Leptospirosis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [2]

Overview

Leptospirosis must be differentiated from other diseases that cause fever, diarrhea, nausea and vomiting, such as ebola, typhoid fever, malaria, yellow fever, shigellosis, and other enteric bacterial infections. Moderate to severe leptospirosis must be differentiated from dengue fever.

Differential diagnosis

Differential diagnosis list for leptospirosis is very large due to diverse symptomatics. For forms with middle to high severity, the list includes dengue fever and other hemorrhagic fevers, hepatitis of various etiologies, viral meningitis, malaria and typhoid fever. Light forms should be distinguished from influenza and other related viral diseases. Specific tests are a must for proper diagnosis of leptospirosis. Under circumstances of limited access (e.g., developing countries) to specific diagnostic means, close attention must be paid to anamnesis of the patient. Factors like certain dwelling areas, seasonality, contact with stagnant water (swimming, working on flooded meadows, etc) and/or rodents in the medical history support the leptospirosis hypothesis and serve as indications for specific tests (if available).

The table below summarizes the findings that differentiate Leptospirosis from other conditions that cause fever, diarrhea, nausea and vomiting:

Disease Findings
Ebola Presents with fever, chills vomiting, diarrhea, generalized pain or malaise, and sometimes internal and external bleeding, that follow an incubation period of 2-21 days.
Typhoid fever Presents with fever, headache, rash, gastrointestinal symptoms, with lymphadenopathy, relative bradycardia, cough and leucopenia and sometimes sore throat. Blood and stool culture can confirm the presence of the causative bacteria.
Malaria Presents with acute fever, headache and sometimes diarrhea (children). A blood smears must be examined for malaria parasites. The presence of parasites does not exclude a concurrent viral infection. An antimalarial should be prescribed as an empiric therapy.
Lassa fever Disease onset is usually gradual, with fever, sore throat, cough, pharyngitis, and facial edema in the later stages. Inflammation and exudation of the pharynx and conjunctiva are common.
Yellow fever and other Flaviviridae Present with hemorrhagic complications. Epidemiological investigation may reveal a pattern of disease transmission by an insect vector. Virus isolation and serological investigation serves to distinguish these viruses. Confirmed history of previous yellow fever vaccination will rule out yellow fever.
Shigellosis & other bacterial enteric infections Presents with diarrhea, possibly bloody, accompanied by fever, nausea, and sometimes toxemia, vomiting, cramps, and tenesmus. Stools contain blood and mucous in a typical case. A search for possible sites of bacterial infection, together with cultures and blood smears, should be made. Presence of leucocytosis distinguishes bacterial infections from viral infections.
Dengue Presence of atypical lymphocytosis in blood differentiate it from leptospirosis.[1]
Others Viral Hepatitis, rheumatic fever, typhus, and mononucleosis

Differential Diagnosis for Hemorrhagic fever

Disease Incubation period Vector Symptoms Physical signs Lab findings Other findings Treatment
Fever Cough Rash Joint pain Myalgia Diarrhea Common hemorrhagic symptoms Characterestic physical finding Icterus Characteristic lab finding Plasma Creatine kinase Confirmatory test
Leptospirosis 2 to 30 days Rodents

Domestic animals

Fever last for 4-7 days, remission for 1-2 days and then relapse Present over legs, Hemorrhagic rash

(Severe myalgia is characteristic of leptospirosis typically localized to the calf and lumbar areas)

conjunctival hemorrhage,

Hemoptysis

Conjunctival suffusion Elevated Microscopic agglutination test of urine History of exposure to soil or water

contaminated by infected rodents

Recent history travel to tropical, sub tropical areas or humid areas

NSAIDs
Dengue 4 to 10 days Aedes mosquito Fever last for 1-2 days,

remission for 1-2 days and then relapse for 1-2 days (Biphasic fever pattern)

X Over legs and trunk

pruritic rash May be hemorrhagic

X Upper gastrointestinal bleeding X Elevated hematocrit,

Drop in platelet count,

Atypical lymphocytes

Serology showing positive IgM or IgG Recent travel to South America, Africa, Southeast Asia Supportive care

Avoid aspirin and other NSAIDs

Malaria
  • Plasmodium falciparum: 9-14 days
  • Plasmodium vivax: 12-18 days
  • Plasmodium ovale: 18-40 days
Female Anopheles Fever present daily or on alternate day or every 3 days depending on Plasmodium sps. X No rash X X Bloody urine Hepatosplenomegaly Hemolytic anemia showing
  • Hemoglobinuria
  • Elevated indirect bilurubin
  • Low hepcidin
Normal Giemsa stained thick and thin blood smears Recent travel to South America, Africa, Southeast Asia Anti malarial regimen
Ebola 2 to 21 days. No vector

Human to human transmission

Air born disease

Maculopapular,

non-pruritic rash with  erythema

Centripetal distribution

May be bloody in the early phase

Epistaxis

Mucosal bleeding

Influenza 1-4 days No vector

Air born disease

✔/X X X Normal Viral culture or PCR Health care workers

Patients with co-morbid conditions

Symptomatic treatment

Oseltamivir or zanamivir

Yellow fever 3 to 6 days Aedes or Haemagogus species mosquitoes X X X
Typhoid fever 6 to 30 days No vector

Air born disease

X Blanching erythematous 

maculopapularlesions on the lower chest and abdomen

Intestinal bleeding Rose spots X Blood or stool culture showing salmonella typhi sps. Residence in endemic area

Recent travel to endemic area

References

  1. Levett, P. N. (2001). "Leptospirosis". Clinical Microbiology Reviews. 14 (2): 296–326. doi:10.1128/CMR.14.2.296-326.2001. ISSN 0893-8512.