LAUSR

Dear Editor, Leptospirosis is a zoonotic disease that predominates in the tropics and whose incidence increase during the rainy season [1]. In Europe, the disease is often seen in returning travelers from areas where contacts with infecting sources are common [2]. Miailhe et al. [3] describe a French cohort of patients admitted to intensive care units (ICU) with leptospirosis evidencing lower mortality (9%) than in tropical countries [1]. In our region, Brazil, we have observed an important mortality decrease in leptospirosis-associated AKI, from 22% (1980s/1990s) to 11.6% (1990s/2000s) [4], which could be attributable to early diagnosis and treatment improvement. The lower mortality in the French cohort could be explained by the lower prevalence of severe disease (40%) and also the institution of “goldstandard” treatment, including early institution of antibiotics (with a mean of 5 days after the first symptoms). Also different serovars could justify these difference in disease severity. As reported in the French cohort, ICU admissions due to leptospirosis were characterized by a severe disease, and patients were older. Also in our region, age was a predictor of ICU admission [1], but our patients were younger (mean age 36 years) in comparison with the French patients (mean age 54 years), evidencing an important epidemiological difference and a possible difference in exposure (in France 95% of patients had some risk factors for leptospirosis: contact with animals, contact with river or lake water, specific occupations and also recent travel history). In tropical areas, such as Brazil, most people are exposed to the risk of contracting leptospirosis, especially when flooding occur, and this increases the number of cases and make young people more susceptible [1], but patients admitted with leptospirosis in tropical countries refer no clear contact with potent transmitter of the disease. Regarding the clinical manifestations, among the 160 French patients, the most frequent symptoms were fever, myalgia, debilitation, and jaundice, which is similar to what we observe in our region, but we also frequently see as important manifestations in leptospirosis: headache, vomiting, dehydration and chills (in > 60% of the cases) [1]. The cases presented in the French cohort calls attention due to the severity of the disease, as almost all (6/9) patients had died in the first day of ICU admission. Early predictors of death were older age, worse SOFA score and need for invasive ventilation or renal replacement therapy. Previous studies, in our region, even including younger patients, had evidenced that advanced age increases mortality in leptospirosis, but also hypotension, arrhythmias, and oliguria were predictors of mortality [4]. Leptospirosis, in its severe presentation, can have a fatal outcome and can be often forgotten in the differential diagnosis of febrile disease, especially in non-endemic areas, but due to its widespread distribution it should be taken into consideration for every case of severe febrile disease, mainly when there is association of AKI with other manifestations discussed above. Along with clinical evaluation, specific diagnostic scores seem to be useful for this purpose [5].