ORIGINAL ARTICLE
Pulmonary Involvement Predicts Mortality in Severe Leptospirosis Patients Eko Budiono, Sumardi, Bambang Sigit Riyanto, Barmawi Hisyam, Anggoro Budi Hartopo Department of Internal Medicine, Faculty of Medicine, Gadjah Mada University-Dr. Sardjito Hospital. Jl. Kesehatan Sekip no. 1, Yogyakarta. Correspondence mail to:
[email protected]
ABSTRACT Aim: to evaluate the influence of pulmonary involvement at admission in predicting mortality among patients with severe leptospirosis. Methods: reprospective cohort study from medical record registry in Dr. Sardjito Hospital, Yogyakarta from 2003 to 2007. Pulmonary involvement was defined by the presence of pulmonary infiltrate, consolidation or pleural effusion in thorax radiography. Pulmonary edema was excluded. Admission data were collected. Follow-up records were noted until patients were discharded or died. The correlation between predictors (some patient characteristics on admission) and outcome (mortality) were evaluated using univariate analysis, and then proceeded to multivariable logistic regression analysis. P < 0.05 is considered statistically significant. Results: sixty patients with severe leptospirosis as a main diagnosis were evaluated. Fifty-five subjects were eligible for analysis, male patients 37 (67.3%) and mean age 42±15 years old.. Pulmonary involvement was presence in 7 patients (12.7%). In univariate analysis only the presence of meningismus and pulmonary involvement were associated with mortality (p=0.001 and 0.006 respectively). In multivariable logistic regression, pulmonary involvement was independently a strong predictor of mortality (OR 9.9 95%CI (1.17 – 84.03), p=0.035). Conclusion: pulmonary involvement at admission is a strong predictor of mortality among patients with severe leptospirosis. Key words: pulmonary involvement, leptospirosis, meningism, mortality.
INTRODUCTION
Leptospirosis is a zoonotic disease found worldwide. Some animals, both domestic and wild animals, are potential reservoirs for the leptospira species. Transmission usually occurs in the means of direct or indirect exposure to urine or other body fluid of host animals. Clinical manifestations of leptospirosis vary widely. In human, severe leptospirosis mostly results from infection of serovars of icterohemorrhagic serogroup.1,2 Biphasic pattern occurs as clinical presentation of leptospirosis, with acute phase or septicemia during one week followed by another one week of immune phase that is characterized by the production of antibody and excretion of leptospira in urine. Most complication correlated with localization of leptospira in body tissue during immune phase. This usually happens in two weeks from disease onset.2 The majority of leptospirosis infection is subclinical or very mild that patients usually reconvalescent without seeking medication.3 Pulmonary involvement in leptospirosis cases was initially noted by Silverstein. Some subsequent reports showed that pulmonary involvement may become chief manifestation of leptospirosis in some clusters or sporadic cases. The severity of this respiratory disease does not correlate with the presence of icteric sign.3 About 5-10% leptospirosis patients have icteric appearance. This sign does not corrrelate with hepatocellulare necrosis and liver function will return to normal after reconvalescence. Complication of severe leptospirosis involves multisystem derangement. Leptospirosis is the main cause of acute renal failure, which occurs in about 16-40% cases.4 The spectrum of symptoms of pulmonary involvement in leptospirosis ranges from cough, dyspneu, and hemoptysis (mild to severe) to acute respiratory 11
Eko Budiono
distress syndrome (ARDS). Intra-alveolar bleeding can be detected in the majority of patients, even in patient without severe pulmonary symptom. Pulmonary hemorrhage can be so severe that it can lead to lethal outcome. 5 Radiology patterns usually show diffuse small opacities that are discretely disseminated through pulmonary field or confluent to form bigger consolidation area. The severity of radiology patterns correlates directly with the severity of clinical symptom. Other radiology findings are pleural effusion or patchy infiltrate. The presence of infiltrate combined with dyspneu complaint is bad prognostic indicator in severe leptospirosis.2,6 The aim of the study is to evaluate the impact of pulmonary involvement to predict mortality in patients with severe leptospirosis. METHODS Study Design
Retrospective study is done to note and evaluate the patient’s medical record with diagnostic code leptospirosis (code ICD X A27.9). Study Population
Target population is patients hospitalized because of severe leptospirosis. Study population is patients hospitalized in Dr. Sardjito General Hospital with diagnosis leptospirosis (ICD X A27.9) from January 2003 to December 2007. Inclusion criteria : 1) all hospitalized patients with diagnosis leptospirosis (ICD X A27.9) and 2) all male and female patients between 14 and 65 years old. Exclusion criteria: 1) patient died in < 12 after admission, 2) presence of cardiomegaly and pulmonary oedema in thorax x-ray and 3) incomplete medical records (no radiology data).
Acta Med Indones-Indones J Intern Med
level needed at least one time haemodyalisis, pulmonary involvement defined by thorax radiology pattern of pulmonary infiltrate, pneumonia or pleural effusion. All data were recorded at admission. Antibiotic therapy and haemodialysis were noted during the course of disease. Outcome was the death of patients during hospitalization. We did not analyse patients who were transferred to intensive care unit or discharged without doctor permission. Statistical Analysis
Baseline charactheristics were analysed with descriptive analysis. To compare continued data between two groups (deaths and survivors) we use unpaired student T test (normal data) or Mann-Whitney U test (not normal data). Categorical data were compared with Chi-square test or Fisher-exact test. Variables that statistically significant in univariate analysis were then proceeded to multivariable logistic regression analysis to evaluate the correlation between variables with outcome and measure Odds ratio. The statistic is significant if p
