Hypocalcemia, Hypochloremia, and Eosinopenia As Clinical Predictors Of

Journal of Infection and Public Health 13 (2020) 216–220

Contents lists available at ScienceDirect

Journal of Infection and Public Health

j ournal homepage: http://www.elsevier.com/locate/jiph

Hypocalcemia, hypochloremia, and eosinopenia as clinical predictors

of leptospirosis: A retrospective study

a b a c

Cheng-Yee Fish-Low , Ahmed D. Balami , Leslie T.L. Than , King-Hwa Ling ,

a d a,∗

Niazlin Mohd Taib , Anim Md. Shah , Zamberi Sekawi

Department of Medical Microbiology and Parasitology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia

Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia

Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia

Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia

r t i c l e i n f o a b s t r a c t

Article history: Background: Underestimation of leptospirosis cases is happening in many countries. The most common

Received 1 December 2018

factor of underreporting is misdiagnosis. Considering the limitations of direct detection of pathogen and

Received in revised form 15 July 2019

serological diagnosis for leptospirosis, clinical features and blood tests though non-speciﬁc are usually

Accepted 27 July 2019

referred in making presumptive diagnosis to decide disease management.

Methods: In this single-centre retrospective study, comparative analysis on clinical presentations and

Keywords:

laboratory ﬁndings was performed between conﬁrmed leptospirosis versus non-leptospirosis cases.

Leptospirosis

Results: In multivariate logistic regression evidenced by a Hosmer-Lemeshow signiﬁcance value of

Diagnostic scoring

Hypocalcemia 0.979 and Nagelkerke R square of 0.426, the predictors of a leptospirosis case are hypocalcemia (cal-

Hypochloremia cium <2.10 mmol/L), hypochloremia (chloride <98 mmol/L), and eosinopenia (absolute eosinophil count

Eosinopenia <0.040 10 /L). The proposed diagnostic scoring model has a discriminatory power with area under the

curve (AUC) 0.761 (p < 0.001). A score value of 6 reﬂected a sensitivity of 0.762, speciﬁcity of 0.655, a

positive predictive value of 0.38, negative predictive value of 0.91, a positive likelihood ratios of 2.21, and

a negative likelihood ratios of 0.36.

Conclusion: With further validation in clinical settings, implementation of this diagnostic scoring model

is helpful to manage presumed leptospirosis especially in the absence of leptospirosis conﬁrmatory tests.

for Health Sciences. This is an open access article under the CC BY-NC-ND license (http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction The microscopic agglutination test (MAT) for detection of agglu-

tinating antibodies [3] serves as the gold standard of serological

A broad array of clinical manifestations has been documented diagnosis for leptospirosis [2]. MAT is not an ideal test for lep-

for human leptospirosis [1,2]. Leptospiral infections may be asymp- tospirosis diagnosis especially during the bacteremia phase, and

tomatic, or with symptoms ranging from mild and self-limiting in regions where the diagnostic facilities are poorly accessible or

febrile illnesses to multi-organ dysfunction with fatal outcomes. not available. Although there are many other commercially avail-

Leptospirosis may mimic other febrile illnesses, which makes the able rapid serological tests, the problem of delayed diagnosis due to

clinical manifestations not fully reliable for the diagnosis of lep- late sero-conversion and undetectable antibodies titre still exists.

tospirosis. Underreporting due to misdiagnosis of leptospirosis is On the other hand, direct detection of leptospiral DNA by

therefore common. Reliance on laboratory diagnostic tests to differ- polymerase chain reaction (PCR) has been proposed to be used

entiate leptospirosis from other diseases is not entirely practicable routinely in leptospirosis diagnosis as it overcomes the limita-

considering the limitations of currently available leptospirosis tions of MAT especially during the early acute phase [4]. However,

diagnostic tests. it may have more stringent requirements on sampling tim-

ing and type of specimen. This is because leptospiremia may

end very soon after the onset of symptoms [5]. The success of

molecular detection of leptospiral DNA depends not only on the

∗

Corresponding author. bacterial load in clinical materials, but also on the speciﬁcity

E-mail address: [email protected] (Z. Sekawi).

https://doi.org/10.1016/j.jiph.2019.07.021

CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

C.-Y. Fish-Low et al. / Journal of Infection and Public Health 13 (2020) 216–220 217

and sensitivity of the primers or probes that are used in the of total antibodies in MAT [2] using a 20-serovar panel, which

detection. consisted of Australis, Autumnalis, Bataviae, Canicola, Celledoni,

To address the non-availability of a rapid conﬁrmatory diag- Djasiman, Grippotyphosa, Hardjoprajitno, Icterohaemorrhagiae,

nostic test for leptospirosis, several scoring models have been Javanica, Patoc, Pomona, Pyrogenes, Tarassovi, IMR LEP/1, IMR

developed as guidelines in diagnosing presumptive leptospirosis. LEP/115, IMR LEP/175, IMR LEP 803/11, IMR LEP/27, and IMR

Faine’s criteria [6] were first developed based on clinical data (Part LEP/22. A confirmed leptospirosis case (CLC) is defined as single

A), epidemiological factors (Part B), and bacteriological and labo- serum titre of 1:400 or at least a four-fold rise in titre of paired

ratory ﬁndings based on only MAT titre (Part C). A score of 26 or sera in the standard MAT, a positive culture of Leptospira in blood

more in Part A or in Part A + Part B, or 25 or more as the total of or urine sample, or positive detection of Leptospira DNA in PCR

three parts may suggest a presumptive diagnosis. Faine’s criteria [12]. All cases of conﬁrmed leptospirosis are tested negative in

were then modiﬁed, hence known as modiﬁed Faine’s criteria [7] both aerobic and anaerobic blood culture, and negative in dengue

to include other formats of serological tests under Part C. The modi- IgM and NS1 detection. The cases otherwise are non-leptospirosis

ﬁed Faine’s criteria were later amended (known as modiﬁed Faine’s (NLC).

criteria with amendment) to improve the usefulness in clinical set-

tings [8]. Statistical analysis

Despite several amendments of the guidelines, a scoring section

based on blood test proﬁle has never been incorporated. This study The data collected was analysed by using IBM Statistical

aimed to determine the clinical predictors for leptospirosis based Package for Social Sciences (SPSS) version 22. The laboratory

on comparative analysis of blood test parameters between con- ﬁndings were categorized as normal, low or high, based on

ﬁrmed leptospirosis versus non-leptospirosis cases. Then a scoring the hospital’s pre-deﬁned cut-off values. Comparative analysis

model is developed for the determined predictors. between CLC (n = 30) and NLC (n = 107) was performed. Bivariate

analysis using the Chi-square test was run on all the vari-

Material and methods ables, to determine any difference between the two groups.

Variables signiﬁcant in the bivariate analysis along with other

Ethics statement variables with p-value <0.25 were entered into a multivariate

logistic regression using the Backward-LR method, and the best

The study protocol was approved by the Institutional Review model was selected to obtain the predictors of leptospirosis

Board of Faculty of Medicine and Health Sciences, Universiti Putra infection.

Malaysia, and the Medical Research Ethics Committee (MREC), Min-

istry of Health Malaysia (NMRR-15-2148-27536). Development of diagnostic scoring model

Study design and study subjects In line with a previous similar study [14], the beta coefﬁcients

of the predictor variables were used to develop a practical scoring

This study utilized a cross-sectional study design among clin- system. All the coefﬁcients were divided by the smallest coefﬁ-

ically suspected leptospirosis patients [2] admitted in Hospital cient, and then multiplied by 4, the results of which were rounded

Serdang, Selangor, Malaysia. Since leptospirosis was gazetted as up to the nearest whole number. This scoring system was then

a notiﬁable disease in Malaysia in December 2010, patients admit- used to generate the receiver operating characteristics (ROC) curve.

ted from 2011 to 2017 constituted the sampling frame. Patients The sensitivity, speciﬁcity, positive predictive value (PPV), nega-

in the paediatric age group (below 18 years old) and patients tive predictive value (NPV) and likelihood ratios (LR) were also

with past history of autoimmune diseases or any known comor- computed.

bidities were excluded. The one proportion formula was used to

calculate the minimum required sample size [9]. The expected Results

prevalence (P) of leptospirosis (8.4%) was taken from a previ-

ous study in Malaysia [10]. The Z-statistic and precision level A total of 137 subjects were included in the study, 72.3% of whom

(d) were substituted with 1.96 and 0.05 respectively [11], and were males. Their ages ranged from 18 to 86 years, and a mean

an adjustment for 90% eligibility to obtain a minimum sample (SD) age of 35.5 (14.8) years. Their ethnicities were: Malay (68.6%),

size requirement of 133 respondents. Case notes of all suspected Indian (13.1%), Chinese (6.6%) and others (11.7%). Around one-ﬁfth

leptospirosis patients admitted between 2011 and 2017 were (21.9%) had a diagnosis of conﬁrmed leptospirosis. Out of the 30

extracted from the hospital’s medical patients’ electronic database, cases of conﬁrmed leptospirosis, 53.3% (n = 16) gave positive PCR

using the ‘Filter’ function. The ﬁle serial numbers of these patients result, 36.7% (n = 11) was positive by MAT, 3.3% (n = 1) was positive

was then copied and transferred to Excel spreadsheet from where in blood cultures, and 6.7% (n = 2) of the cases were positive in both

137 out of these were randomly selected using the ‘Random’ func- urine cultures and MAT. tion.

Bivariate analysis

Data collection and case deﬁnition

Table 1 shows the comparison of clinical and laboratory char-

A structured proforma was used to collect data from the acteristics of CLC and NLC. There was a signiﬁcant difference

selected case notes. Data on clinical presentations were collected between the two groups in their proportions of temperature above

◦

on a binary scale (Yes or No), while the values for the labo- 39 C, low calcium (<2.10 mmol/L), high urea (>9.2 mmol/L), low

ratory ﬁndings were collected in their raw numerical forms as sodium (<136 mmol/L), low chloride (<98 mmol/L), and low abso-

continuous variables. The cases were categorized into conﬁrmed lute eosinophil count (<0.040 × 10 /L).

leptospirosis versus non-leptospirosis. The conﬁrmatory diagno-

sis of leptospirosis was performed by the Institute for Medical Multivariate analysis

Research (IMR), Ministry of Health Malaysia [12]. The tests per-

formed were pathogen isolation [2], detection of leptospiral DNA For the multivariate logistic regression, the model ﬁtted

by real-time polymerase chain reaction [13], and and detection the sample, evidenced by a Hosmer-Lemeshow signiﬁcance

218 C.-Y. Fish-Low et al. / Journal of Infection and Public Health 13 (2020) 216–220

Table 1

Comparison of clinical and laboratory features of conﬁrmed (CLC) and non-conﬁrmed leptospirosis cases (NLC).

NLC (n = 107) CLC (n = 30) p-value

Characteristic

Frequency (%) Frequency (%)

Headache 48 (44.9) 16 (53.3) 0.411

Fever 99 (92.5) 28 (93.3) 0.880

◦ *

Temperature >39 C 17 (15.9) 10 (33.3) 0.034

Conjunctival suffusion 14 (13.1) 3 (10.0) 0.651

Myalgia 72 (67.3) 20 (66.7) 0.949

Jaundice 11 (10.3) 3 (10.0) 0.964

Haemoptysis / shortness of breath 14 (13.1) 4 (13.3) 0.972

Skin rash 15 (14.0) 4 (13.3) 0.924

Gastrointestinal symptoms 83 (77.6) 27 (90.0) 0.130

Haemorrhages 6 (5.6) 2 (6.7) 0.827

Creatinine kinase <29 U/L 4 (3.7) 0 (0.0) 0.657

Creatinine kinase >200 U/L 63 (58.9) 19 (63.3) 0.830

C-reactive protein >5 mg/L 66 (81.5) 18 (90.0) 0.362

Calcium <2.10 mmol/L 43 (62.3) 20 (90.9) 0.014

Calcium >2.55 mmol/L 1 (1.4) 0 (0.0) 1.000

Magnesium <0.85 mmol/L 51 (72.9) 15 (68.2) 0.476

Magnesium >1.05 mmol/L 8 (11.4) 2 (9.1) 0.529

Albumin <35 g/L 57 (54.3) 18 (60.0) 0.614

Albumin >50 g/L 1 (1.0) 0 (0.0) 0.614

Bilirubin, total >20.5 ␮mol/L 32 (30.2) 10 (33.3) 0.742

Alkaline phosphatase <40 U/L 2 (1.9) 1 (3.3) 0.526

Alkaline phosphatase >150 U/L 14 (13.1) 4 (13.3) 1.000

Aspartate transferase >34 U/L 83 (77.6) 23 (76.7) 0.917

Urea <2.5 mmol/L 8 (7.5) 2 (6.7) 0.767

Urea >9.2 mmol/L 17 (15.9) 12 (40.0) 0.004

Sodium <136 mmol/L 66 (61.7) 26 (86.7) 0.010

Potassium <3.5 mmol/L 23 (21.5) 8 (26.7) 0.640

Potassium >5.1 mmol/L 5 (4.7) 0 (0.0) 0.364

Chloride <98 mmol/L 26 (24.3) 16 (53.3) 0.004

Chloride >107 mmol/L 6 (5.6) 1 (3.3) 0.972

␮

Creatinine <53 mol/L 1 (0.9) 0 (0.0) 1.000

Creatinine >115 ␮mol/L 38 (35.8) 15 (50.0) 0.172

Red blood cell <3.80 × 10 /L 6 (5.6) 1 (3.3) 0.664

Red blood cell >5.80 × 10 /L 19 (17.8) 7 (23.3) 0.527

Haemoglobin <11.5 g/dL 13 (12.1) 1 (3.3) 0.160

Haemoglobin >18.0 g/dL 3 (2.8) 1 (3.3) 1.000

Platelet <150 × 10 /L 24 (22.4) 9 (30.0) 0.490

Platelet >400 10 /L 6 (5.6) 0 (0.0) 0.204

White blood cell <4.0 × 10 /L 11 (10.3) 5 (16.7) 0.285

White blood cell >11.0 × 10 /L 33 (30.8) 10 (33.3) 0.601

Absolute neutrophil <2.00 × 10 /L 7 (6.5) 5 (16.7) 0.069

Absolute neutrophil >7.50 × 10 /L 42 (39.9) 12 (40.0) 0.588

Absolute lymphocyte <1.50 × 10 /L 65 (60.7) 23 (76.7) 0.069

Absolute lymphocyte >4.00 × 10 /L 1 (0.9) 0 (0.0) 0.588

Absolute monocyte <0.200 10 /L 9 (8.4) 1 (3.3) 0.439

Absolute monocyte >0.800 × 10 /L 43 (40.2) 10 (33.3) 0.367

9 *

Absolute eosinophil <0.040 × 10 /L 24 (22.4) 14 (46.7) 0.014

Absolute eosinophil >0.400 × 10 /L 9 (8.4) 1 (3.3) 0.577

Statistically signiﬁcant at p < 0.05.

Table 2

Predictors of presumptive leptospirosis.

Factors B SE Wald df p-value Adjusted OR 95% CI

Calcium

Normal – – – – – 1.00 –

Low (<2.10 mmol/L) 2.04 1.00 4.17 1 0.041 7.72 1.09–54.98

Chloride

Normal – – – – – 1.00 –

Low (<98 mmol/L) 1.70 0.77 4.82 1 0.028 5.45 1.20–24.79

Absolute eosinophil

Normal – – – – – 1.00 –

Low (<0.040 × 10 /L) 1.76 0.73 5.75 1 0.017 5.80 1.38–24.41

B = beta coefﬁcient; SE = standard error; df = degrees of freedom; OR = odd ratio; CI = conﬁdence interval.

value of 0.979. The Nagelkerke R square was 0.426, and Fig. 1 shows the receiver operating characteristics (ROC) curve

the predictors of being a case of leptospirosis are pre- to differentiate between leptospirosis and non-leptospirosis. The

sented in Table 2. Table 3 illustrates the proposed score for area under the curve (AUC) was 0.761 (p < 0.001). As presented in

diagnosis of leptospirosis, based on the multivariate analysis Table 4, score value of 6 reﬂected a sensitivity of 0.762, speciﬁcity of

results. 0.655, a positive predictive value (PPV) of 0.38, negative predictive

C.-Y. Fish-Low et al. / Journal of Infection and Public Health 13 (2020) 216–220 219

Table 3

Proposed score for diagnosis of leptospirosis, based on multivariate analysis.

Factor Beta coefﬁcient Calculated Score (rounded to

score nearest integer)

Calcium <2.10 mmol/L 2.044 4.80 5

Chloride <98 mmol/L 1.696 4.00 4

Eosinophil 1.758 4.15 4

<0.040 × 10 /L

Maximum possible 13

score

value (NPV) of 0.91, a positive likelihood ratios (PLR) of 2.21, and a

negative likelihood ratios (NLR) of 0.36.

Discussion

As observed in the present study and other similar studies

that compared serum biochemistry between leptospirosis and

non-leptospirosis patients, the variables proposed in the respec-

tive diagnostic score models may be cohort- or region-speciﬁc.

A Sri Lankan cohort-based study [14] reveals high creatinine

(>150 ␮mol/L), high bilirubin (>30 ␮mol/L), neutrophil >80%, low

platelet count (<85,000/mm ), and exposure to possible source

of leptospirosis are positively associated with the conﬁrmed

diagnosis. A recent Thai cohort-based study [15] reported the

presence of hypotension, jaundice, muscle pain, acute kidney

Fig. 1. Coordinates of the ROC curve for outcome—positive leptospirosis.

failure, low haemoglobin (<12 g/dL), and hypokalemia (potas-

sium <3.5 mEq/L) with hyponatremia (sodium <135 mEq/L)

are signiﬁcant predictors for leptospirosis. On the other hand, observation may be explained by calcium deposition in damaged

hypocalcemia (calcium <2.10 mmol/L), hypochloremia (chloride muscle followed by resolving calciﬁcation once the renal functions

<98 mmol/L), and eosinopenia (<0.040 × 10 /L) are proposed as the have recovered [26].

scoring criteria for leptospirosis in this Malaysian cohort-based Phenomenon of low eosinophil count in leptospirosis is either

study. has not been evaluated or lacks of emphasis in previous studies.

Despite none of the predictors in any of the abovementioned It has once been reported in canine leptospirosis [27]. Eosinopenia

studies are present in another study, abnormal renal panel is com- is evidenced to be associated with peritonitis [28], sepsis [29], and

mon across these studies. Perturbations of electrolytes: chloride, enteric fever [30]. Bass DA et al. [31] speculated that the migra-

potassium, sodium, and creatinine (waste product), and calcium tion of eosinophils to the inﬂammatory site, which was triggered

(minerals) may serve as indications of renal involvement during by chemotactic factors during acute inﬂammation has resulted in

leptospirosis. eosinopenia.

Hypokalemia is regularly seen in leptospirosis [16,17] whereas Further analysis on renal proﬁle of leptospirosis patients would

hyponatremia resolves quickly as soon as the infection is con- be beneﬁcial and have diagnostic values. Kidney is the known target

trolled [18]. Leptospirosis-induced acute kidney injury (AKI) organ where leptospires may colonize and persist [32,33], possibly

causes rapid increment of serum creatinine and blood urea nitro- related to their ability of forming bioﬁlm [34]. In addition, leptospi-

gen [19]. Though not proven in the context of leptospirosis, ral outer membrane proteins have been demonstrated to induce

dyschloremia is proposed as a risk factor for development of AKI, renal inﬂammation and interstitial nephritis [35]. Collectively, bac-

and hypochloremic patients are particularly having higher mortal- terial invasion, inﬂammation, haemodynamic perturbations and,

ity rate [20]. pathogenicity of bacterial products contribute to the develop-

Mild hypocalcemia usually develops asymptomatically and ment of leptospiral nephropathy [19]. Varying clinical spectrum

unnoticed or otherwise may show cardiac arrest, seizures, numb- of renal involvement are documented in leptospirosis, ranging

ness, and confusion [21,22]. It can be caused by kidney failure, from mild course of proteinuria [36], serum electrolyte changes

rhabdomyolysis, overdose of calcium channel blocker, and med- [16] to severe acute renal failure associated with rhabdomyolysis

ications [21]. Hypocalcemia in leptospirosis is recognized as one [37].

of the reasons leading to arrhythmias [23,24]. The biphasic cal-

cium kinetic in leptospirosis that was reported by Zakout R et al. Conclusion

[23] is found consistent with that seen in rhabdomyolysis-induced

AKI [25], which hypocalcemia occurred in oliguric phase and then Conﬁrmatory diagnosis of leptospirosis is challenging and cur-

hypercalcemia in diuretic phase during recovery. This sequential rently limited by many well recognized factors. A scoring model

Table 4

Diagnostic model performance (sensitivity, speciﬁcity, positive and negative predictive value and likelihood ratios).

Score Sensitivity Speciﬁcity PPV NPV PLR NLR

4 0.810 0.483 0.29 0.96 1.45 0.14

6 0.762 0.655 0.38 0.91 2.21 0.36

10 0.238 0.966 0.38 0.89 2.18 0.43

PPV = positive predictive value; NPV = negative predictive value; PLR = positive likelihood ratios; NLR = negative likelihood ratios.

220 C.-Y. Fish-Low et al. / Journal of Infection and Public Health 13 (2020) 216–220

based on clinical predictors of blood test parameter, particularly [14] Rajapakse S, Weeratunga P, Niloofa R, Fernando N, de Silva NL, Rodrigo C,

et al. A diagnostic scoring model for leptospirosis in resource limited settings.

the renal proﬁle will efﬁciently improve leptospirosis diagnosis.

PLoS Negl Trop Dis 2016;10:e0004513, http://dx.doi.org/10.1371/journal.pntd.

It may be of great diagnostic potential if the proposed scoring 0004513.

model to be combined with both epidemiological risk factors and [15] Sukmark T, Lumlertgul N, Peerapornratana S, Khositrangsikun K, Tungsanga

K, Sitprija V, et al. Thai-Lepto-on-admission probability (THAI-LEPTO) score as

clinical manifestations. Case history such as contact with possi-

an early tool for initial diagnosis of leptospirosis: result from Thai-Lepto AKI

ble infected animals or exposure to leptospire-containing water

study group. PLoS Negl Trop Dis 2018;12:e0006319, http://dx.doi.org/10.1371/

is especially useful in the diagnosis of leptospirosis as leptospires journal.pntd.0006319.

[16] Seguro AC, Lomar AV, Rocha AS. Acute renal failure of leptospirosis: nono-

are mostly transmitted via direct or indirect contact with infected

liguric and hypokalemic forms. Nephron 1990;55(146), http://dx.doi.org/10.

animals. We acknowledge the limitations of this study as the

1159/000185943.

enrolled cases may not be representative of all leptospirosis cases [17] Abdulkader RCRM, Seguro AC, Malheiro PS, Burdmann EA, Marcondes M. Pecu-

in Malaysia. Until the proposed scoring model is validated in liar electrolytic and hormonal abnormalities in acute renal failure due to

leptospirosis. Am J Trop Med Hyg 1996;54(1), http://dx.doi.org/10.4269/ajtmh.

larger cohort size and involves multicentre, it shows potential to

1996.54.1.

be incorporated into the modiﬁed Faine’s criteria with amend-

[18] Sitprija V. Altered ﬂuid, electrolyte and mineral status in tropical disease, with

ment, or can be applied as a standalone diagnostic guideline for an emphasis on malaria and leptospirosis. Nat Clin Pract Nephrol 2008;4(91),

leptospirosis. http://dx.doi.org/10.1038/ncpneph0695.

[19] Visith S, Kearkiat P. Nephropathy in leptospirosis. J Postgrad Med Educ Res

2005;51:184–8.

Funding [20] Shao M, Li G, Sarvottam K, Wang S, Thongprayoon C, Dong Y, et al. Dyschloremia

is a risk factor for the development of acute kidney injury in critically ill

patients. PLoS One 2016;11:e0160322, http://dx.doi.org/10.1371/journal.pone.

This work was funded by the Ministry of Higher Education,

0160322.

Malaysia Long Term Research Grant Scheme (LRGS) [UPM/700-

[21] Soar J, Perkins GD, Abbas G, Alfonzo A, Barelli A, Bierens JJLM, et al. European

2/1/LRGS/5526400]. resuscitation council guidelines for resuscitation 2010 section 8. Cardiac arrest

in special circumstances: electrolyte abnormalities, poisoning, drowning, acci-

dental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery,

Competing interest

trauma, pregna. Resuscitation 2010;81:1400–33, http://dx.doi.org/10.1016/j. resuscitation.2010.08.015.

None declared.

[22] Fong J, Khan A. Hypocalcemia: updates in diagnosis and management for pri-

mary care. Can Fam Physician 2012;58:158–62.

Ethical approval [23] Zakout R, do Carmo M, Freitas P. Reversible myocardial calciﬁcation following

severe leptospirosis complicated with rhabdomyolysis-induced acute kidney

injury and magnesium-wasting nephropathy. J Med Cases 2013;4:92–8.

Not required.

[24] de Sousa Soares D, Galdino GS, Rodrigues BC, Silva Jr G, Daher EF. Arrhythmias

in leptospirosis-associated acute kidney injury: a case series. Braz J Infect Dis

Acknowledgements 2017;21(209), http://dx.doi.org/10.1016/j.bjid.2016.11.010.

[25] Pakkyara A, Mohsin N, Budruddin M, Mohammad AJE, Mohammad K. Calcium

kinetic in a patient with acute renal failure due to rhabdomyolysis. A case report

We would like to thank the Director General of Health Malaysia

and review of literature. Oman Med J 2010;25, http://dx.doi.org/10.5001/omj.

for his permission to publish this article. The authors are indebted

2010.93, e013–e013.

to all the clinicians and supporting staff from Hospital Serdang, [26] Akmal M, Goldstein DA, Telfer N, Wilkinson E, Massry SG. Resolution of mus-

cle calciﬁcation in rhabdomyolysis and acute renal failure. Ann Intern Med

Malaysia. The authors also express their appreciation to all the

1978;89:928–30, http://dx.doi.org/10.7326/0003-4819-89-6-928.

members of Malaysia Leptospirosis Research Network (MyLepto)

[27] Rentko VT, Clark N, Ross LA, Schelling SH. Canine leptospirosis: a retrospective

and to all the study participants. study of 17 cases. J Vet Intern Med 1992;6:235–44, http://dx.doi.org/10.1111/

j.1939-1676.1992.tb00345.x.

References [28] Jagdeesh TS, Mishra A, Saxena A, Sharma D. Eosinopenia as a prognostic marker

in patients with peritonitis. ISRN Infect Dis 2013;2013:8, http://dx.doi.org/10.

5402/2013/540948.

[1] Centers for Disease Control and Prevention. Infectious diseases related to travel.

[29] Lavoignet CE, Le Borgne P, Slimani H, Forato M, Kam C, Kauffmann P, et al.

New York: Oxford University Press; 2017.

Relevance of eosinopenia as marker of sepsis in the emergency department. La

[2] World Health Organization. Human leptospirosis: guidance for diagnosis,

Rev Médecine Interne 2016;37(730), http://dx.doi.org/10.1016/j.revmed.2016.

surveillance and control. World Health Organization; 2003, http://dx.doi.org/ 02.018.

10.1590/S0036-46652003000500015.

[30] Matono T, Kutsuna S, Kato Y, Katanami Y, Yamamoto K, Takeshita N, et al.

[3] Turner LH. Leptospirosis II: serology. Trans R Soc Trop Med Hyg

Role of classic signs as diagnostic predictors for enteric fever among returned

1968;62:880–99, http://dx.doi.org/10.1016/0035-9203(68)90017-5.

travellers: relative bradycardia and eosinopenia. PLoS One 2017;12:e0179814,

[4] Mullan S, Panwala TH. Polymerase chain reaction: an important tool for early http://dx.doi.org/10.1371/journal.pone.0179814.

diagnosis of leptospirosis cases. J Clin Diagn Res 2016;10:DC08–11, http://dx.

[31] Bass DA, Gonwa TA, Szejda P, Cousart MS, DeChatelet LR, McCall CE. Eosinope-

doi.org/10.7860/JCDR/2016/22462.9010.

nia of acute infection: production of eosinopenia by chemotactic factors of

[5] Turner LH, Leptospirosis I. Trans R Soc Trop Med Hyg 1967;61:842–55, http://

acute inﬂammation. J Clin Invest 1980;65:1265–71, http://dx.doi.org/10.1172/

dx.doi.org/10.1016/0035-9203(67)90045-4. JCI109789.

[6] Faine S. Guidelines for the control of leptospirosis. Geneva: WHO offset publi-

[32] Athanazio DA, Silva EF, Santos CS, Rocha GM, Vannier-Santos MA, McBride

cation; 1982, no. 67.

AJA, et al. Rattus norvegicus as a model for persistent renal colonization by

[7] Shivakumar S, Shareek PS. Diagnosis of leptospirosis utilizing modiﬁed Faine’s

pathogenic Leptospira interrogans. Acta Trop 2008;105(176), http://dx.doi.org/

criteria. J Assoc Phys India 2004;52:678–9. 10.1016/j.actatropica.2007.10.012.

[8] Shivakumar S. Indian guidelines for the diagnosis and management of human

[33] Ratet G, Veyrier FJ, Fanton d’Andon M, Kammerscheit X, Nicola M-A, Picardeau

leptospirosis. Med Update 2013;23:23–9.

M, et al. Live imaging of bioluminescent Leptospira interrogans in mice reveals

[9] Daniel WW. Biostatistics: a foundation for analysis in the health sciences. 7th

renal colonization as a stealth escape from the blood defenses and antibi-

ed. New York: Wiley; 1999.

otics. PLoS Negl Trop Dis 2014;8:e3359, http://dx.doi.org/10.1371/journal.

[10] Raﬁzah AAN, Aziah BD, Azwany YN, Imran MK, Rusli AM, Nazri SM, et al. A pntd.0003359.

hospital-based study on seroprevalence of leptospirosis among febrile cases

[34] Ristow P, Bourhy P, Kerneis S, Schmitt C, Prevost M-C, Lilenbaum W, et al.

in northeastern Malaysia. Int J Infect Dis 2013;17:e394–7, http://dx.doi.org/10.

Bioﬁlm formation by saprophytic and pathogenic leptospires. Microbiology 1016/j.ijid.2012.12.012.

2008;154:1309–17, http://dx.doi.org/10.1099/mic.0.2007/014746-0.

[11] Naing L, Winn T, Rusli BN. Practical issues in calculating the sample size for

[35] Yang CW, Wu MS, Pan MJ. Leptospirosis renal disease. Nephrol Dial Transplant

prevalence studies. Arch Orofac Sci 2006;1:9–14. 2001;16(Suppl):73–7.

[12] Ministry of Health Malaysia. Guidelines for diagnosis management, prevention

[36] Thresiamma KC, Asha B, Reetika C, Manjula S, Chithra J, Sunil T, et al. Proteinuria

and control of leptospirosis. 1st ed. BKPKKM; 2011.

in early detection of human leptospirosis. Int J Res Med Sci 2017;5:646–52,

[13] Ahmed A, Engelberts MFM, Boer KR, Ahmed N, Hartskeerl RA. Development and http://dx.doi.org/10.18203/2320-6012.ijrms20170168.

validation of a real-time PCR for detection of pathogenic Leptospira species in

[37] Droulias J, Moutzouris D, Kassimatis T, Kollia K, Apostolou T, Hadjikonstantinou

clinical materials. PLoS One 2009;4:e7093, http://dx.doi.org/10.1371/journal.

V. Rhabdomyolysis-induced acute renal failure in a patient with leptospirosis.

pone.0007093.

Saudi J Kidney Dis Transpl 2007;18:430–1.