Classically, leptospirosis has been considered a biphasic illness. However, many patients with mild disease will not have symptoms of the secondary “immune” phase of illness, and patients with very severe disease will have a relentless progression from onset of illness to jaundice, renal failure, hemorrhage, hypotension, and coma. The illness is biphasic in about half of patients, with relapse occuring approximately 1 week after resolution of the initial febrile illness. A late complication is anterior uveitis, seen in up to 10% of patients months to years after convalescence. Leptospirosis in pregnancy is associated with spontaneous abortion, but it is not known to increase the rate of congenital anomalies.

Case-fatality rates for leptospirosis are less than 1%, and the illness is usually self-limited. Liver and renal dysfunction are reversible, with return to normal function over 1 to 2 months. The mortality rate for icteric disease has been reported in different studies to be 2.4% to 11.3%, with deaths resulting from renal failure, gastrointestinal and pulmonary hemorrhage, and the adult respiratory distress syndrome.

Diagnosis

Leptospirosis most often manifests as a nonspecific flu-like illness, so recognition of epidemiologic risk factors is essential (Table 166.3). Occupational exposure to animal urine (e.g., veterinarians) has classically been considered the chief epidemiologic risk, but recent outbreaks highlight the importance of recreational water use (e.g.,

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