Leptospirosis: complications, causes of death and pathomorphogenesis

Abstract

The purpose of the study The improvement the diagnosis and prognosis of the course of leptospirosis on the basis of the study of characteristics of clinical picture and pathomorphogenesis, determination of the main causes of lethal outcomes at different stages of the disease, in dependence on the level of the management of specialized medical care. Materials and methods There were analyzed medical records and autopsy protocols of 168 patients who died from leptospirosis in the Krasnodar region in 1969-2014 and medical records of 125 patients with both severe course of leptospirosis and the development of multiple organ insufficiency. 4 groups were considered: 1st -patients died in 1969-1988 before applying of efferent methods therapy, 86 lethal cases; 2nd - patients died in 1989-1997, application of hemosorption and hemofiltration, 31 cases; 3rd - 1998-2008, the use of plasmapheresis and immunocorrectors, 33 cases; 4-th group of 18 patients who died in 2009-2014, up-to-date medical assistance. There was studied autopsy material in 55 patients. The etiological role of L.icterohaemorrhagiae was proved in 75% of lethal cases, L.grippotyphosa - in 16.7%, L.sejroe (Mus 24) - in 8.3%. The results of the study In the initial period at the 3-5 days of illness life-threatening events are toxic shock and hemorrhagic syndrome. In the period of the height of disease (2-3 weeks) polyorganic failure in form of acute renal and hepatic insufficiency , and also combination of hemorrhagic syndrome with acute respiratory distress syndrome assume a great significance Starting From the 4th week, the first place in the risk of the development of the unfavorable outcome is occupied by secondary bacterial complications, sepsis and septic shock. Pathomorphological changes at leptospirosis correspond to organ-system lesions typical for Systemic inflammatory response syndrome - SIRS . Multiple organ dysfunction formed in the height of leptospirosis is a consequence not only of the alternative effect of leptospira and its toxins, but the result of immunopathological reactions of systemic inflammation. At the present time of the observation the lethal outcome occurs in average on the 17,9±2,30 day of illness, the average patient day in reanimation unit is prolonged up to 11,2±2,43. DIC and acute respiratory distress syndrome as a components of multiple organ failure, and at the later stages of the disease - pneumonia and sepsis, indicate to the negative forecast. Risk factors for the unfavorable outcome include late hospitalization and the increased percentage of comorbidity (61%). For the determination of the severity and the prognosis of the course of the disease it is worth to use SIRS criteria and Sepsisrelated Organ Failure (SOFA) rating scale of organ dysfunction. The development of lethal outcome with a probability of 70% is determined in cases with the failure of 4 or more functional systems. The total Score on a SOFA scale in lethal outcomes is 18.7 scores at the first week of illness, and 14.5 scores at the 5-6th weeks. Conclusion The main causes of lethal outcomes leptospirosis are determined by the stage of pathogenesis, depend of the stage of the disease and methods of therapy. The treatment of patients with leptospirosis should be carried out in specialized infectious hospitals with ICUs equipped for efferent methods of detoxification.