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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0005"></elsevierMultimedia></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Background</span><p id="par0025" class="elsevierStylePara elsevierViewall">Leptospirosis is a zoonosis of worldwide distribution and is caused by spirochetes of the genus <span class="elsevierStyleItalic">Leptospira</span>&#46; A number of wild &#40;e&#46;g&#46;&#44; mice&#41; and domestic &#40;e&#46;g&#46;&#44; pigs and dogs&#41; animal species act as reservoirs for leptospirae&#44; which&#44; when excreted in urine&#44; contaminates areas with stagnant water from where it can subsequently infect humans&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Leptospirosis is predominantly found in tropical areas&#44; mainly Latin America and South East Asia&#44; where it is a serious public health issue&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Occasionally&#44; the bacteria behave like an emerging disease&#44; with outbreaks such as the severe pulmonary hemorrhage syndrome epidemic in Nicaragua in 1995&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In developed countries in temperate regions&#44; there have also been cases of leptospirosis as an occupational disease &#40;rice farmers&#44; livestock breeders&#44; veterinarians and military people&#41; and has also been diagnosed in homeless people living in large cities&#44; in cases related to recreational activities and in people who live with pets&#46; It is possible that the actual incidence of the disease is underestimated in some parts of the developed world&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4&#44;5</span></a> Furthermore&#44; the recent increase in mean global temperatures and the related meteorological phenomena &#40;heat waves and torrential rains&#41; could lead to an increase in the frequency of infectious waterborne diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Although the disease can manifest as severe icterohemorrhagic fever or Weil&#39;s syndrome in 5&#8211;10&#37; of patients&#44; most cases present with febrile symptoms of no apparent cause and are occasionally biphasic or asymptomatic&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The diagnosis is often upheld with serological testing&#44; although molecular biological techniques &#40;such as PCR&#41; are an increasingly popular alternative&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In the last 15 years&#44; small case series of leptospirosis have been published in Spain&#44; the majority with Weil&#39;s syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;11</span></a> In 2 seroprevalence studies conducted on at-risk groups &#40;workers in contact with stagnant water and veterinary students&#41;&#44; a high incidence of infection was detected during a 1-year follow-up &#40;6&#46;4&#37; and 4&#37; for the 2 studies&#44; respectively&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> A study conducted in Portugal on more than 1000 cases of leptospirosis&#44; which is important due to its geographic proximity to Spain&#44; revealed an incidence of 1&#46;7&#47;100&#44;000 inhabitants&#47;year&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The aim of this study was to determine the epidemiological&#44; clinical and prognostic aspects of leptospirosis in the Badajoz healthcare area&#44; a region with extensive irrigation and a mountain environment dedicated to raising cattle and pigs&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patients and methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">The healthcare area of Badajoz is currently responsible for 274&#44;000 inhabitants &#40;INE&#44; 2010 Municipal Census&#41; who receive hospital care at the University Hospital of Badajoz&#46; The most populous area is the city of Badajoz &#40;152&#44;000 inhabitants in 2012&#44; up from 123&#44;000 in 1997&#41;&#44; the population of which works mainly in activities that fall within the services sector&#46; In addition&#44; its healthcare area includes 3 municipalities with more than 10&#44;000 inhabitants&#46; The rest of the population works mainly in agriculture and raising cattle&#44; with a minimum presence in the food industry and a growing number of agritourism-related activities&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">All patients over age 14 who were diagnosed with leptospirosis at the University Hospital of Badajoz were retrospectively analyzed between April 1&#44; 1997 and April 1&#44; 2013&#46; In the cases treated by the Infectious Disease Unit&#44; a review was conducted on the case histories of those requiring hospital admissions&#44; on the reports from consultations in outpatient diagnostics and on the reports from check-up visits&#44; which were conducted 3 weeks after hospital discharge&#46; For the remaining patients&#44; the data were obtained from the minimum basic data set&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The diagnosis was based on the simultaneous presence of compatible sets of symptoms &#40;fever&#44; chills&#44; myalgia&#44; headache&#44; with or without skin rashes&#44; conjunctivitis&#44; lymphocytic meningitis&#44; jaundice and renal failure&#41; and <span class="elsevierStyleItalic">Leptospira</span> antibodies &#40;Panbio<span class="elsevierStyleSup">&#174;</span><span class="elsevierStyleItalic">Leptospira</span> IgM ELISA E-LEP01<span class="elsevierStyleHsp" style=""></span>M&#47;E-LEP01M05&#41;&#46; The diagnosis was accepted when the antibody titer for <span class="elsevierStyleItalic">Leptospira</span> was higher than 0&#46;9 in the full-blown stage or when seroconversion was demonstrated at 3 weeks &#40;3&#215; or more increase in the full-blown stage titer&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Demographic data&#44; epidemiological history and clinical and blood test data were collected&#44; as well as the treatment and progress&#46; In each case&#44; the municipality and district of residence were specified&#44; as well as any history of working in contact with stagnant water or ranch animals &#40;e&#46;g&#46;&#44; pigs&#44; cows&#44; sheep&#44; goats and horses&#41; and pets &#40;e&#46;g&#46;&#44; dogs&#41; and the season and year of diagnosis&#46; Any hospital admissions were recorded&#44; along with the duration of symptoms prior to diagnosis and the clinical presentation of those symptoms&#46; Hyperaminotransferasemia was defined as any value of glutamic-pyruvic transaminase higher than 1&#46;5&#215; the upper limit of normal&#59; thrombocytopenia was defined as a platelet count lower than 100<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">3</span>&#47;liter&#59; renal failure was defined as creatinine plasma levels higher than 2<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; and hyperbilirubinemia was defined as bilirubin levels higher than 2<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; A diagnosis of meningitis was established for any white blood cell count in the cerebrospinal fluid &#40;CSF&#41; greater than 10<span class="elsevierStyleHsp" style=""></span>leukocytes&#47;&#956;L&#46; The CSF biochemical data and cell count was evaluated&#46; Weil&#39;s disease was defined as the simultaneous presence of &#40;1&#41; renal failure&#44; &#40;2&#41; hyperbilirubinemia and &#40;3&#41; hypertransaminasemia&#44; hemorrhagic phenomena or thrombocytopenia&#46; Antibody titers were quantified for <span class="elsevierStyleItalic">Leptospira</span> in the acute phase &#40;first visit or on admission&#41; and in the convalescent phase&#44; 3 weeks later&#46; In addition&#44; serologic testing was conducted for <span class="elsevierStyleItalic">Brucella</span> spp&#46; &#40;using the Rose-Bengal and Coombs agglutination tests&#41; and <span class="elsevierStyleItalic">Coxiella burnetii</span> &#40;using indirect immunofluorescence&#41;&#46; Finally&#44; the prescribed antimicrobial treatment and mortality rate were assessed&#46; Mortality was the study&#39;s main outcome variable&#59; however&#44; the variables associated with mortality and the need for hospital admission were also analyzed&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">To compare the quantitative variables&#44; we used Student&#39;s <span class="elsevierStyleItalic">t</span>-test and the Mann Whitney <span class="elsevierStyleItalic">U</span> test&#44; depending on whether they followed a normal distribution&#46; For the categorical variables&#44; we used the chi-squared test with the Yates correction or Fisher&#39;s exact test&#46; The quantitative variables are presented as arithmetic means&#44; standard deviations and ranges&#59; the qualitative variables are presented as percentages&#46; To detect the factors that influence mortality&#44; a univariate logistic regression analysis was conducted that included covariables for age &#40;categorized as younger or older than 60 years&#41;&#44; gender&#44; the season during which the diagnosis was made and the diagnosis of Weil&#39;s disease&#46; A <span class="elsevierStyleItalic">p</span>-value &#60;&#46;05 was considered statistically significant&#46; The statistical study was conducted using the SPSS 15&#46;0 software package&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">Eighty-six patients were diagnosed with leptospirosis&#44; 67 of whom were diagnosed by the Infectious Disease Unit &#40;56 while hospitalized&#44; 11 as outpatients&#41;&#44; 10 by the Department of Internal Medicine&#44; 6 in the Intensive Care Unit and 3 by the Department of Nephrology&#46; The mean age of the patients included in the study was 43&#46;1 years &#40;&#177;13&#46;8 years&#44; median 41 years&#44; 75&#37; of whom were younger than 52 years&#41;&#44; with a clear predominance of men &#40;73 patients&#44; 84&#46;9&#37;&#41;&#46; The number of cases diagnosed each year is displayed in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; It should be noted that the largest number of cases diagnosed in 2007 was not due to any local epidemic or outbreak&#46; There were no cases diagnosed in 2005&#44; and in the remaining years&#44; the incidence varied between 0&#46;74 cases&#47;100&#44;000 inhabitants in 2004 and 5&#46;56&#47;100&#44;000 in 2007&#46; The mean incidence in the 16 years of the study was 1&#46;99 cases&#47;100&#44;000 inhabitants per year&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Sixty-three of the 67 patients &#40;94&#37;&#41; reported engaging in risk activities&#44; 52 of whom reported having contact with animals &#40;82&#46;5&#37; overall&#44; 57&#46;4&#37; with pigs&#44; 38&#46;1&#37; with dogs&#44; 31&#46;7&#37; with cows and 22&#46;2&#37; with sheep&#41; and 20 &#40;31&#46;7&#37;&#41; of whom had contact with stagnant water&#46; An accumulation of cases was discovered in the meadows of the Guadiana River and in mountain pasture areas dedicated to raising cattle&#46; Only 7&#47;61 patients &#40;11&#46;5&#37;&#41; lived in the city of Badajoz&#46; In addition&#44; 33&#46;7&#37; of all cases were diagnosed in the summer&#59; the other seasons had a similar distribution of cases &#40;19&#46;8&#37; in spring&#44; 22&#46;1&#37; in autumn and 24&#46;4&#37; in winter&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The median duration of symptoms was 7 days &#40;mean&#44; 8&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;4&#59; range&#44; 1&#8211;30&#41;&#44; but in a quarter of the cases&#44; the symptoms lasted more than 10 days&#46; The main clinical manifestations are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and include fever &#40;94&#46;1&#37; of cases&#41;&#44; arthromyalgia &#40;60&#46;7&#37;&#41; and headache &#40;53&#46;3&#37;&#41;&#46; Jaundice and eye disorders &#40;uveitis and conjunctivitis&#41; were detected in 11&#46;9&#37; and 9&#37; of the patients&#44; respectively&#46; The main laboratory test abnormalities were hypertransaminasemia &#40;50&#37;&#41;&#44; renal failure &#40;26&#46;3&#37;&#41;&#44; thrombocytopenia &#40;16&#46;9&#37;&#41; and hyperbilirubinemia &#40;15&#46;1&#37;&#41;&#46; For 13 patients&#44; the clinical symptoms were consistent with Weil&#39;s disease&#59; lymphocytic meningitis was reported in 11 patients&#44; and 2 patients &#40;2&#46;3&#37;&#41; experienced myopericarditis&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">All patients with related meningitis presented clear CSF&#44; with a mean white blood cell count of 160<span class="elsevierStyleHsp" style=""></span>leukocytes&#47;&#956;L &#40;range&#44; 40&#8211;400&#41;&#46; The typical fluid pattern consisted of mononuclear pleocytosis &#40;70&#37;&#41;&#44; high CSF protein concentrations &#40;85&#8211;216<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; &#40;72&#46;7&#37;&#41; and normal CSF glucose concentrations &#40;90&#46;9&#37;&#41;&#46; One patient had high glucose concentrations&#46; Patients with meningitis were on average younger &#40;31&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;2 vs&#46; 44&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;2 years&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#41;&#44; and those with Weil&#39;s disease were on average older &#40;53&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;8 vs&#46; 41&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;5 years&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;007&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Fifty-six of the patients &#40;66&#46;3&#37;&#41; were hospitalized&#46; Hospitalizations were significantly associated with a shorter duration of symptoms and the presence of headache&#44; renal failure&#44; hypertransaminasemia&#44; thrombocytopenia&#44; meningitis and Weil&#39;s disease &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; By dividing the study into 2 time periods &#40;1997&#8211;2005 and 2005&#8211;2013&#41;&#44; we found no significant differences in the proportion of hospital admissions and cases of meningitis and Weil&#39;s disease between the 2 periods&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">The mean IgM titer for <span class="elsevierStyleItalic">Leptospira spp&#46;</span> was 2&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;3 and 2&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;5 in the full-blown and convalescence stages&#44; respectively &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;135&#41;&#46; One patient&#44; a veterinarian by profession&#44; presented a probable coinfection with <span class="elsevierStyleItalic">Brucella spp&#46;</span> &#40;titers of 1&#47;640 and 1&#47;1280 in the Coombs and tube seroagglutination tests&#44; respectively&#41; and <span class="elsevierStyleItalic">Leptospira</span> &#40;seroconversion after 3 weeks of clinical symptoms&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Six patients &#40;7&#37;&#41; did not undergo antimicrobial treatment&#44; and none required hospitalization&#46; Among those treated&#44; the most commonly used antibiotics were doxycycline &#40;55&#47;67&#44; 82&#46;1&#37;&#41;&#44; ceftriaxone &#40;9&#47;67&#44; 13&#46;4&#37;&#41;&#44; cefuroxime &#40;2&#47;67&#44; 3&#37;&#41; and ciprofloxacin &#40;1&#47;67&#44; 1&#46;5&#37;&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Six patients died &#40;7&#37;&#41;&#44; all of them as a direct consequence of leptospirosis&#46; The deceased patients at the time of their death were significantly older on average than the survivors &#40;66&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;9 vs&#46; 41&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;9 years&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41; and were more frequently diagnosed with Weil&#39;s disease &#40;66&#46;7&#37; vs&#46; 11&#46;25&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#41;&#46; All of the deceased patients had been hospitalized in autumn or winter&#46; In the univariate analysis&#44; mortality was associated with an age equal to or older than 60 years &#40;odds ratio &#91;OR&#93;&#44; 45&#46;0&#59; 95&#37; CI 4&#46;7&#8211;434&#46;6&#41; and the presence of Weil&#39;s disease &#40;OR 15&#46;8&#59; 95&#37; CI 2&#46;5&#8211;98&#46;7&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">For the 67 cases treated by the Infectious Disease Unit&#44; outpatient check-ups were conducted after 3weeks &#40;following the first consultation or after hospital discharge&#41;&#46; In all of these visits&#44; the patients&#8217; progress was good&#44; with no sequelae&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">This study reveals that leptospirosis has a mean incidence &#40;with significant variations&#41; of 1&#46;99&#47;100&#44;000 inhabitants&#47;year in our community&#44; which is similar to neighboring Portugal&#46; The most common clinical presentation is fever with no apparent cause&#44; in men engaged in risk activities&#46; There were a noticeably high percentage of patients who presented symptoms with acute lymphocytic meningitis &#40;12&#46;8&#37;&#41; and a mortality rate &#40;7&#37;&#41; that was far from negligible&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In recent years&#44; the predominance of leptospirosis in middle-aged men &#40;a median age of 43&#41; has been similar among cases observed in Spain and Portugal&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#8211;11&#44;14</span></a> The coincidence in the incidence of leptospirosis found in Badajoz and in the central regions of Portugal is consistent with the similar climate&#44; agriculture and livestock industries&#46; It is also interesting to note that the vast majority of cases &#40;94&#37;&#41; were diagnosed in people with a history of disease&#44; notably those who have had occupational contact with livestock &#40;especially pigs&#41; and stagnant water&#46; Two prevalence studies conducted in the Spanish provinces of Seville and Zaragoza found that leptospirosis was associated with a number of specific occupations&#44; such as working in rice fields&#44; slaughterhouses and butcher shops and individuals performing veterinary work with pets and on farms&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In our series&#44; leptospirosis behaved as a febrile disease lasting approximately 1 week and was commonly accompanied by arthromyalgia and headache&#44; requiring hospitalization in two-thirds of cases and proving to be fatal in 7&#37; of cases&#46; The patients who did not require hospitalization had longer lasting clinical symptoms but were less symptomatic&#46; The frequency of hypertransaminasemia &#40;50&#37;&#41; was similar to that described in other case series&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;15</span></a> The frequency with which leptospirosis manifested as Weil&#39;s disease &#40;15&#46;1&#37;&#41; is in the high range of that described by Barthi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The observed mortality rate of 7&#37; is comparable to that recorded in a large Dutch historical series &#40;6&#46;5&#37;&#41; and lower than that of epidemics reported in Brazil &#40;15&#37;&#41; and the Philippines &#40;10&#46;8&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#8211;18</span></a> The relationship among mortality rates&#44; ages over 60&#44; renal failure&#44; jaundice and the delay in starting antimicrobial treatment have been previously reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The presence of lymphocytic meningitis deserves special mention&#44; given the 13&#37; incidence of such cases&#46; A similar frequency for meningitis was reported in a 10-year retrospective study conducted in France&#44; in which meningeal signs were detected in 12 of 97 cases&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The typical fluid patterns were of mononuclear pleocytosis with elevated protein levels and normal glucose levels&#44; with a single case of hypoglycorrhachia&#44; a condition that is rarely reported&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> In regions of Brazil&#44; positive serologies have been detected for <span class="elsevierStyleItalic">Leptospira</span> in CSF in 8&#8211;15&#37; of lymphocytic meningitis cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> The frequency of the diagnosis of leptospirosis in our community and its association with lymphocytic meningitis leads us to suggest a diagnosis of leptospirosis in patients with acute lymphocytic meningitis and exposure to animals or stagnant water and even to evaluate the possibility of empiric antimicrobial treatment&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">There are certain limitations to our study&#46; First&#44; it is likely that a number of patients with leptospirosis who lived in our healthcare area were not diagnosed or were not treated at our hospital center&#46; There were also likely an indeterminate number of people with minor clinical symptoms or who were asymptomatic and did not require medical care or who were treated at primary care medical centers or had spontaneous resolutions&#46; These circumstances are common to all series of patients with leptospirosis&#58; only those patients who seek consultations and are diagnosed are included&#46; Another limitation is the serologic technique used &#40;Panbio ELISA&#41;&#44; which is highly specific &#40;89&#37;&#41;&#44; although this specificity is reduced when there is high endemicity&#44; particularly with acute disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;23</span></a> The standard serologic method employed to diagnose leptospirosis is microscopic agglutination&#44; but this test is slow and labor-intensive&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Molecular techniques &#40;such as PCR&#41;&#44; on the other hand&#44; can provide fast and precise diagnoses&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;8&#44;22</span></a> The ELISA IgM test can be extremely useful and its diagnostic capacity increases in the convalescent stage&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Our observations support the inclusion of leptospirosis in the differential diagnosis of patients with febrile syndrome of no apparent cause&#44; Weil&#39;s syndrome or lymphocytic meningitis with a compatible epidemiological history&#46; Our results also highlight the serious potential of symptoms&#44; especially in patients over 60 years of age&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            2 => "Lymphocytic meningitis"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Leptospirosis is a zoonosis of worldwide distribution and tropical predominance&#46; Its incidence could be underestimated in template regions&#46; We describe the manifestations of leptospirosis in an area of Southwestern Spain&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Eighty-six cases of leptospirosis &#40;April 1997&#8211;April 2013&#41; were retrospectively analyzed&#46; The diagnosis was based in clinical and serological &#40;Leptospira IgM ELISA&#41; judgment&#46; Epidemiological&#44; clinical&#44; laboratory&#44; and prognostic dates were recorded&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The mean age was 43&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;8 years &#40;84&#46;9&#37; males&#41;&#46; The mean annual incidence was 1&#46;99&#47;100&#44;000&#46; There were activities of risk in 94&#37;&#58;82&#46;5&#37; contact with animals &#40;57&#46;4&#37; pigs&#44; 38&#46;1&#37; dogs&#44; 31&#46;7&#37; cows&#44; 22&#46;2&#37; sheeps&#41;&#44; and 31&#46;7&#37; contact with pooled water&#46; The most frequent symptoms were fever &#40;94&#46;1&#37;&#41;&#44; arthromyalgias &#40;60&#46;7&#37;&#41;&#44; and cephalalgia &#40;53&#46;3&#37;&#41;&#46; The main laboratory alterations were hypertransaminemia &#40;48&#37;&#41;&#44; renal insufficiency &#40;26&#46;3&#37;&#41;&#44; and thrombocytopenia &#40;16&#46;9&#37;&#41;&#46; A lymphocytic meningitis was associated in 11 cases &#40;12&#46;5&#37;&#41; and a picture of Weil&#39;s disease was observed in 13 patients &#40;15&#46;1&#37;&#41;&#46; The patients with meningitis were younger &#40;31&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;2 versus 44&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;2&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#41;&#46; The patients with Weil&#39;s disease were older &#40;53&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;8 versus 41&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;5&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;007&#41;&#46; Fifty seven patients were hospitalized &#40;66&#46;3&#37;&#41; and 6 patients died &#40;7&#46;0&#37;&#41;&#46; Factors independently associated with mortality were age &#62;<span class="elsevierStyleHsp" style=""></span>60 years &#40;odds ratio &#91;OR&#93; 45&#46;0&#44; confidence interval 95&#37; &#91;CI 95&#37;&#93; 4&#46;7&#8211;434&#46;6&#41; and diagnosis of Weil&#39;s disease &#40;OR 15&#46;8&#44; CI 95&#37; 2&#46;5&#8211;98&#46;7&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In our experience&#44; leptospirosis have a not despicable incidence and tends to show fever and arthromyalgias in men with risk activities&#46; Leptospirosis should be included in the differential diagnosis of lymphocytic meningitis&#46; Mortality is associated with older age&#46;</p>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La leptospirosis tiene una distribuci&#243;n mundial y predomina en regiones tropicales&#46; Su incidencia puede estar infraestimada&#46; Describimos las caracter&#237;sticas de la leptospirosis en el suroeste de Espa&#241;a&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Serie de casos retrospectiva de 86 casos de leptospirosis diagnosticados entre abril de 1997 y abril de 2013&#46; Se analizan datos epidemiol&#243;gicos&#44; cl&#237;nicos&#44; anal&#237;ticos y pron&#243;sticos&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La edad media de los pacientes fue de 43&#44;1 a&#241;os &#40;desviaci&#243;n est&#225;ndar 13&#44;8&#41;&#46; El 84&#44;9&#37; fueron varones&#46; La incidencia anual media fue de 1&#44;99&#47;100&#46;000 habitantes&#46; El 94&#37; de los pacientes ten&#237;an actividades de riesgo&#58; contacto con animales en el 82&#44;5&#37; y con aguas estancadas en el 31&#44;7&#37;&#46; Las principales manifestaciones cl&#237;nicas fueron la fiebre &#40;94&#44;1&#37;&#41;&#44; artromialgias &#40;60&#44;7&#37;&#41; y cefalea &#40;53&#44;3&#37;&#41;&#46; El 48&#37; de los casos tuvieron hipertransaminemia&#44; el 26&#44;3&#37; insuficiencia renal y el 16&#44;9&#37; trombocitopenia&#46; Trece pacientes &#40;15&#44;1&#37;&#41; tuvieron enfermedad de Weil &#40;EW&#41; y 11 meningitis&#46; Los pacientes con meningitis eran de menor edad &#40;31&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#44;2 frente a 44&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#44;2&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;004&#41; y los pacientes con EW de mayor edad &#40;53&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#44;8 frente a 41&#44;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#44;5&#44; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;007&#41;&#46; Cincuenta y siete pacientes requirieron hospitalizaci&#243;n &#40;66&#44;3&#37;&#41; y 6 de ellos fallecieron &#40;7&#44;0&#37;&#41;&#46; Se asociaron a mortalidad la edad superior a los 60 a&#241;os &#40;odds ratio &#91;OR&#93; 45&#44;0&#44; intervalo de confianza al 95&#37; &#91;IC 95&#37;&#93; 4&#44;7-436&#44;6&#41; y el diagn&#243;stico de EW &#40;OR 15&#44;8&#44; IC 95&#37; 2&#44;5-98&#44;7&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La leptospirosis tiene en nuestro entorno una incidencia no despreciable&#46; Incide preferentemente en varones con actividades reconocidas como de riesgo&#44; que presentan fiebre y artromialgias&#46; Debe incluirse en el diagn&#243;stico diferencial de la meningitis linfocitaria&#46; La mortalidad se asocia a mayor edad&#46;</p>"
      ]
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    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Rodr&#237;guez-Vidigal FF&#44; Vera-Tom&#233; A&#44; Nogales-Mu&#241;oz N&#44; Mu&#241;oz-Garc&#237;a-Borruel M&#44; Mu&#241;oz-Sanz A&#46; Leptospirosis en un &#225;rea sanitaria del suroeste espa&#241;ol&#46; Rev Clin Esp&#46; 2014&#59;214&#58;247&#8211;252&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">No&#46; of patients&#47;total analyzed&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&#46;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">15&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Not hospitalized &#40;29 patients&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Factors associated with hospitalization of the patients with leptospirosis included in the study&#46;</p>"
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          "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">What we know&#63;</span><p id="par0010" class="elsevierStylePara elsevierViewall">Leptospirosis is a zoonosis of worldwide distribution&#44; caused by spirochetes of the genus <span class="elsevierStyleItalic">Leptospira</span>&#46; It is predominantly found in tropical regions&#44; mainly Latin America and South East Asia&#44; where it is a serious public health risk&#46; Its prevalence might be underestimated in certain parts of the developed world&#46; The aim of this study was to examine the epidemiological&#44; clinical and prognostic aspects of leptospirosis in the healthcare area of Badajoz&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">What this article provides&#63;</span><p id="par0015" class="elsevierStylePara elsevierViewall">The incidence of leptospirosis is approximately 1&#46;99&#47;100&#44;000 inhabitants per year&#46; It mostly affects men engaged in risk activities and typically behaves as a week-long febrile illness&#44; often accompanied by arthromyalgia and headache&#46; In 15&#37; of the cases in this study&#44; the clinical symptoms were consistent with Weil&#39;s disease and 12&#46;8&#37; of cases had associated lymphocytic meningitis&#46; The mortality rate for leptospirosis was 7&#37; and was associated with Weil&#39;s disease and higher age groups&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The Editors</p></span></span>"
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                            0 => "A&#46;R&#46; Bharti"
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                            0 => "F&#46;F&#46; Rodr&#237;guez-Vidigal"
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                            2 => "D&#46;A&#46; Ashford"
                            3 => "E&#46;M&#46; McClure"
                            4 => "C&#46; Jarquin-Gonz&#225;lez"
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                  ]
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                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Infect Dis"
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                            3 => "A&#46;I&#46; Ko"
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Journal Information
Vol. 214. Issue 5.
Pages 247-252 (June - July 2014)
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Vol. 214. Issue 5.
Pages 247-252 (June - July 2014)
Brief Original
Leptospirosis in South-western Spain
Leptospirosis en un área sanitaria del suroeste español
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F.F. Rodríguez-Vidigal, A. Vera-Tomé, N. Nogales-Muñoz, M. Muñoz-García-Borruel, A. Muñoz-Sanz
Corresponding author
agus.munozsanz@gmail.com

Corresponding author.
Unidad de Patología Infecciosa, Hospital Universitario de Badajoz, Badajoz, Spain
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Table 1. Main clinical symptoms and blood test abnormalities of leptospirosis in the patients included in the study.
Table 2. Factors associated with hospitalization of the patients with leptospirosis included in the study.
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Abstract
Introduction

Leptospirosis is a zoonosis of worldwide distribution and tropical predominance. Its incidence could be underestimated in template regions. We describe the manifestations of leptospirosis in an area of Southwestern Spain.

Patients and methods

Eighty-six cases of leptospirosis (April 1997–April 2013) were retrospectively analyzed. The diagnosis was based in clinical and serological (Leptospira IgM ELISA) judgment. Epidemiological, clinical, laboratory, and prognostic dates were recorded.

Results

The mean age was 43.1±13.8 years (84.9% males). The mean annual incidence was 1.99/100,000. There were activities of risk in 94%:82.5% contact with animals (57.4% pigs, 38.1% dogs, 31.7% cows, 22.2% sheeps), and 31.7% contact with pooled water. The most frequent symptoms were fever (94.1%), arthromyalgias (60.7%), and cephalalgia (53.3%). The main laboratory alterations were hypertransaminemia (48%), renal insufficiency (26.3%), and thrombocytopenia (16.9%). A lymphocytic meningitis was associated in 11 cases (12.5%) and a picture of Weil's disease was observed in 13 patients (15.1%). The patients with meningitis were younger (31.2±9.2 versus 44.8±15.2, p=0.004). The patients with Weil's disease were older (53.5±15.8 versus 41.2±14.5, p=0.007). Fifty seven patients were hospitalized (66.3%) and 6 patients died (7.0%). Factors independently associated with mortality were age >60 years (odds ratio [OR] 45.0, confidence interval 95% [CI 95%] 4.7–434.6) and diagnosis of Weil's disease (OR 15.8, CI 95% 2.5–98.7).

Conclusions

In our experience, leptospirosis have a not despicable incidence and tends to show fever and arthromyalgias in men with risk activities. Leptospirosis should be included in the differential diagnosis of lymphocytic meningitis. Mortality is associated with older age.

Keywords:
Leptospirosis
Zoonosis
Lymphocytic meningitis
Resumen
Introducción

La leptospirosis tiene una distribución mundial y predomina en regiones tropicales. Su incidencia puede estar infraestimada. Describimos las características de la leptospirosis en el suroeste de España.

Pacientes y métodos

Serie de casos retrospectiva de 86 casos de leptospirosis diagnosticados entre abril de 1997 y abril de 2013. Se analizan datos epidemiológicos, clínicos, analíticos y pronósticos.

Resultados

La edad media de los pacientes fue de 43,1 años (desviación estándar 13,8). El 84,9% fueron varones. La incidencia anual media fue de 1,99/100.000 habitantes. El 94% de los pacientes tenían actividades de riesgo: contacto con animales en el 82,5% y con aguas estancadas en el 31,7%. Las principales manifestaciones clínicas fueron la fiebre (94,1%), artromialgias (60,7%) y cefalea (53,3%). El 48% de los casos tuvieron hipertransaminemia, el 26,3% insuficiencia renal y el 16,9% trombocitopenia. Trece pacientes (15,1%) tuvieron enfermedad de Weil (EW) y 11 meningitis. Los pacientes con meningitis eran de menor edad (31,2±9,2 frente a 44,8±15,2, p=0,004) y los pacientes con EW de mayor edad (53,5±15,8 frente a 41,2±14,5, p=0,007). Cincuenta y siete pacientes requirieron hospitalización (66,3%) y 6 de ellos fallecieron (7,0%). Se asociaron a mortalidad la edad superior a los 60 años (odds ratio [OR] 45,0, intervalo de confianza al 95% [IC 95%] 4,7-436,6) y el diagnóstico de EW (OR 15,8, IC 95% 2,5-98,7).

Conclusiones

La leptospirosis tiene en nuestro entorno una incidencia no despreciable. Incide preferentemente en varones con actividades reconocidas como de riesgo, que presentan fiebre y artromialgias. Debe incluirse en el diagnóstico diferencial de la meningitis linfocitaria. La mortalidad se asocia a mayor edad.

Palabras clave:
Leptospirosis
Zoonosis
Meningitis linfocitaria

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