9-Jul-2012
Well, it was more than a “brush” actually. The damned bug floored me for almost 13 days, 7 nights of which was spent in hospital and caused me much suffering, apart from the additional burden of a huge hospital bill!
This article was written in the hope that it will help enlighten my fellow mountain bikers and others, who may be at some risk from this much-feared malaise, on the symptoms, dangers and treatment for this disease.
So what happened in my case?
Well, I believe I may have been exposed to the spirochaete bacterium which causes leptospirosis during a mountain-bike ride from Kg Pusu to Kemensah on 10-Jun-12. This was an epic 7+ hr ride that involved wading across numerous shallow streams and slow-moving/stagnant pools, skirting around stagnant waterlogged mud-pools in the centre of the trail, etc. The area is leech infested so most of us had multiple leech bites – resulting in open, bleeding wounds. This was probably how the bacteria invaded into my body.
I had no inkling of any infection until about 10 days after the ride when I began to feel unusually fatigued at the end of the working day. Then the fever started – with body temperature soaring as high as 39.7 deg Centigrade (104 degrees Farenheight), interspersed with uncontrollable bouts of chills resulting in me shivering uncontrollably despite being covered by blankets. Popping 2 pills of Panadol (paracetymol) every six hours did help to bring down the fever each time after an hour followed by profuse sweating. Once the effect of the Panadol wore off, the fever would inevitably resume again with a vengeance. The muscles and joints in my body began to ache badly, particularly around the legs. It became so bad that I could barely manage the few steps from the bed to the attached bathroom without leaning on to the walls for support. I lost all appetite for food and hardly ate anything since the fever started.
After 24 hours of the fever and a couple of Panadols later, I thought that the fever was sufficiently under control for me to make a short visit to a customer’s office over some technical support issues. I had parked at the basement of the office building and it was just a flight of steps to the ground floor. I only realized then how bad my condition was when I literally struggled to climb up the few steps to the ground floor. I decided then that there was no way I could continue with the visit and decided to return to my car. On the drive back, I was suddenly struck by uncontrollable nausea (vomiting).
Well, I did manage to make it safely home though I had to sit for quite a few minutes in my car after parking at my apartment to muster the strength and determination to walk back to my apartment. The fever came back again that afternoon but, surprisingly, after taking some hydration salts, it seemed to help control the fever.
Until this point, the suspicion I had was that I could be suffering from dengue fever. Based on feedback from friends then, the belief was that it was too early to get tested for dengue as apparently dengue could only be positively tested for and identified after at least 3 – 4 days of fever.
However, that evening, I decided to visit the Emergency Room of SDMC (Subang Jaya Medical Centre) for some medical consultation on my condition although my fever had been running for about 48 hours only. The doctor on duty duly arranged for an antigen blood test for dengue as apparently this antigen test could detect dengue after 24 hours of fever (as opposed to testing for dengue anti-bodies which can only be made after 3+ days of fever). The antigen test for dengue test turned out negative. However, the white blood cell count in my blood was elevated above normal, indicating that “something was attacking me” (to quote the doctor verbatim). Surprisingly, his only advice to me then was to take Panadol every 6 hours to control the fever and since I said I had Panadol at home, no medicine was dispensed. Well, I went back from the hospital none the wiser but somewhat relieved that I wasn’t suffering from dengue.
Unfortunately, the fever bouts and chills continued over the next 48 hours. I dutifully took Panadol every 6 hours and endured the profuse sweating that accompanied the pills followed by the occasional chills. I hardly took any solid food as the total loss of appetite persisted.
On the 5th day after the fever started, I felt that the fever was not running as high as previously (though it was still around 37+ deg Centigrade) and thought that I was finally getting better. I managed to make it to my office to attend to some urgent matters. At the end of the day, I decided to visit the Emergency Room of SDMC again as I wanted to run more blood tests to identify what was afflicting me all this while. The thinking then was that it could have been Chikungunya (another nasty mosquito-borne virus with similar high fever symptoms to dengue). I was also informed that Leptospirosis also exhibited similar high fever and joint ache symptoms so that was also on the testing to-do list.
When the mandatory blood pressure test was done on me prior to seeing the doctor on duty, it was discovered that my blood pressure was only registering 90-50, far below the normal 120-80 range that one should normally be in. The doctor was somewhat alarmed by this and said that for a male, this was unusually low blood pressure. He also detected some tenderness at the side of my abdominal area near the liver. He however agreed to arrange for the further blood tests I requested :-
- Dengue (results could be known in 1 – 2 hours, just in case the antigen test done earlier was unreliable),
- Chikungunya (results could only be known the next morning)
- Leptospirosis (results only in 2 weeks)
Two weeks for leptospirosis testing! I found that incredible. Apparently, it could not be done in-house and the blood sample had to be sent to IMR (Institute of Medical Research) for the testing.
Fortunately, the young doctor on duty suggested that he should also run a liver function blood test as viral infections such as dengue and chikungunya often affected the liver functions.
About 1+ hours later, some of the test results came through. The dengue test was still negative but almost all the parameters of my liver function test were off the chart! The doctor then suggested that I should be immediately warded and he voiced his opinion that my gall bladder could be the cause of my problem as gall bladder, gall stones and bile duct issues often caused recurring high fever symptoms similar to mine. I was then asked to choose which general surgeon I would prefer to have as the attending specialist.
Heck! I had thought I was afflicted by dengue but that turned out negative. Then I thought that it could be chikungunya but that could not be confirmed until the morning. Now I am being told I might be a candidate for some gall bladder issue that could potentially require surgery! It was enough to spoil anyone’s day!
Another senior doctor that I happen to have consulted before also echoed the suspicion on the gall bladder being the culprit when I approached him for recommendations on general surgeons in SDMC.
Finally, the Emergency Room personnel managed to contact by phone one of three names of general surgeons I wanted as the attending specialist. Fortunately, this general surgeon requested that I be made to undergo an immediate ultrasound scan of my gall bladder and liver before he decides to take on my case. The ultrasound scan revealed that my gall bladder was perfectly normal but that my liver was “grossly enlarged”. Upon learning this, the general surgeon decided my case was not for him to take up and that I should be referred to a physician specialist.
When the physician specialist reviewed my case, he became quite convinced that I was suffering from leptospirosis and said that treatment of the clinical symptoms had to begin immediately regardless of the lack of confirmation of this infection. As my blood pressure was rapidly dropping and there was a serious risk of damage or organ failure of my kidneys and liver as a result, the treatment could not be delayed further. He explained that whilst it was impossible to confirm leptospirosis as the root cause of my malaise, the strategy had to be to use a broad treatment approach that would help control leptospirosis as well as any other possible root causes of my infection.
Things moved quickly then. I was stuck with intravenous injection needles on both hands and wheeled to the CCU (Coronary Care Unit – a sort of ICU primarily for serious heart patients). This came as quite a shock – only 3 hours ago, I was walking around the Emergency Room and Radiology Department on my own with no signs of feeling faint or in danger of being comatose in any way and now I was headed to the CCU! I had numerous intravenous drips attached to me, heart ECG sensors monitoring my heart continuously round the clock, a blood pressure band automatically squeezing my arm every 15 mins to take the blood pressure readings and an oxygen tube stuck up my nose.
I was literally tethered to a huge monitoring machine in the centre of the room – with no possibility for me to get off the bed without tearing some tubes out. It was like a torture chamber of sorts!
That night, my blood pressure continued to drop further and more drastic steps were taken to try to raise my blood pressure. I was being intravenously injected with noradrenaline and dopamine to try to raise my blood pressure.
The next morning, a radiologist was present at my bedside to undertake a local anaesthetic procedure to insert a “central venous catheter” into the jugular vein on my neck with about 15 cm of the tube leading down towards my heart. Apparently, this is a useful multi-purpose device that can be used to accurately measure the internal blood pressure near the heart as well as to take blood samples and as well as providing additional intravenous injection points for administering intravenous drips or drugs. Unfortunately, it was noticed not long after the procedure that my heart developed “heart flutter” – where the upper chamber of the heart does not pump strongly in unison with the lower chamber as it normally should but it instead “flutters” or vibrates at a high rate of 200 – 300 beats per minute whilst the lower chamber continues to pump at the usual heartrate rhythm. This condition causes an elevated risk of stroke as the inefficient clearing of the blood flow in the upper chamber can result in blood clots forming and this could cause a stroke if the blood clots reach the brain. Initially, it was thought that the central venous catheter could have been inserted too deep and could be touching the heart muscle– thereby causing the heart flutter. The radiologist had to make a corrective shortening of the catheter insertion by 3 cm but unfortunately this did not return the heart to the correct normal rhythm. My cardiologist was called in and he administered blood thinning drugs to reduce the risk of blood clots forming whilst suggesting that the situation be monitored a bit longer to see if the heart returned to normal.
The heart did not return to normal and it was decided the next day that I needed to undergo a Electroshock Therapy for Cardiac Arrhythmia. This is equivalent to “re-booting” the heart with an electric shock under general anaesthesia. Thankfully, this procedure worked with one 150 joule shock and the heartrate returned to normal.
I was treated with a potent combination of antibiotics. Apparently, there are only 3 types of “old” antibiotics which are effective against the spirochaete bacterium, one of which is penicillin-based. All are “nasty” drugs with possible potent side-effects and apparently are hardly prescribed nowadays in view of the newer antibiotics in the market (which unfortunately are not effective against the spirochaete bacterium). I was told that I actually went into shock when administered one of these antibiotics and it was quickly stopped.
According to the doctors, my stay at the CCU could have been a bit shorter if not for the heart flutter / arrhythmia complication. Was the arrhythmia caused by professional negligence? Unfortunately, this is not an easy question to answer. Some of the drugs administered to raise my blood pressure are documented to have potential side effects on the heart rhythm. There is also a recent article from a doctor in India indicating that leptospirosis has been known to cause arrhythmia complications.
I spent a total of 5 nights in the CCU and another 2 nights in the normal ward before being discharged. Fortunately, my recovery from this unpleasant episode appears to have been quite fast. I was back on my saddle for 3 consecutive days of biking 3 days after being discharged from hospital. Confidence in my recovery is improving by the day and my appetite is back with a relish.
The total hospital bill came to RM18,600+. Hospital CCU bed and normal ward room charges only amounted to approximately 15% of the total bill. The rest of the charges were for specialist fees, pharmacy charges, laboratory charges, sterile consumable charges, etc etc. As it turned out, my company’s hospitalization and surgical insurance coverage will not be sufficient to cover the full costs even though my insurance coverage hospital room charge limit is RM480.00/night – more than sufficient for the CCU bed and normal ward charges. It’s the coverage of the other specialist fees and other related charges that is inadequate. Fortunately, I have another personal hospitalization insurance to cover the short-fall.
Despite questions on the source of the heart flutter / arrhythmia complications I faced, I have found the doctors attending to me at SDMC to be excellent in their professionalism and bedside manners. The overall experience with SDMC in terms of their healthcare staff, equipment and responses has been positive and I believe I had received the best medical care possible.
What is Leptospirosis?
To the uninitiated, leptospirosis is commonly referred to in layman’s terms as the “rat urine disease”. It gained infamy a few years ago when the local Malaysian news reported that many members of a search and rescue team, who went into the jungle in one of the remote outlying areasin Peninsular Malaysia to look for a missing picnicker who was swept away at a waterfall, began dying mysteriously one-by-one after the rescue operation. They all developed symptoms of high fever and many succumbed to meningitis (an inflammation of the brain tissue) and other complications. Eventually, their deaths were attributed to leptospirosis.
More recently, there had been numerous reports of sudden, unexpected fatalities amongst Malaysian National Service camp attendees who developed high fever and subsequent complications, including meningitis. Tragically, some of them died at home after being sent back from the camps due to their recurring high fever. The causes of some of these illnesses were linked to “water based activities” in contaminated rivers and open ponds. Eventually, the problem became so widespread and serious that all water-based activities at National Service camps has been banned until and unless the camps are equipped with properly sanitized concrete “pools”.
Leptospirosis is not a virus infection but is caused by the spirochaete bacterium (ie, “bug or germ”) which is commonly present in the urine of infected rats. However, the common misconception is that only rats cause this disease. The reality is that other feral animals can be infected, including domestic dogs, cats, rabbits, cattle, deer, etc. One of my friends mentioned wild boar as a potential source of infection too. Apparently, stagnant water pools in the jungle or even slow moving bodies of water can be dangerously infested with this bacteria.
The leptospire bug itself is extremely small and looks like a spiral-shaped worm, typically about 0.1 micron in body diameter and perhaps up to 10 - 20 microns in length (see figure below). It is much, much smaller than a red blood cell which is about 7 microns in diameter. The very small width of leptospires makes them difficult to see under optical microscopes unless a contrast-enhancing technique such as dark-field is used. The live specimens wriggles very quickly and under visible light their rapid rotation cam make them appear as a chain of dots instead of a continual structure. (Source: The Leptospirosis Information Center)
Computer Enhanced Electron Micrograph of Leptospira
The spirochaete bacterium enters the human body through any open wound or break in the human body skin (eg any minute scratches, cuts or even open leech bite wounds) or through the mucus membranes of the nose, mouth or female sexual organs. Those who swim or immerse their faces in infected water and/or accidentally swallow such water are particularly at risk. Once the spirochaete bacterium enters the human body, it multiplies very rapidly in the bloodstream.
Leptospires cause illness in a few ways :-
Toxicity
They contain chemicals that cause inflammation and cell death nearby.
Adhesion
They stick to the walls of certain cells in the body such as the cells lining blood vessels and so exit into the tissues. They spread throughout the entire body and lead to the generalized symptoms of muscle pains, hemorrhages, rashes, headaches, etc. It also can cause liver or other organ failure by causing rapid tissue death.
Auto Immune Activity
The body’s immune system can ‘over-react’ and launch such a large-scale attack on the leptospires that the body’s own tissues are damaged, leading to illness.
(Source: The Leptospirosis Information Center)
Symptoms of leptospirosis infection include persistent high fever, headache, chills, muscle aches, nausea (vomiting), jaundice, red eyes, abdominal pain, diarrhea and rash.
Some infected persons may not display any symptoms at all.
“The time between a person’s exposure to a contaminated source and becoming sick is 2 days to 4 weeks. Illness usually begins abruptly with fever and other symptoms. Leptospirosis may occur in two phases:
- after the first phase (with fever, chills, headache, muscle aches, vomiting, or diarrhea) the patient may recover for a time but become ill again.
- if a second phase occurs, it is more severe; the person may have kidney or liver failure or meningitis. This phase is also called Weil’s disease.
The illness lasts from a few days to 3 weeks or longer. Without treatment, recovery may take several months.” (Source: http://www.cdc.gov/leptospirosis/symptoms/index.html).
According to Dr Nor Liza, the Specialist for Infectious Diseases in Subang Jaya Medical Centre (“SDMC”), only approximately 5% of those exposed to leptospirosis infection have been known to develop the second phase Weil’s disease.
So let’s be clear about something here : Leptospirosis is a potentially deadly infection which can cause serious organ failure in the second stage (Weil’s disease stage) with “haemorrhagic manifestations (internal bleeding) and multi-organ failure. Leptospirosis is also known as “the Great Mimicker” and may be overlooked and underdiagnosed due to its varied clinical presentations.” According to the table CASES OF LEPTOSPIROSIS IN MINISTRY OF HEALTH HOSPITALS, MALAYSIA FROM YEAR 2004 TO 2009, in 2009 alone, there were 1,418 cases reported in Government Hospitals alone with 62 fatalities amongst these cases. (Source : http://jknpahang.moh.gov.my/v3/uploaddir/muatturun/Guidelines%20Leptospirosis%202011.pdf)
It is interesting that just as I was about to wrap up this article, I received a call from a Ministry of Health official conducting a survey on where and how I might have contracted Leptospirosis. They are trying to put up warning signboards to alert the public at all the known areas of infection. He related a story of a group of about 50 employees from a public listed company that went on a picnic recently to a waterfall (Templers’ Park, if I am not mistaken). More than 30 of the group were tested positive for leptospirosis after the picnic. The problem appears to be very widespread. He was lamenting that they could not try to chlorinate the waterfalls and streams as this would kill off all the fish and fauna in the water. Eradicating the rats as the source of infection is also near impossible. He even mentioned monkeys as possible carriers of the bacteria.
So what are the lessons to be learned from my experience:-
1) You don’t need to suffer for a few days of high fever to confirm if you have contracted dengue. The antigen test conducted after 24 hours of fever can confirm if you indeed have dengue. Waiting unnecessarily long with high fever before seeking sound medical assistance could have very serious consequences and may even prove fatal.
2) If you don’t have dengue and continue to have high fever, consult a reputable, experienced doctor or check into a reputable hospital for further diagnosis of your situation. A blood test of your liver function and advice on whether you should have an ultrasound scan if your liver is suspected of being enlarged/infected could save your life. Watch especially and alert the doctor if you show signs of having jaundice (yellow tinge to the eyes, etc) as it is clear indication of the liver being badly affected.
3) If you can afford it, go to a big, reputable hospital where you can get fast results on your blood tests, immediate ultrasound diagnostics, good attention from experienced doctors, etc. It could be a matter of life and death and be well worth the extra costs.
Many deaths arising from leptospirosis could have simply been avoided had the right diagnostics and treatment been applied in time.
Ignorance or inexperience of doctors or other medical personnel attending to you could have dire consequences for you when timeliness of the right treatment is of utmost importance.
4) Don’t expect quick, positive testing for leptospirosis. When I first asked for the leptospirosis blood test, it was made clear that it would take 2 weeks for the results. Even after my admission, SDMC was only able to “confirm” that I had leptospirosis on the last (8th day) of my stay at the hospital. Even then, a further external MAT test has to be done to be absolutely certain of the leptospirosis diagnosis.
Treatment for the clinical symptoms such as falling blood pressure, failing vital organs such as kidneys, etc has to be carried out immediately before any confirmation of the cause of infection.
5) Make sure you are well covered in your hospitalization insurance. If you do not have a hospitalization insurance card that guarantees payment of your hospitalization fees, a private hospital like SDMC will ask for at least RM3,500.00 deposit upon admission. If you are to be admitted to the ICU/CCU, the deposit goes up to RM10,000.00. Make sure your credit card has sufficient credit limit for this if the insurance card is not available!
6) I actually thought I was feeling better and recovering on the 5th day of my fever with much lower fever temperature or no fever and the ability to walk around (unlike the first few days of the fever). How wrong this proved to be!
My mistake was not to take my blood pressure regularly in addition to my temperature. I dread to think what could have happened if I had not decided to go to the hospital the second time despite the feeling that I was “recovering”.
The doctors have mentioned to me that in many cases, the leptospirosis victims only sought treatment when they were already in very bad condition (requiring dialysis, etc). I know of friends who went into coma or have had to be hospitalized for 30 days and heard of others who were hospitalized for 3 months and needed 3 more months of physiotherapy at home to fully recover.
As for some leptospirosis victims not showing any symptoms at all, well, that is really scary as the second phase Weils disease can potentially still kick in later.
7) WRONG : Risk of contracting leptospirosis is only when one ventures into the jungle, wade in stagnant water pools with open wounds, etc.
Doctors have told me of cases where victims of leptospirosis have never ventured into jungle areas but appear to have contracted it from their own garden while gardening, from renovation work sites, etc. The doctors however also reported treating numerous victims who appear to be infected from the Ulu Yam area.
Remember that the spirochaete bacterium can survive in any moist or wet environment. It does not have to be a stagnant water pool. You can potentially get it from brushing against some wet leaves of a shrub that could have been contaminated by a dog, cat, rabbit or some other animals if the spirochaete bacterium can gain entry into your body through an open wound or through your mucous membranes.
Hello, campers! Don’t rely on just your water filters (no matter how expensive) to filter stream water to be sufficiently fit for human consumption. I am not sure if sterilization tablets are even good enough. Even washing your face in the stream could be a risk factor.
Finally, stay safe and stay healthy!
END
Recommended references:-
http://jknpahang.moh.gov.my/v3/uploaddir/muatturun/Guidelines%20Leptospirosis%202011.pdf
