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Correspondence to Dr Joselito R Chavez, [email protected]
Background
The Philippines experiences several typhoons each year resulting in massive floods during the rainy season. In 2009, the very devastating typhoon Ketsana hit the Philippines and caused massive flooding. There was an increase of patients diagnosed with leptospirosis who were admitted to the National Kidney and Transplant Institute (NKTI).
The NKTI is a 350-bed tertiary medical centre for patients with kidney diseases who come from various regional hospitals in the nation. A temporary ward for patients with leptospirosis was set up, in order to accommodate more than 60 patients with leptospirosis during that time. Majority or 83.12% (128 out of 154) of leptospirosis patients developed acute kidney injury (AKI) of which 73.4% necessitated dialysis. Overall mortality was 15.6% and the most common cause was pulmonary haemorrhage.1 Since then, almost every year, these leptospirosis outbreaks have occured, despite educational campaigns of the government’s health department, on antibiotic prophylaxis for this disease. Recently, even without major typhoons, monsoon rains have resulted in similar outbreaks.
Leptospirosis is a bacterial disease caused by exposure of mucous membranes to urine of infected animals, usually rats in urban cities. In its most severe form it results in jaundice, renal failure and pulmonary haemorrhage called Weil’s disease. The addition of steroids to standard treatment in various studies resulted from the increasing evidence of an immune-mediated injury underlying the renal failure and pulmonary haemorrhagic complications in leptospirosis via an exaggerated host immune response.2
At the NKTI, there was a significant survival benefit (88% vs 74%), and improvement in partial thromboplastin time in patients with severe leptospirosis (prolonged bleeding parameters, AKI and acute lung injury requiring ventilatory support) who were given a 3 day course of intravenous methylprednisolone (MPP) and a single dose of cyclophosphamide (CP), compared with patients given standard therapy plus a 3 day course of hydrocortisone.3 In our institute, a 3-year review of a protocol using intravenous MPP and CP in 194 patients showed a 25% mortality; 32 (16%) died from pulmonary haemorrhage, 13 (7%) due to multiple organ failure and 4 (2%) due to hospital acquired pneumonia.2 Significant predictors of mortality included a low platelet count (p value<0.001), prolonged prothrombin time (p value 0.026) and the presence...