Iran Red Crescent Med J. 2014 October; 16(10): e16030.

DOI: 10.5812/ircmj.16030
Published online 2014 October 5. Research Article

Corticosteroid in the Treatment of Moderate to Severe Thrombocytopenia

Due to Leptospirosis
1 2 1 1,* 3
Shahriar Alian ; Hasan Asghari ; Narges Najafi ; Alireza Davoudi ; Jamshid Yazdani
1Department of Infectious Diseases and Tropical Medicine, Antimicrobial Resistance Research Center, Mazandaran University of Medical Sciences, Sari, IR Iran
2Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, IR Iran
3Department of Biostatistics, Health Sciences Research Center, Faculty of Health, Mazandaran University of Medical Sciences, Sari, IR Iran

*Corresponding Author: Alireza Davoudi, Department of Infectious Diseases and Tropical Medicine, Antimicrobial Resistance Research Center, Mazandaran University of Medical
Sciences, Sari, IR Iran. Tel: +98-1232316319, Fax: +98-1232316319, E-mail: [email protected]

Received: November 9, 2013; Revised: January 21, 2014; Accepted: February 24, 2014

Background: Thrombocytopenia is associated with a bad prognosis in Leptospirosis.

Objectives: We investigated the effect of corticosteroids to improve thrombocytopenia due to leptospirosis.
Patients and Methods: In a clinical trial, all patients admitted with leptospirosis in Razi Hospital of Ghaemshahr, north of Iran were
enrolled in a 2-year study. Totally, 56 patients with moderate to severe thrombocytopenia were randomized to control and treatment
groups. The treatment group received corticosteroid (prednisolone 1 mg/kg/day for maximum one week) in addition to the standard
antibiotic therapy.
Results: There was no significant difference regarding age and gender between the two groups (P = 0.254, P = 0.789, respectively). The
mean duration to improve thrombocytopenia was 4.41 ± 0.197 days in the treatment group and 5.72 ± 0.318 days in the control group,
which was significantly different (P = 0.003). Duration of hospitalization in the treatment group was 5.24 ± 0.244 days and 6.23 ± 0.329
days in the control group, which was significantly different (P = 0.028). The two groups had no significant difference regarding mortality,
intubation, level of platelet, duration of ICU admission and pulmonary, renal or hepatic involvement.
Conclusions: Corticosteroid therapy decreased the length of hospitalization only in severe subgroup thrombocytopenia, but not in the
moderate subgroup.

Keywords:Leptospirosis; Thrombocytopenia; Corticosteroids

1. Background
Leptospirosis is a zoonotic infection in humans and ani- penetration of tissue barriers, including invasion to the
mals caused by Leptospira species of the spirochete fam- central nervous system and aqueous humor of the eye.
ily (1). There are two stages in the disease process. The first Transendothelial migration of spirochetes is facilitated
phase occurs during the active leptospira infection named by a systemic vasculitis, accounting for a broad spectrum
as bacteriemic or septicemic phase. In this phase, flu-like of clinical illness (2, 7). Severe vascular injury can be de-
symptoms (including fever, severe headache, myalgia, veloped, leading to pulmonary hemorrhage, ischemia of
chills, nausea and vomiting, conjunctival suffusion, ab- the renal cortex and tubular-epithelial cell necrosis, and
dominal pain, anorexia, coughing and sore throat) occur destruction of the hepatic architecture, resulting in jaun-
for more than 5-7 days. The second phase, immunologic, dice and liver cell injury, with or without necrosis (2, 8-11).
occurs immediately after the bacteriemic phase or 1-3 days Immune-mediated mechanisms have been postulated
after asymptomatic period. Patient's symptoms vary in to affect the severity of symptoms and immune mecha-
this phase. Many patients have mild fever, headache, vom- nisms, including circulating immune complexes, anticar-
iting and rash. Aseptic meningitis is most common in the diolipin antibodies, and antiplatelet antibodies, but their
second phase. Ten percent of patients with leptospirosis significance has not been proven yet (2). Old age, pneumo-
are affected by a severe form of disease or Weil's syndrome nia, renal failure, and thrombocytopenia are associated
(with a mortality rate of 5-40%) (2). Common symptoms of with a bad prognosis (1). Thrombocytopenia occurs in the
this syndrome are due to liver, kidney and blood vessels absence of disseminated intravascular coagulation and
involvement. Symptoms of this severe disease occur af- may accompany progressive renal dysfunction (2).
ter 3 to 7 days and include persistent jaundice, decreased

2. Objectives
urine output, anemia, rash, hypotension, shock, changes
in consciousness, skin and mucosal hemorrhagic lesions
and pulmonary hemorrhage (1-6). On entering the body, In this study, we investigated the role of corticosteroids
there is widespread hematogenous dissemination and to improve thrombocytopenia due to leptospirosis.
Copyright © 2014, Iranian Red Crescent Medical Journal; Published by Kowsar. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in
noncommercial usages, provided the original work is properly cited.
 Alian S et al.

3. Patients and Methods 4. Results

This study was a randomized double-blind clinical trial. Patients’ age in the two groups (cases and controls)
This study was approved by the Ethics Committee of Ma- was compared using independent T-test, which had no
zandaran University of Medical Sciences (Code No: 9186, significant difference (P = 0.254). The average age in case
Date: December 19, 2012). The sample size in each group group was 49.75 ± 8.45 and 46.68 ± 11.26 years in the con-
was calculated based on previous studies including that trol group. Gender was assessed using Chi-Square test,
performed by Villanueva et al. (12). The sample size was which revealed no statistical difference between the two
calculated as 22 based on the following formula, but we groups (P = 0.789). Treatment group included 14 females
enrolled 56 patients. and 14 males and control group 13 females and 15 males.
Time needed for the improvement of thrombocytopenia
n = (2 × (Z1-α/2 + Z1-β) 2 × σ2)/(µ1 - µ2)2 = 22 was evaluated in the two groups using Kaplan-Meier and
µ1 = 8.3, µ2 = 7.6, α = 0.05, β = 0.2, σ2 = 0.0625. Log Rank Test. The treatment group required a mean du-
ration of 4.41 ± 0.197 days and the control group 5.72 ±
Totally, 187 patients were admitted as leptospirosis based 0.318 days. The treatment group had a median of 4 ± 0.215
on clinical and epidemiologic criteria in Razi Hospital days and the control group 5 ± 0.255 days (Log Rank was
of Ghaemshahr, north of Iran from August 2011 to Sep- 8.625), which was statistically significant (P = 0.003) (de-
tember 2013 (two years) (serology tests had not positive gree of freedom (DF) = 1) (Figure 1 and Table 3).
results in all cases, those patients diagnosed clinically Duration of hospitalization in the two groups was com-
with false negative serology results were excluded). Razi pared using Kaplan-Meier, Log Rank and Breslau Test. The
Hospital is a governmental and teaching hospital with treatment group had a mean of 5.24 ± 0.244 days and the
200 beds. Infectious disease ward is a referral ward in control group 6.23 ± 0.329 days. The treatment group
Mazandaran province. Thrombocytopenia was classified had a median of 5 ± 0.221 days and the control group 6
to mild (PLT < 150000), moderate (PLT < 100000) and se- ± 0.297 days (Log Rank was 4.825); therefore, there was
vere (PLT < 50000). Platelet count had normal findings in a significant difference between them (P = 0.028), DF =
17 patients and 98 cases had mild thrombocytopenia and 1 and Breslau = 4.916 with DF = 1 and P = 0.027 (Figure 2
thus excluded. The remaining 72 patients with moderate and Table 3).
to severe thrombocytopenia were enrolled. Patients who There was no significant difference between the
met the inclusion criteria were randomized to control two groups regarding mortality rate, intubation,
and treatment groups. We applied simple randomization platelet count, duration of ICU admission, and pul-
method. The treatment group received corticosteroid monary, renal or hepatic involvement. In our study,
(prednisolone 1 mg/kg/day) in addition to antibiotic ther- five patients expired including two patients in the
apy (ceftriaxone 1 g/Iv/daily) until improvement of throm- case group (one in moderate thrombocytopenia sub-
bocytopenia or for a maximum one-week and the control group and the other in the severe thrombocytopenia
group received the same dosage of antibiotics, but re-
ceived placebo instead of corticosteroid during this peri- Table 1. Patients Characteristics
od. Exclusion criteria were patients with negative MAT or Characteristics No.
those with any health-threatening complications caused
by corticosteroid or patients who had previous intake of Suspected Patients 187
steroids or other antibiotics two weeks or less prior to the Thrombocytopenia
diagnosis of disease and patients whom their clinician
did not administered steroids due to some compelling Negative 17
factors like hypersensitivity to steroids, and finally those Positive 170
who were not willing to participate. Sixteen patients due
to absence of serologic evidence (MAT had negative re- Severity of Thrombocytopenia
sults) were excluded and the final analysis was performed Mild 98
on 56 patients in two divided groups. Statistical analysis
Moderate & severe 72
was performed by independent T-test, Chi-Square, Kaplan-
Meier, Log Rank and Breslau using SPSS software (version Serology
13). To confirm the diagnosis of leptospirosis by MAT,
Negative 16
10mL blood sample of each patient was obtained. Serum
was separated immediately and poured into a sterile poly- Positive 56
propylene tube and sent to the Reference Laboratory of
Groups
Hisarak while maintaining the cold chain. Patients were
visited daily and monitored closely. Laboratory changes Case 28
in patients, including platelet count were check daily. Pa-
Control 28
tients were followed up until discharge (Tables 1 and 2).

2 Iran Red Crescent Med J. 2014;16(10):e16030

 Alian S et al.

Table 2. Distribution of Patients in Moderate and Severe Sub-

Survial Functions
groups
1.0
group
Thrombocytopenia Case Control Total
1
2
1-censored

Moderate
2-censored
15 19 34 0.8

Sever 13 9 22

Cum Survuval
Total
0.6
28 28 56

0.4
subgroup) and three in the control group (all in the
severe thrombocytopenia subgroup). One died due
to acute renal failure and others died due to multi- 0.2

organ failure. The two groups were divided into two

subgroups according to the severity of thrombocyto-
0.0
penia (Table 2) as moderate (50000 < PLT < 100000)
and severe (PLT < 50000). The two subgroups of mod- 0 2 4 6 8 10

erate and severe thrombocytopenia were compared Hospitalization

regarding required time for thrombocytopenia im-
provement; P-values in moderate and severe subgroup Figure 2. Survival Function Regarding Duration of Hospitalization in the
Two Groups
were 0.016 and 0.001, respectively, which was statisti-
cally significant. Besides, duration of hospital stay was
Table 3. Statistical Analysis Regarding Improvement of
compared between moderate and severe subgroups us-
ing Brislow test; P-values were 0.06 and 0.006, respec- Thrombocytopenia and Length of Hospitalization
tively, there was no significant differences in moder-
ate group, but the group there were severe a statistical Group Mean/M. Median Breslau/ Log P Value
difference was significant (Table 3). There was no sig- Rank Rank
nificant difference between the two subgroups (mod- Duration a 8.626 0.003
erate and severe thrombocytopenia) between the case
and control groups regarding mortality, intubation, Case 4.411 4.000
length of stay in ICU, pulmonary, renal or hepatic in- Control 5.722 5.000
volvement and platelets count.
Moderate 5.779 0.016

Case 4.200 4.000

Survial Functions Control 4.947 5.000

group
1.0 1 Severe 12.035 0.001
2
1-censored
2-censored Case 4.641 5.000
0.8
Control 7.563 7.000

Hospitalizationb
Cum Survuval

4.916 0.027
0.6
Case 5.241 5.000

0.4
Control 6.231 6.000

Moderate 3.546 0.060

0.2 Case 4.800 5.000

Control 5.579 5.000

0.0 Severe 7.505 0.006
0 2 4 6 8 10
Case 5.678 6.000
duration
Control 7.875 7.000
a Duration, Duration in days required for improvement of
Figure 1. Survival Function Regarding Required Duration for the Im-
thrombocytopenia.
provement of Thrombocytopenia in the Two Groups b Hospitalization, length of hospital stay (in days).

Iran Red Crescent Med J. 2014;16(10):e16030 3

 Alian S et al.

Table 4. Demographic Characteristics and Frequency of Clinical and Laboratory Findings in the Groups a
Group/Analysis Variable Received Corticosteroid Group Not-received Corticosteroid P-Value Total
Group Frequency
Number of Patients 28 28 56 (100)
Moderate Thrombocytopenia 15 19 34 (60.7)
Severe Thrombocytopenia 13 9 22 (39.2)
Gender 0.789
Female 14 13
Male 14 15
Age 49.75 ± 8.45 46.68 ± 11.26 0.254
Kidney involvement 5 (17.9) 5 (17.9) 1.000
Lung involvement 5 (17.9) 6 (21.4) 0.737
Liver involvement 9 (32.1) 12 (42.9) 0.408
Intubation 4 (14.2) 4 (14.2) 1.000
Mortality 2 (7.1) 3 (10.7) 0.500
ICU admission, Mean Rank 28.02 28.98 0.758
Dialysis
Platelet Consumption, Mean Rank 27.79 29.21 0.568
Durationb 0.003
Mean 4.41 ± 0.197 5.72 ± 0.318
Median 4 ± 0.215 5 ± 0.255
Hospitalizationc 0.028
Mean 5.24 ± 0.244 6.23 ± 0.329
Median 5 ± 0.221 6 ± 0.297
Rural 24 (85.7) 24 (85.7) 48 (85.7)
Farmer 24 (85.7) 25 (89.2) 49 (87.5)
Weakness 28 (100) 28 (100) 56 (100)
Fever 28 (100) 28 (100) 56 (100)
Anorexia 20 (71) 20 (71) 40 (71.4)
Myalgia 25 (89.28) 24 (85.71) 49 (87.5)
Arthralgia 20 (71.42) 20(71.42) 40 (71.4)
N/V 9 (32.1) 7 (25) 16 (28.5)
Cough 6 (21.4) 5 (17.8) 11 (19.6)
Headache 7 (25) 7 (25) 14 (25)
Abdominal pain 5 (17.8) 5 (17.8) 10 (17.8)
Hemoptysis 1 (3.5) 2 (7.1) 3 (5.35)
Diarrhea 2 (7.1) 2 (7.1) 4 (7.1)
Hypotension 3 (10.7) 3 (10.7) 6 (10.7)
Tachypnea 5 (17.8) 6 (21.4) 11 (19.6)
Tachycardia 9 (32.1) 9 (32.1) 18 (32.1)
LOC 2 (7.1) 3 (10.7) 5 (8.9)
Fever blister 8 (28.5) 8 (28.5) 16 (28.5)
Rash 5 (17.8) 5 (17.8) 10 (17.8)
Suffusion 11 (39.2) 12 (42.8) 23 (41.0)
Icter 9 (32.1) 12 (42.8) 21 (37.5)
LAP 0 1 (3.5) 1 (1.7)
Rales 4 (14.2) 4 (14.2) 8 (14.2)
Abdominal tenderness 5 (17.8) 6 (21.4) 11 (19.6)
Splenomegaly 2 (7.1) 3 (10.7) 5 (8.9)
Hepatomegaly 0 1 (3.5) 1 (1.7)
Muscular tenderness 10 (35.7) 10 (35.7) 20 (35.7)
Arrhythmia 1 (3.5) 0 1 (1.7)
Oliguria 5 (17.8) 5 (17.8) 10 (17.8)
EKG Changes 2 (7.1) 1 (3.5) 3 (5.35)
CXR Changes 5 (17.8) 7 (25) 12 (21.4)

4 Iran Red Crescent Med J. 2014;16(10):e16030

 Alian S et al.

Leukocytosis 6 (21.4) 8 (28.5) 14 (25)

Leucopenia 1 (3.5) 3 (10.7) 4 (7.1)
Azotemia 5 (17.8) 5 (17.8) 10 (17.8)
Hyperglycemia 2 (7.1) 3 (10.7) 5 (8.9)
Hypoglycemia 0 0 0
Hyperkalemia 5 (17.8) 6 (21.4) 11 (19.6)
Hypokalemia 5 (17.8) 5 (17.8) 10 (17.8)
Hematuria 5 (17.8) 7 (25) 12
ESR, Total mean 30.20 ± 19.323
CRP, Total mean 0.86 ± 0.724 (0-2 plus)
INR, Total mean 1.10 ± 0.128
BILL-T, Total mean 4.675 ± 4.1387
BILL-D, Total mean 1.996 ± 2.0695
AST, Total mean 114.75 ± 89.278
ALT, Total mean 125.93 ± 91.229
ALK.P, Total mean 374.07 ± 131.135
a Abbreviations: ICU, intensive care unit; CXR, chest x-ray; N/V, nausea and vomiting; LOC, decreased level of consciousness; LAP, lymphadenopathy;
ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; INR, international normalized ratio; BILL-T, bilirubin-total; BILL-D, bilirubin-direct; AST,
aspartate aminotransferase; ALT, alanine aminotransferase; ALK.P, alkaline phosphatase.
b Duration = Duration in days required for the improvement of thrombocytopenia.
c Hospitalization = length of hospital stay (in days).

5. Discussion
There was no significant difference between the two (not in the moderate subgroup). To optimally determine
groups regarding renal, pulmonary or hepatic involve- whether adjunctive steroid use in leptospirosis is ben-
ment, intubation, mortality rate and hospitalization eficial, an adequately powered randomized control trial
duration in ICU. The above situations were not improved with a larger sample size is recommended.

Acknowledgements
with treatment of glucocorticoid. Despite the fact, re-
quired duration for the improvement of thrombocytope-
nia and duration of hospitalization in two groups were We would like to thank nurses of the infection diseases
different significantly. On the other hand, treatment with Ward of Ghaemshahr Razi Hospital to help in data col-
glucocorticoid caused more rapid recovery of thrombo- lection.
cytopenia and shorter hospital stay. Corticosteroids have
an essential role in the treatment of many immune-as- Authors’ Contributions
sociated diseases, such as SLE, rheumatoid arthritis (RA) Study concept and design: Shahriar Alian, Alireza
and ITP. Prednisolone (1 mg/kg/day) is used for the treat- Davoudi, Narges Najafi, Hasan Asghari, Jamshid Yazdani.
ment of mild ITP (Immune or Idiopathic Thrombocyto- Acquisition of data: Shahriar Alian, Hasan Asghari, Ali-
penic Purpura); while, high-dose corticosteroid (steroid reza Davoudi. Analysis and interpretation of data: Hasan
pulse therapy) is used for the severe forms (1, 13). Russell Asghari, Jamshid Yazdani. Drafting of the manuscript:
Villanueva et al. in the Philippines, performed an investi- Alireza Davoudi. Critical revision of the manuscript for
gation on 36 patients with leptospirosis and found no sig- important intellectual content: Narges Najafi. Statistical
nificant reduction in mortality, duration of hospitaliza- analysis: Jamshid Yazdani.
tion and dialysis rates between the control and steroids

Funding/Support
groups (12). Furthermore, a study by Trivedi et al. in India
performed on 602 patients showed that renal and liver
involvements had no effect on mortality (14). Similarly, in This project was supported by a grant received from the
this study, statistical analysis showed that renal, lung or Vice-Chancellor for research of Mazandaran University of
liver involvements and the severity of thrombocytopenia Medical Sciences.
had no effect on mortality. Contrary to our results, a clini-
cal trial on 30 patients by VV Shenoy et al. in India showed References
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