title: Early Indicators of Fatal Leptospirosis during the 2010 Epidemic in Puerto Rico.
abstract: BACKGROUND
  Leptospirosis is a potentially fatal bacterial zoonosis that is endemic throughout the tropics and may be misdiagnosed as dengue. Delayed hospital admission of leptospirosis patients is associated with increased mortality.
  
  
  RESULTS
  During a concurrent dengue/leptospirosis epidemic in Puerto Rico in 2010, suspected dengue patients that tested dengue-negative were tested for leptospirosis. Fatal and non-fatal hospitalized leptospirosis patients were matched 1:1-3 by age. Records from all medical visits were evaluated for factors associated with fatal outcome. Among 175 leptospirosis patients identified (4.7 per 100,000 residents), 26 (15%) were fatal. Most patients were older males and had illness onset during the rainy season. Fatal case patients first sought medical care earlier than non-fatal control patients (2.5 vs. 5 days post-illness onset [DPO], p < 0.01), but less frequently first sought care at a hospital (52.4% vs. 92.2%, p < 0.01). Although fatal cases were more often diagnosed with leptospirosis at first medical visit (43.9% vs. 9.6%, p = 0.01), they were admitted to the hospital no earlier than non-fatal controls (4.5 vs. 6 DPO, p = 0.31). Cases less often developed fever (p = 0.03), but more often developed jaundice, edema, leg pain, hemoptysis, and had a seizure (p ≤ 0.03). Multivariable analysis of laboratory values from first medical visit associated with fatal outcome included increased white blood cell (WBC) count with increased creatinine (p = 0.001), and decreased bicarbonate with either increased WBC count, increased creatinine, or decreased platelet count (p < 0.001).
  
  
  CONCLUSIONS
  Patients with fatal leptospirosis sought care earlier, but were not admitted for care any earlier than non-fatal patients. Combinations of routine laboratory values predictive of fatal outcome should be considered in admission decision-making for patients with suspected leptospirosis.
authors.affiliation: Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.|Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico.
authors.forename: Tyler M
authors.initials: TM
authors.lastname: Sharp
authors.affiliation: Puerto Rico Department of Health, San Juan, Puerto Rico.
authors.forename: Brenda
authors.initials: B
authors.lastname: Rivera García
authors.affiliation: Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico.
authors.forename: Janice
authors.initials: J
authors.lastname: Pérez-Padilla
authors.affiliation: Bacterial Special Pathogens Branch, Division of High Consequence Pathogens, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Renee L
authors.initials: RL
authors.lastname: Galloway
authors.affiliation: Bacterial Special Pathogens Branch, Division of High Consequence Pathogens, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Marta
authors.initials: M
authors.lastname: Guerra
authors.affiliation: Puerto Rico Department of Health, San Juan, Puerto Rico.
authors.forename: Kyle R
authors.initials: KR
authors.lastname: Ryff
authors.affiliation: Bacterial Special Pathogens Branch, Division of High Consequence Pathogens, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Dana
authors.initials: D
authors.lastname: Haberling
authors.affiliation: Bacterial Special Pathogens Branch, Division of High Consequence Pathogens, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Sharada
authors.initials: S
authors.lastname: Ramakrishnan
authors.affiliation: Bacterial Special Pathogens Branch, Division of High Consequence Pathogens, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Sean
authors.initials: S
authors.lastname: Shadomy
authors.affiliation: Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Dianna
authors.initials: D
authors.lastname: Blau
authors.affiliation: Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico.
authors.forename: Kay M
authors.initials: KM
authors.lastname: Tomashek
authors.affiliation: Bacterial Special Pathogens Branch, Division of High Consequence Pathogens, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: William A
authors.initials: WA
authors.lastname: Bower
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D002648:Child; D002675:Child, Preschool; D042241:Early Diagnosis; D058872:Epidemics; D005260:Female; D006801:Humans; D007223:Infant; D007919:Leptospira / Q000235:genetics / Q000302:isolation & purification* / Q000502:physiology; D007922:Leptospirosis / Q000175:diagnosis* / Q000453:epidemiology / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D011647:Puerto Rico / Q000453:epidemiology; D055815:Young Adult