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. 2020 Feb 27;20(1):179.
doi: 10.1186/s12879-020-4903-5.

Leptospirosis in Indonesia: diagnostic challenges associated with atypical clinical manifestations and limited laboratory capacity

Muhammad Hussein Gasem  1 , Usman Hadi  2 , Bachti Alisjahbana  3 , Emiliana Tjitra  4 , M M D E A H Hapsari  1 , Endang Sri Lestari  1 , Abu Tholib Aman  5 , Dewi Lokida  6 , Gustiani Salim  7 , Herman Kosasih  8 , Ketut Tuti Parwati Merati  9 , Kanti Laras  7 , Mansyur Arif  10 , Nurhayati Lukman  7 , Pratiwi Sudarmono  11 , Vivi Lisdawati  12 , Chuen-Yen Lau  13 , Aaron Neal  13 , Muhammad Karyana  4   7
Affiliations

Leptospirosis in Indonesia: diagnostic challenges associated with atypical clinical manifestations and limited laboratory capacity

Muhammad Hussein Gasem et al. BMC Infect Dis. .

Abstract

Background: The burden of leptospirosis in Indonesia is poorly understood. Data from an observational study conducted from 2013 to 2016 in seven cities across Indonesia was used to estimate the incidence of leptospirosis and document its clinical manifestations in patients requiring hospitalization.

Methods: Specimens from patients hospitalized with acute fever were collected at enrollment, 14-28 days, and 3 months. Demographic and clinical information were collected during study visits and/or retrieved from medical records and double-entered into clinical report forms. After initially screening for dengue virus and other pathogens, specimens were tested at a central Reference Laboratory for anti-Leptospira IgM using commercial ELISA kits and for Leptospira DNA using an in-house quantitative real-time PCR assay.

Results: Of 1464 patients enrolled, 45 (3.1%) confirmed cases (by PCR and/or sero-coversion or four-fold increase of IgM) and 6 (0.4%) probable cases (by high titer IgM) of leptospirosis were identified by the Reference Laboratory. Disease incidence at sites ranged from 0 (0%) cases in Denpasar to 17 (8.9%) cases in Semarang. The median age of patients was 41.2 years (range of 5.3 to 85.0 years), and 67% of patients were male. Twenty-two patients (43.1%) were accurately diagnosed at sites, and 29 patients (56.9%) were clinically misdiagnosed as having another infection, most commonly dengue fever (11, 37.9%). Clinically, 20 patients (39.2%) did not present with hyperbilirubinemia or increased creatinine levels. Two patients (3.9%) died, both from respiratory failure. Fifteen patients (29.4%) clinically diagnosed with leptospirosis at sites were negative based on IgM ELISA and/or PCR at the Reference Laboratory.

Conclusions: Leptospirosis remains an important cause of hospitalization in Indonesia. It can have diverse clinical presentations, making it difficult to differentiate from other common tropical infections. PCR combined with ELISA is a powerful alternative to the cumbersome gold-standard microscopic agglutination test, particularly in resource-limited settings.

Keywords: Atypical manifestations; Diagnostic challenge; Indonesia; Leptospirosis.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Schema for identifying leptospiral infections amongst patients hospitalized with acute fevers
Fig. 2
Fig. 2
Distribution of leptospirosis cases in each city by gender and age categories
See this image and copyright information in PMC

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