A case history :A case history A 25 year old man is brought to the Out Patient Department with history of fever of 3 days duration with following symptoms & signs. High grade fever of continuous nature. Generalized aches & severe myalgia. Yellowish discoloration of eyes & urine. Non-specific head ache.


Slide 2:LEPTOSPIROSIS


Introduction :Introduction Leptospirosis is a most widespread zoonotic disease in the world caused by the pathogenic bacteria called leptospires. Human to human transmission occurs only very rarely. Generally it is transmitted by the infected urine of rodents. Case fatality may vary from 0.3 – 8 %. Severe form of leptospirosis is called Weil’s Syndrome Also included as water borne & milk borne disease


Distribution :Distribution Worldwide disease. Most common in tropical & subtropical areas with high rainfall. In India with frequent outbreaks in Maharashtra ,Gujarat,Karnataka , Kerala & Andaman islands especially during the monsoon.


Incidence :Incidence No: of cases worldwide is not known precisely. 0.1 – 1 /100,000 per year in temperate climates. 10 – 100 /100,000 per year in humid tropics. During outbreaks & in high exposure risk groups it may reach >100 per 100,000.


Leptospirosis-synonyms :Leptospirosis-synonyms Mud fever Japanese seven day fever Leptospiral Jaundice Spirochete Jaundice Autumn fever Elippani (mal)


History of Leptospirosis :History of Leptospirosis Adolf Weil described leptospirosis as a disease entity in 1886.


Leptospirosis in India :Leptospirosis in India 1931 – An outbreak in Andaman islands. 1960 – Serological evidence 1983 – An outbreak in cattles Now endemic in all parts of India. All cases of fever with jaundice are now screened for leptospirosis as a mandatory laboratory test.


Leptospirosis in Kerala :Leptospirosis in Kerala Reported in Kerala from 1997 onwards . Increasing trend of incidence is clearly seen. Case fatality rate in 2005 -10.62% 2006 -13.78% up to June 2007 -10.53% Majority of cases occurred in late Monsoon.


Epidemiological determinants :Epidemiological determinants


Causative agent-Leptospira :Causative agent-Leptospira Corkscrew -shaped delicate flexible spirochetes. About 6 – 20 micrometer long & 0.1 micrometer thick. Posses a large number of closely wound spirals & characteristic end hooks. Actively motile.


Leptospira -- :Leptospira -- Too thin to visible under ordinary microscope. dark field micros copy is using. Order-Spirochaetals. Family- Leptospiraceae. Genus- Leptospira


LEPTOSPIROSIS :LEPTOSPIROSIS


Slide 14:LEPTOSPIRA L.INTERRGANS L.BIFLEX ICTERROHAEMORRHAGIAE-SERO.GP Icterrohaemorrhagiae,copenhageni,smithi etc Serovar OVER 200 SEROVARS HAVE BEEN IDENTIFIED & ASSEMBLED IN 23 SEROGROUPs. A new serovar Barathy strain Kolenchery belonging to the Austarlis group has been identified from Kerala.


Natural maintenance hosts & serovars :Natural maintenance hosts & serovars Rats – icterohaemorrhagiae,copenhageni & smithi, etc Dogs – canicola etc Cattle – pomona ,hardjo ,etc


resistance- leptospira :resistance- leptospira Very susceptible to heat 10 mnts at 50 degree centigrade 10 seconds in 60 degree centi: Sensitive to acid Readily destroyed by chlorine


Reservoir of infection :Reservoir of infection Rodents –(Rattus rattus ,Rattus norvegicus, Mus musculus ) Dogs Wild animals Domesticated animals Caged game animals


Source of infection :Source of infection Leptospires are excreted in the urine of infected animals ,rodents etc.


Host factor :Host factor Age –most affected age group is 20-40 yrs Children acquire infection from domestic dogs Sex - males are more prone to get infection Occupation – agricultural & live stock farmers Immunity – Asolid serovar specific immunity follows an infection


Risk groups :Risk groups Agricultural & Live stock farmers Workers in rice fields & sugar cane fields Underground sewers Meat & animal handlers Swimmers


Environmental factors :Environmental factors Endemic in many countries. Has a seasonal distribution. Associated with Poor housing Limited water supply Inadequate method of waste disposal Rodent intensity.


Leptospirosis as Epidemic- :Leptospirosis as Epidemic- Associated with 1. Changes in human behavior 2. Contamination of water by animal / sewage 3. Changes in animal reservoir density 4. Follow natural disasters like cyclones & floods


Slide 23:BLOOD TISSUES ORGANS CONVOLUTED TUBULES OF KIDNEY URINE LEPTOSPIRA Leptospires in the body


Incubation period :Incubation period Usually 10 days Range- 4-20 days


Mode of transmission :Mode of transmission 1. Direct contact with urine or tissue of infected animal a.through skin abrasions b.intact mucus mem: 2. Indirect contact- a.broken skin with infected soil,water or vegetation b.through ingestion of food & water contaminated with leptospira 3. Droplet infection- inhalation of droplets of infected urine


Pathogenesis of severe disease :Pathogenesis of severe disease Leptospira Damage to small blood vessels vasculitis Direct cytotoxic injury Immunological injury Massive migration of fluid from Intravesicular to interstitial compartment Renal dysfunction,vascular injury To internal organs


Clinical variety :Clinical variety 1.Mild / Anicteric Presents with fever , myalgia conjunctival suffusion & head ache. 2. Severe (Weil’s syndrome ) / Icteric Present with jaundice & renal failure along with all features of mild cases Multiple organ involvement manifest as different complications.


Clinical patterns-as per WHO :Clinical patterns-as per WHO 1. Mild –influenza like illness 2. Weil’s syndrome characterised by jaundice,renal failure,haemorrhage, &myocarditis with arrhythimias 3. Meningitis/ Meningo encephalitis 4. Pulmonary haemorrhage with respiratory failure


SYMPTOMS :SYMPTOMS Leptospirosis in humans may show a wide variety of symptoms and signs including: fever; severe headache; myalgias; conjunctival suffusion; jaundice; general malaise; stiff neck; chills; abdominal pain; joint pain; anorexia; nausea; vomiting;


SYMPTOMS-- :SYMPTOMS-- – diarrhoea; – oliguria/anuria; – haemorrhages; – skin rash; – photophobia; – cough; – cardiac arrhythmia; – hypotension; – mental confusion; – psychosis; – delirium.


diagnosis :diagnosis Suspected clinically by Deep jaundice Sub- conjunctival haemorrhage Muscle tenderness Decreased urine output Possible exposure to rat’s urine


Laboratory diagnosis :Laboratory diagnosis Dark field microscopy (MAT) Culture from blood (IgM ELISA) PCR Blood-First week. Urine-Second up to sixth week (intermittently). ELISA- Genus specific. MAT – Serovar / serogroup specific. RAPID Test – Lepto- Tek –Dri –Dot.


Diagnosis by lab methods :Diagnosis by lab methods Presence of proteinuria, RBC ,cell casts. Polymorphonuclear leucocytosis & high ESR. Thrombocytopenia in peripheral smear. Elevated serum creatinine. Positive Weil’s antibody test.


Differential diagnosis :Differential diagnosis Influenza; Dengue and dengue haemorrhagic fever; Yellow fever and other viral haemorrhagic fevers; Malaria Pyelo nephritis Aseptic meningitis Viral hepatitis Typhoid & other enteric fevers


Complications :Complications Renal failure Acute hepatic failure Acute cardio vascular failure Haemorrhage Meningitis pneumonia


Prognosis :Prognosis Mortality of severe leptospirosis is high . range varies =3.5 to 40 %


Cause of death :Cause of death Renal failure Cardio pulmonary failure Widespread haemorrhage Liver failure rare


Recovery from Leptospirosis :Recovery from Leptospirosis Most patient recover completely. Some patients may take months/years. Late sequlae may occur.


Late complications :Late complications Chronic fatigue Neuro-psychiatric sym : - Headache ,paresis ,paralysis ,mood swings & depression. Uveitis & Iridocyclitis


Management :Management


General measures :General measures Complete bed rest Light easily digestible diet Plenty of oral fluids Anti-pyretic medication as needed Patients with complication shall be admitted Sodium, pottassium & phosphorus may be restrictd Nephrotoxic drugs should be avoided


Treatment :Treatment Penicillin is the drug of choice when given early -7 days. If penicillin allergic tetracycline /erythromycin.


Hepatic involvement :Hepatic involvement Jaundice- mild to severe starts 4-7 days following illness acute liver failure is rare elevation of serum bilirubin with raised alkaline phosphatase, CPK is very much elevated. Treatment- mainly symptomatic & supportive. Hephatic encephalopathy- proteins restricted. Coagulation failure is corrected with Vit-K.


RENAL INVOLVEMENT :RENAL INVOLVEMENT Invariably seen in all cases. Urine is abnormal with cells ,BUN Creatinine levels elevate later Renal failure may be oliguria or anuria. Treatment-severe patients require dialysis support.


Pulmonary complications :Pulmonary complications Cough & hemoptysis ,may progress rapidly to breathlessness & res: failure >9% mortality is due to alveolar hemorrhage Treatment- continuous oxygen therapy & ventilatory support


Cardiovascular complications :Cardiovascular complications Hypotension& shock due to intravascular fluid leak Myocarditis with serious arrhythimias & cardiac failure. Hemorrhage- fatal GI hemorrrhage, hemetemsis, alveolar hemorrhage & epistaxis Treatment- fluid replacement ,vasopressors ,arrhythimias should be treated in the ICU setting


Management of severe cases :Management of severe cases Should be treated in higher centre with facilities for organ support. Organ dysfunction may be treated on standard lines. There is nothing specific treatment to leptospirosis. Hypovolemia should be corrected with normal saline. Adequate calories (1000Kcal+100Kcal/year of age) may be given.


Prevention & control :Prevention & control Should be targeted at the 1.Source of infection 2.Route of transmission 3.Level of human host


Source of infection :Source of infection Possible interventions a. Rodent control. b. Infected animals can be treated with antibiotics. c. Immunization of pets & farm animals. d. Excreta of domestic animals should be disposed


Anti-rodent measures :Anti-rodent measures 1.Sanitation measures- a. Proper storage,collection & disposal of garbage. b. Proper storage of food stuffs. c. Constructing rodent proof warehouses & other food / harvest depots. d. Elimination of rat burrow by blocking with concrets.


Anti-rodent measures-- :Anti-rodent measures-- 2.Trapping - box causes temporary reduction in the commensal rats . 3. Rodenticides single dose- a. Barium carbonate -tasteless white powder. b. Zinc phosphide -efficient, extensively used in India.recommended for large scale use.


Anti- rodent measures :Anti- rodent measures Multiple dose poison are warfarin -anti-coagulant cause internal haemorrhage & slow death in 4- 10 days. diphacinone 4.Fumigation-Calcium cyanide ,methyl bromide, sulphur dioxide etc. effective method of destroying both rats & ratfleas. 5.Chemosterilants temporary / permanent sterility on either sex / both sexes


Interventions at the transmission route :Interventions at the transmission route Wearing protective clothings (boots,gloves ,aprons mask ,etc) . Covering skin lesions with water proof dressings. Strictly maintaining hygienic measures during handling all animals. Mechanization in agricultural operations. Disinfection of water & swimming pool with chlorine.


Interventions at the level of human host :Interventions at the level of human host Raising awareness about the disease. Antibiotic prophylaxis- Doxycycline give some degree of protection.It can reduce the severity of disease. Immunization in available countries.Vaccine give protection only against the specific serovar. Health education.


Rat bite fever :Rat bite fever Characterized by relapsing fever ,rashes , arthralgia occurring days /weeks after a rat bite. Causative organism - natural parasites of rodents. 1.Streptobacillus moniliformis 2.Spirillum minus


Rat bite fever (RBF) :Rat bite fever (RBF) Streptobacillus moniliformis – RBF develops 2-10 days after exposure with abrupt fever ,headache & myalgia followed by petechial rashes & arthritis. Relapses common in untreated cases. Spirillum minus incubation period-1- 4 weeks. Rat bite wound may suppurates at the onset of fever with regional lymph adenopathy . Both respond to Penicillin & Tetracycline. oral penicillin & doxycycline after rat bite is effective in prophylaxis


An Ayurvedic perspective :An Ayurvedic perspective


MOOSHIKA VISHAM :MOOSHIKA VISHAM


Mooshika :Mooshika Acharyas Susruta & Vagbhata explained 18 types of mooshikas. Susrtua also explained the details about the signs & symptoms of 18 types separately with special treatment. But now a days it is very difficult to differentiate them.


Mooshikas mentioned by Susrtua & Vagbhata :Mooshikas mentioned by Susrtua & Vagbhata 1.Laalana 2.Putrka putra 3.Krishna shabala 4.Hamsira 5.Chucchundara 6.Alasa Ajira 7.Kashayadasana K danta 8.Kalinga kulaka 9.Achita asita 10.Chapala 11.Kapila 12.Kokila 13.Aruna 14.Mahakrishna chikkira 15.Undura palitondura 16.Mahasweta sweta 17. Maha kapila rsalakhya 18.Kapotaabha kapota


Mooshika as medicine :Mooshika as medicine Susrtua chikitsa explains 1.mooshika egg is used for the preparation of Vryshya grtham. 2.Thaila prepared with mooshika sareera is used for Guda bramsam (Vagbhata)


16 Adhistana of Animal Poison :16 Adhistana of Animal Poison Drushti Arthavam Niswasa Mukhasadamsam Damshtra Visarditham Nakham Gudam Mootram Asthi Pureesham Pittam Sukram Savam laalasravam


Properties of Visha :Properties of Visha cq£apjvWw XYm Xo£vWw kq£vaamip hyhmbn N hnImjn hniZw ssNh eLp A]mIn N XZv kvarXw


Visha guna :Visha guna Rooksha- vitiates vata. Ushna – vitiates rektha & pitta. Theekshna – penetrating power. Sookshma – easy entry to all organs & damage their function. Asu – kills fast. Vyavayi –spreads all over the body.. Vikashi – causing looseness of joints,dialating the tissue spores. Visada – easy spread to whole body. Laghu –difficult to treat. Apaki – not undergoing digestion.


Mooshika visha –various opinions :Mooshika visha –various opinions Carakacharya – Dooshivisha (Ca.Chi.23) Ashtanga hridaya- Sleshmanubhandi (A.H.38/5) Ashtanga samgraha- Vyavahi guna


Adhishtana of mooshika visha :Adhishtana of mooshika visha (Su. kal. 7/7.dalhana com:)


Adhishtana of Mooshika visha :Adhishtana of Mooshika visha According to all Samhitas - Sukra Dalhana commentary on Susrtua 5 types of adhishtana (Su.Kal.7/7) 1.Sukra 2.Purisha 3.Mootra 4.Nakha 5.Danta Prayoga samuchhaya explained 4 types except Purisha


pathogenesis :pathogenesis


Visha samprapthi :Visha samprapthi VISHAM VITIATE REKTHA KAPHA PITHA VATA HRIDAYAM


Characterastic of mooshika visha :Characterastic of mooshika visha Mooshika visha is spreading nature, Difficult to cure & relapsing nature.


Signs & Symptoms-Caraka,Susruta &Vagbhata :Signs & Symptoms-Caraka,Susruta &Vagbhata Granthi Sopham Karnika + kodam Mandala Pidakopachaya --nil Visarpam Kitabham-- nil Parvabedham Romaharsham Rujasthirva Moorcha Angasadana Jwara - seethajwara Daurbalya --nil Aruchi Swasam --nil vamadu


Symptoms of mooshika visha :Symptoms of mooshika visha Xet\mthmSv ]\nbpw Ip£nthZ\bpw XYm cpNntbm¶nepanÃmsX h¶nSpw t\{XtcmKhpw I¼hpw I^hpw ioXw XYm kÀÆmwKkmZhpw taseÃmw h«ambnSpw s]m«nSpw tNmdnbpw ]p\ (hnjsshZytPmÕ\nI 11)


Five stages of rat poisoning :Five stages of rat poisoning 1st vega –itching(kandu), toda (pain). tmt- kalka of sireesha panchanga with milk. 2ndvega- daha ,granthi. tmt – jalukavacharana & thanduleeyaka with milk. 3rdvega-headache ,yellowish discolouration of urine. tmt-ankola twak with milk / kanji. 4thvega- pain in joints & mandala like lesions tmt- bedbug mixed with sireeshaswarasa for Nasya. 5thvega-moha,thirst,vomiting,pain all over body,later death. Tmt- nasya with vishagna thaila


Signs of Bad prognosis :Signs of Bad prognosis


Signs of bad prognosis :Signs of bad prognosis Fainting Swelling of the body Discoloration Exudation Loss of hearing Fever Feeling of heaviness of head Excess salivation Vomiting of blood


Fatal complications :Fatal complications


Fatal complications :Fatal complications Swelling of urinary bladder. Discoloration of lips. Body covered with nodules resembling rats. Emitting smell like of rat.


Management :Management TREATMENT PRINCIPLE VISHAHARA CHIKITSA


Treatment of Rat bite :Treatment of Rat bite AT BITE SITE Dahanam Lepanam – paste of SireeshaRajani ,Vakra,Kunkuma. Kshalanam – any sour liquid. Siravedam. Vamanam – Neeli kashayam /Sireesha ankola moola ks. Virechana – Trivrut ,Neeli & Triphala.


Mooshika chikitsa -- :Mooshika chikitsa -- Nasya – sireesha saraphala. Anjana –sookshma trikatu choorna with Gomayaresa Snehapanam – 1.Thanduleeyakamoolasidha ghrta. 2.Dwinisadi ghrta-Amrtu,two haridra, swetagunja,manjishta & yeshtimadu. 3.Ghee prepared with roots of Asphota or five products of Kapitha Sinduvaradi kashayam with honey Sarapunga beeja choornam with thakram.


As per Ashtanga hridaya :As per Ashtanga hridaya Most useful drug is ANKOLA


Acc.to Vishavaidyajyotsnika :Acc.to Vishavaidyajyotsnika Bhringarajaswarasam used as thalam on moordha For internal use Karpasaphala with thaila Thanduleeyaka samoola with kanji Sireesha panchanga with kanji Ankolamoolam with ksheera or kanji


As per Ashtanga samgraha :As per Ashtanga samgraha Mainly concentrated on chronic management. Highlighting Dooshivisha chikitsa only. Acute management at the bite site followed to Susruta. Jwara in mooshika visha is managed by Kiratathikthadi kashayam.


According to Charaka samhita :According to Charaka samhita Comes under Dooshivisha. Dooshivisha treatment. Sarvamooshika vishahara yoga


According to Bhavaprakasa :According to Bhavaprakasa Ankola moola is the drug of choice Matra -10 Ratti


Mooshika visha –fever& complications :Mooshika visha –fever& complications Sweta arkaksheera taken 7 drops mixed with amalaki pramana Guda –quick relief is seen (Balakrishnan nair) Shadanga kwatha is beneficial for jwara


Liver & kidney involvement :Liver & kidney involvement


According to Shaligrama nighantu :According to Shaligrama nighantu Red variety of Arka pushpi is the drug of choice


Kushtadi choornam :Kushtadi choornam


Kashaya yogas :Kashaya yogas Padola kadurohinyadi ks Neelikaranjadi ks Musthadi ks Punarnavadi ks Guluchyadi ks


gulikas :gulikas Vilwadi gulika Dooshivishari gulika Chandrodayam gulika


Swarasam & Putapakam :Swarasam & Putapakam Vasaswarasam with honey. Vasaputapakam with honey.


Diet :Diet Diet to be used Sali & shashtika rice Koradoosha ,saindhava Thanduleeyaka,jeevanthi Varthakam,mandookaparni Mudgam,dhatri,dadimam Meat of ena, sikhi etc Diet should not be used Alcahol Navadhanyam Thilam,kulatha,panasaphala Virudharas etc


Ojovardhaka chikitsa :Ojovardhaka chikitsa Importance of ghee in Visha chikitsa Purgation ,external application ,food & medicine without addition of ghee is not suitable. (there is no medicine better than ghee.)eg:-thikthaka ghrta


Correlation ofMooshika visha with Leptospirosis :Correlation ofMooshika visha with Leptospirosis


Mode of transmission of disease :Mode of transmission of disease In mooshika visha direct contact of mooshika sukla manifest visha in our body. In leptospirosis direct/ indirect contact of infected urine of rodents (rats).


Symptoms of incurable stageMooshika visha Leptospirosis :Symptoms of incurable stageMooshika visha Leptospirosis Fainting Swelling of the body Discolouration Exudation Loss of hearing Fever Felling of heaviness of head Excess salivation Vomitting of blood Renal failure Acute hepatic failure Acute cardio vascular failure Haemorrhage Meningitis Encephalitis pneumonia


Fatal complicationsmooshika visham leptospirosis :Fatal complicationsmooshika visham leptospirosis Swelling of urinary bladder. Discoloration of lips. Body covered with nodules resembling rats. Emitting smell like of rat. Renal failure. Cardiopulmonary failure. Widespread haemorrhage. Liver failure rare.


NATURE CURE for Leptospirosis :NATURE CURE for Leptospirosis Aim –Eliminate the accumulation of morbid matter in the body. Fasting- according to rogi bala & roga bala.


Fasting :Fasting Assists to expel the foreign matter & disease producing wastes from the body system. Duration depends on the nature of disease ,age of the patient. Alternate days are advisable. Cooked food may be avoided. Fruit juices,vegetable juices, tender coconut, rice soup etc.


Nature cure-- :Nature cure-- May be given Tulasi leaves ,Punarnava leaves ,Koovala leaves – equal quantity of all /separately each one with vazhapindi (bananapith ) juice. Keezharnelli samoolam (amalaki matra) with water. Wet pad on forehead & joints. Hip bath with warm water +gentle massage on the lower abdomen. Boiled water with gokshura ,Barley for drinking.


Prevention :Prevention


PREVENTIVE MEASURES :PREVENTIVE MEASURES Abhyanga with tila thaila / coconut oil daily. Always wear chappals /shoes to protect feet. Pancha sodhana chikitsa regularly. Since the disease spread in rainy season following diet & regiments for Varsharitucharya may prevent the disease.


Preventive measures :Preventive measures Adoption of Swasthavritha Sadvritha Nidanaparivarjana Measures to improve Yukthikrita bala Srotoprasadaka measures


Preventive measures-- :Preventive measures-- Swasthavritha Dinacharya- conduct of healthy man to maintain the healthy state. Ritucharya – following diet & regimen mentioning in each seasons improves the immunity & there by prevents communicable diseases. Sadvritha – 2 objectives- maintenance of positive health & control of sense faculties.


Preventive measures --- :Preventive measures --- Improve yukthikruta bala – (enhancement of resistance) Resayanachikitsa- brings in a change in the tissues by arresting some of decaying process ,thereby supplementing the tissues with a vitality ,so as to withstand or fight the disease process. Eg: - chyvanaprasa ,brahmiresayana ,milk ,ghee etc.


Preventive measures -- :Preventive measures -- Srotoprasadhaka measures- Twachya measures are abhynga ,snana ,alepana ,vastradharana etc to prevent invasion of infection through skin. chakshushya – anjana ,nasya ,tarpana etc to eye diseases.


Purification of polluted water :Purification of polluted water Spraying kashayam hnezmVIo bh£mc ]mSeo _mÂlntImjWm {io]À®o iÃIobptàm \njvIzmY t{]m£Ww ]cw khnjw t{]m£nXw tX\ ktZym `hXn \nÀhnjw (A. k. kq .8)


conclusion :conclusion Leptospirosis is a potentially serious zoonosis especially during rainy season. There is no specific treatment for weil’s syndrome. In Ayurveda it can be correlated with Mooshikavisha. Vishahara chikitsa is the good choice treatment. Vilwadi gulika is the drug of choice- as pana ,anjana & nasya. A life style in accordance with dinacharya & ritucharya improves the immunity and thereby prevents all the communicable diseases.