������� - ��� + CXR abnormal

การรกษา Specific sepsis) Supportive : PGS 2 mu IV ทก 6 ชม. X 7 วน : Add Ceftriaxone 2 gm IV OD (ถาม : Hypotension : : Thrombocytopenia c bleeding Acute renal failure Respiratory failure Hyperbilirubinemia clinical

Clinical manifestation in leptospirosis Fever Headache Muscle tenderness Conjunctival suffusion Jaundice Hepatomegaly Cough Patient 144 92 91 49 31 11 Percent 97. 3 62. 2 61. 5 33. 1 20. 9 19. 6

Clinical manifestation in leptospirosis Diarrhae GI hemorrhage Bleeding per gum Epitaxis Hemoptysis Sore throat Patient Percent 7 4. 7 6 4. 1 5 3. 4 2 1. 4

Clinical manifestation in leptospirosis Patient Percent Hypotension Impaired renal function Pulmonary complication ARDS Pulmonary hemorrhage Interstitial pneumonitis Pulmonary edema 94 85 32 14 9 6 3 64 58 22 10 6 4 2

Clinical manifestation in leptospirosis Total bilirubin > 2. 5 mg/dl Hyperbilirubinemia Thrombocytopenia Hyperkalemia (K > 5 mmol/L) Hypokalemia (K< 3. 5 mmol/L) Abnormal urine finding G-6 -PD deficincy Patient Percent 60 40. 5 21 14 61 41 9 6 38 26 90 61 34 24

Hypotension Normal renal function creatinine ( mg/dl ) prerenal azotemia Creatinine (mg. /dl) Acute renal failure Creatinine (mg. /dl) Pulmonary complication Pulmonary hemorrhage Pulmonary ededma ARDS Pneumonitis Hypotension ( n = 94 ) Normotension ( n = 54 ) 30 (32%) 0. 9 0. 1 30 (32%) 3. 0 0. 9 34 (36%) 8. 2 2. 7 31 8 3 14 6 33 (61%. ) 1. 0 0. 1 16 (30%) 2. 9 0. 9 5 (5%) 4. 9 1. 7 1 0 0 0 1

Impaired renal funtion Creatinine >1. 5 mg/dl ( 85 patient ) Prerenal (n = 46 ) ARF (n=39) BUN (mg/dl) 60 11. 2 88. 6 2. 4 Cr (mg/dl) Onset Duration Hypotension nonicteric 3 0. 9 6. 5 2. 1 3 day 5 day 30 18 28 3 0 1 0 2 4 day 12 day 34 13 26 29 14 8 3 4 Lung complication -ARDS -Pulmonary Hge - Pulmonary edema -Pnuemonitis

Renal and pulmonary complication in Hypotensive and Normal renal function normotensive patients HT NT (N=30) Serum creatinine(mg/dl) On admission Pulmonary hemorrhage Pulmonary edema ARDS Pneumonitis 0. 9+0. 1 HT (N=33) ARF Pre-renal azotemia NT HT NT (N=30) (N=16) (N=34) (N=5) 1. 0+0. 1 3. 0+0. 9 2. 9+0. 9 8. 2+2. 7 4. 9+1. 7 0 0 1 0 8 0 0 0 3 0 0 0 14 0 0 1 1 4 Admission after onset (day) 2. 8+1. 1 HT : hypotension; NT : normotension 2. 7+1. 1 3. 2+1. 2 3. 1+1. 2 4. 4+1. 5 0 0 4. 4+1. 4

Out come Hemodilysis 7 ��� Peritoneal dialysis 2 ��� PD+HD 1 ��� Blood Exchange 9 ��� Tube on respirator 18 ���

Out come Complete recovery Dead 143 ��� 5 ��� ( mortality 3. 4 % ) Pulmonary Hge 3 ��� ARDS c Sepsis 1 ��� Pneumonia c Sepsis 1 ���