Limiti dello studio

Il primo limite del nostro studio è rappresentato sicuramente dalla sua natura retrospettiva; questa infatti può precludere la conoscenza di dati riferiti all’anamnesi, alla clinica ma soprattutto al follow-up dei pazienti, informazioni che nel nostro caso sarebbero state utili

per valutare più nel dettaglio la differente progressione dell’infezione nelle 4 categorie studiate.

Per quel che riguarda la numerosità del gruppo di studio il limite non è rappresentato tanto dal numero in valore assoluto dei pazienti inclusi, ma piuttosto dalla numerosità delle varie categorie che è risultata piuttosto differente: i sopravvissuti erano 21, i deceduti per cause extra-polmonari e polmonari 6 ciascuno, i deceduti per emorragia polmonare invece 8. Le ultime tre categorie avevano una numerosità simile, ma il gruppo dei sopravvissuti era costituito da più del doppio dei pazienti. Questa differenza potrebbe aver reso meno confrontabili i dati.

Infine, il terzo limite di questo studio è l’assenza di radiografie di controllo; le lastre sono state scattate, per tutti i pazienti, in entrata e prima della dialisi (per valutare il corretto posizionamento di CVC e sondino esofagostomico), ma solo in 5/41 casi sono state eseguite radiografie di controllo a tempi variabili durante il corso della malattia. In tutti e cinque i casi le immagini hanno rispecchiato la clinica e l’esito finale. Infatti, le lesioni polmonari sono andate aggravandosi nel paziente morto per complicazioni polmonari, mentre sono rimaste stabili o migliorate in quelli deceduti per cause extra-polmonari o sopravvissuti.

Più nello specifico, l’unico paziente che ha mostrato un grave peggioramento delle lesioni polmonari è poi effettivamente morto per ARDS. Quest’ultimo, nelle radiografie in entrata, mostrava solo un lieve aumento della radiopacità a carico dei lobi caudali che poi, in circa due settimane, è andato evolvendosi in un pattern interstizio-bronchiale ed infine in un pattern alveolare con broncografia gassosa a carico dei lobi caudali e della regione perilare. Nell’unico paziente dei 4 che è sopravvissuto all’infezione, le alterazioni radiografiche sono andate incontro a un miglioramento costante nel corso di tutto il periodo di follow-up; un lieve miglioramento del quadro polmonare è stato riscontrato anche in un altro paziente che infatti è deceduto per cause extra-polmonari. I due pazienti che sono deceduti per insufficienza renale hanno mostrato condizioni polmonari sostanzialmente stabili nelle radiografie di controllo.

La mancanza di radiografie di controllo non ha reso possibile un confronto tra radiografie in entrata e radiografie di controllo, limitando quindi la possibilità di evidenziare un possibile peggioramento o miglioramento del quadro radiografico di ciascun paziente; nonostante sia stato comunque possibile studiare il ruolo predittivo e prognostico delle radiografie in entrata, avere radiografie di controllo sarebbe stato utile per analizzare in maniera più approfondita la correlazione tra alterazioni radiografiche e outcome della malattia.

Bibliografia

1. Schuller S, Francey T, Hartmann K, Hugonnard M, Kohn B, Nally JE et al. European consensus statement on leptospirosis in dogs and cats. Journal of small animal practice. 2015; 56 (3), 159-179

2. Bharti AR, Nally JE, Ricaldi JN, Matthias MA, Diaz MM, Lovett MA et al. Leptospirosis: a zoonotic disease of global importance. Lancet Infect Dis. 2003; 3(12), 757-71

3. Guglielmini J, Bourhy P, Schiettekatte O, Zinini F, Brisse S, Picardeau M. Genus- wide Leptospira core genome multilocus sequence typing for strain taxonomy and global surveillance. PLOS Neglected Tropical Diseases. 2019; 13(4)

4. Vincent AT, Schiettekatte O, Goarant C, Neela VK, Bernet E, Thibeaux R et al. Revisiting the taxonomy and evolution of pathogenicity of the genus Leptospira through the prism of genomics. PLOS Neglected Tropical Diseases. 2019; 13(5) 5. Le Turnier P & Epelboin L. Mise au point sur la leptospirose. Rev Med Interne. 2018;

40 (5), 306-312

6. Major A, Schweighauser A & Francey T. Increasing incidence of canine leptospirosis in Switzerland. Int J Environ Res Public Health. 2014; 11 (7), 7242-7260

7. Miller RI, Ross SP, Sullivan ND & Perkins NR. Clinical and epidemiological features of canine leptospirosis in North Queensland. Australian Veterinary Journal. 2007; 85(1-2), 13-19

8. Bertelloni F, Cilia G, Turchi B, Pinzauti P, Cerri D, Fratini F. Epidemiology of leptospirosis in North-Central Italy: Fifteen years of serological data (2002-2016). Comparative Immunology, Microbiology and Infectious Disease. 2019; 65, 14-22 9. Van de Maele I, Claus A, Haesebrouck F, Daminet S. Leptospirosis in dogs: review

with emphasis on clinical aspects. The Veterinary Record. 2008; 163 (14), 409-413 10. Ward MP. Seasonality of canine leptospirosis in the United States and Canada and

its association with rainfall. Preventive Veterinary Medicine. 2002; 56 (3), 203-213 11. Rojas P, Monahan AM, Schuller S, Miller IS, Markey BK, Nally JE. Detection and

quantification of leptospires in urine of dogs: maintenance host for the zoonotic disease leptospirosis. Eur J Clin Microbiol Infect Dis. 2010; 29 (10), 1305-1309 12. Medeiros F, Spichler A, Athanazio DA. Leptospirosis-associated disturbances of

13. Goldstein RE, Lin RC, Langston CE, Scrivani PV, Erb HN, Barr SC. Influence of infecting serogroup on clinical features of leptospirosis in dog. J Vet Intern Med. 2006; 20, 489-494

14. Geisen V, Stengel C, Brem S, Muller W, Greene C, Hartmann K. Canine leptospirosis infections-clinical signs and outcome with different suspected Leptospira serogroups. Journal of Small Animal Practice. 2007; 48 (6), 324-328

15. Branger C, Blanchard B, Fillonneau C, Suard I, Aviat F, Chevallier B et al. Polymerase chain reaction assay specific for pathogenic Leptospira based on the gene hap1 encoding the hemolysis-associate protein-1. FEMS Microbiology Letters. 2005; 243 (2), 437-445

16. Murphy K. Dealing with leptospirosis in dogs. Veterinary Record. 2018;183(12),384 17. Tangeman L & Litmann MP. Clinicopathologic and atypical feature of naturally

occurring leptospirosis in dogs: 51 cases (2000-2010). J Am Vet Med Assoc. 2013; 243 (9), 1326-1322

18. Juvet F, Schuller S, O’Neill EJ &Nally PA. Urinary shedding of spirochaetes in a dog with acute leptospirosis despite treatment. Veterinary Record. 2011; 168 (21), 564 19. Sykes JE, Hartmann K, Lunn KF, Moore GE, Stoddard RA & Goldstein RE. ACVIM

Small Animal Consensus Statement on Leptospirosis: Diagnosis, Epidemiology, Treatment and Prevention. J Vet Intern Med. 2011; 25 (1), 1-13

20. Yang CW, Wu MS & Pan MJ. Leptospirosis renal disease. Nephrol Dial Transplant. 2001; 16, 73-77

21. Mastrorilli C, Dondi F, Agnoli C, Turba ME, Vezzali E & Gentilini F. Clinicopathologic features and outcome predictors of Leptospira Interrogans Australis serogroup infection in dogs: a retrospective study of 20 cases (2001-2004). J Vet Intern Med. 2007; 21 (1), 3-10

22. Yang CW. Leptospirosis renal disease: emerging culprit of chronic kidney disease, unknown etiology. Nephron. 2018; 138 (2), 129-136

23. McCallum KE, Constantino-Casas F, Cullen JM, Warland JH, Swales H & Linghley N. Hepatic leptospiral infections in dog without obvious renal involvement. J Vet Intern Med. 2019; 33 (1), 141-150

24. Paganin F, Bourdin A, Borgerini G, Dalban C, Poubeau P, Tixier F et al. Pulmonary manifestation of leptospirosis. Revue des Maladies Respiratoires. 2011; 28 (9), 131- 139

25. Vandroux D, Chanarielle P, Delmas B, Gauzer BA, Allou N, Raffray L et al. Acute respiratory distress syndrome in leptospirosis. Journal of Critical Care. 2019; 51, 165- 169

26. Luks AM, Lakshminarayanan S & Hirschmann JV. Leptospirosis presenting as diffuse alveolare haemmorhage: case report and literature review. Chest. 2003; 123 (2), 639- 643

27. Nally JE, Chantranuwat C, Wu XY, Fishbein MC, Pereira M, Da Silva J, Blanco DR et al. Alveolar septal deposition of immunoglobulin and complement parallels pulmonary hemmorhage in a Guinea pig model of severe pulmonary leptospirosis. Am J Pathol. 2004; 164 (3), 1115-1127

28. Schuller S, Callanan J, Worral J, Francey S, Schweighauser T, Kohn B et al. Immunohistochemical detection of IgM and IgG in lung tissue of dogs with leptospiral pulmonary haemorrhage syndrome. Comparative Immunology, Microbiology and Infectious Diseases. 2015; 40, 47-53

29. Fernando SM, Cardinal P & Brindley PG. Hypoxemic respiratory failure from acute respiratory distress syndrome secondary to leptospirosis. Case report in critical care. 2017; doi: 10.1155/2017/9062107

30. Dolhnikoff M, Mauad T, Bethlem EP & Carvalho CRR. Pathology and pathophysiology of pulmonary manifestation in leptospirosis. Brazilian Journal of Infectious Diseases. 2007; 11 (1), 142-148

31. Da silva JJ, Netto BA, Lilembaum W, Alvim ME & de Oliveira AV. The hemorrhagic syndrome of leptospirosis: an experimental study in guinea pigs model. Rev Soc Bras Med Trop. 1993; 26 (3), 197

32. Rissi DR & Brown CA. Diagnostic features in 10 naturally occurring cases of acute fatal canine leptospirosis. Journal of Veterinary Diagnostic Investigation. 2014; 26 (6), 799-804

33. Greenlee JJ, Bolin CA, Alt DP, Cheville NF & Andreasen CB. Clinical and pathological comparison of acute leptospirosis in dogs caused by two strains of Leptospira kirschneri serovar grippothyposa. Am J Vet Res. 2004; 65 (8), 1100-1107

34. Ward MP, Guptill LF, Prhal A & Wu CC. Prevalence of and risk factors for leptospirosis among dogs in the United States and Canada: 677 cases (1970-1998). J Am Vet Med Assoc. 2002; 220, 53-58

35. Paganin F, Bourdin A, Dalban C, Courtin JP, Poubeau P, Borgherini G et al. Leptospirosis in Reunion Island (Indian Ocean): analysis of factors associated with severity in 147 confirmed cases. Intensive Care Med. 2007; 33 (11), 1959-1966 36. Marchiori E, Lourenco S, Setùbal S, Zanetti G, Gasparetto TD & Hochhegger B.

Clinical and imaging manifestation of haemorragic pulmonary leptospirosis: a state- of-the-art review. Lung. 2011; 189 (1), 1-9

37. Kohn B, Steinicke K, Arndt G, Gruber AD, Guerra B, Jansen A et al. Pulmonary abnormalities in dogs with leptospirosis. J Vet Intern Med. 2010; 24 (6), 1277-1282 38. Im JG,Yeon KM, Han MC, Kim CW, Webb WR, Lee Js et al. Leptospirosis of the lung:

radiographic findings in 58 patients. AJR Am J Roentgenol. 1989; 152 (5), 955-959 39. Adin CA & Cowgill LD. Treatment and outcome of dogs with leptospirosis: 36 cases

(1990-1998). J Am Vet Med Assoc. 2000; 216 (3), 371-375

40. Harkin KR & Garter CL. Canine leptospirosis in new Jersey and Michigan: 17 cases (1990-1995). J Am Anim Hosp Assoc. 1996; 32 (6), 495-501

41. Baumann D & Fluckiger M. Radiographic finding in the torax of dogs with leptospiral infection. Vet Radiol Ultrasound. 2001; 42 (4), 305-307

42. Birnbaum N, Barr SC, Center SA, Schermerhorn T, Randolph JF & Simpson KW. Naturally acquired leptospirosis in 36 dogs: serological and clinicopathological features. Journal of Small Animal Practice. 1998; 39 (5), 231-236

43. Francey T & Schweighauser A. Pulmonary hemmorhage as an emerging complication of acute kidney injury due to canine leptospirosis. Proceedings 18th

ECVIM-CA Congress, Ghent, 2008.

44. Hill Mk & Sanders CV. Leptospiral pneumonia. Sem Resp Inf. 1997; 12, 44-49 45. Teglia OF, Battagliotti C, Villavicencio R & Cunha BA. Leptospiral pneumonia.

Selected Reports. 1997; 12 (1), 44-49

46. Thrall DE. Textbook of Veterinary Diagnostic Radiology. 6th _{ed. Elsevier; 2013}

47. Lord PF. Alveolar lung disease in small animals and their radiographic diagnosis. J Small Anim Pract. 1976; 17 (5), 283-303

48. Citi S, Mannucci T & Oranges M. Radiologia dei piccoli animali. Pisa university press. 2019

49. Tattevin P, Leveiller G, Flicoteaux R, Jaureguiberry S, Le Tulzo Y, Dupont M et al. Respiratory manifestation of leptospirosis: a retrospective study. Lung. 2005; 183 (4), 283-289

50. Montero-Tinnirello J, de la Fuente-Aguado J, Ochoa-Diaz M & Cabadas-avion R. Pulmonary hemmorhage due to leptospirosis. Cartas Cientificas. 2012; 36 (1), 58-59 51. Assimakopoulos ST, Fligou F, Marangos M, Zotou A, Psilopanagioti A & Filos KS. Anicteric leptospirosis-associated severe pulmonary hemorrhagis syndrome: a case series study. The American Journal of the Medical Sciences. 2012; 344 (4), 326-329 52. Gouveia EL, Metcalfe J, de Carvalho AL, Aires TSF, Villasboas-Bisneto JC, Queirroz A et al. Leptospirosis-associated severe pulmonary hemorrhagic syndrome, Salvador, Brazil. Emerging Infectious Diseases. 2008; 14 (3), 505-508

53. Silverstein CM. Pulmonary manifestation of leptospirosis. Radiology. 1953; 61 (3), 327-334

54. Lee REJ, Terry SI, Walker TM & Urquhart AE. The chest radiograph in leptospirosis in Jamaica. Br J Radiol. 1981; 54 (647), 939-943

55. Matos ED, Costa E, Sacramento E, Caymmi AL, Neto CA, Barreto Lopes M et al. Chest radiograph abnormalities in patients hospitalized with leptospirosis in the city of Salvador, Bahia, Brazil. Braz J Infect Dis. 2011; 5 (2), 73-77

56. Wang CP, Chi WU & Lu FL. Studies on anicteric leptospirosis. III. Roentgen observation of pulmonary changes. Chin Med J. 1965; 84, 298-305

57. Marchiori E & Muller NL. Leptospirosis of the lung: High-resolution computed tomography findings in five patients. J Thorac Imaging. 2002; 17 (2), 151-153

58. Knopfler S, Mayer-Scholl A, Luge E, Klopfleisch R, Gruber AD, Nockler K et al. Evaluation of clinical, laboratory, imaging findings and outcome in 99 dogs with leptospirosis. Journal of Small Animal Practice. 2017; 58 (19), 582-588

59. Klopfleish R, Kohn B, Plog S, Weingart C, Nockler K, Mayer-Scholl A et al. An emerging pulmonary haemmorhagic syndrome in dogs: similar to the human leptospiral pulmonary haemmorhagic syndrome? Vet Med Int. 2010; article ID 928541

60. Rentko VT, Clark N, Ross LA & Schelling SH. Canine leptospirosis. J Vet Int Med. 1992; 6 (4), 235-244

61. Sonet J, Barthelemy A, Goy-Thollot I & Pouzot-Nevoret C. Prospective evaluation of abdominal ultrasonographic findings in 35 dogs with leptospirosis. Vet Radiology & Ultrasound. 2017; 59 (1), 98-106

62. Forrest LJ, O’Brien T, Megan MS, Tremelling S, Steinberg H, Cooley J et al. Sonographic renal findings in 20 dogs with leptospirosis. Veterinary Radiology & Ultrasound. 1998; 39 (4)spiri, 337-340

63. Hartman EG, Van den ingh TSGAM & Rothuizen J. Clinical, pathological and serological features of spontaneous canine leptospirosis. An evaluation of the IgM ang IgG-specific ELISA.Veterinary immunology and immunopathology. 1986; 13 (3), 261-271

64. Rossi F, Spattini G, Auriemma E, Benvenuti L, Caleri E, Gerboni GM et al. Manuale di ecografia clinica veterinaria. 2a _{edizione. Edra. 2016}

65. Fernando T, Rodrigo C, Samarakoon L, Navinan MR, Dandeniya C, Constantine G et al. Electrocardiographic and echocardiographic manifestation of cardiac involvement in leptospirosis. Trans R Soc Trop Med Hyg. 2013; 107 (7), 457-459 66. Watt G, Padre LP, Tuazon M & Calubaquib C. Skeletal and cardiac muscle

involvement in severe, late leptospirosis. Journal of infectious diseases. 1990; 162 (1), 266-269

67. Pushpakumara J, Prasath T, Samarajiwa G, Priyadarshani S, Perera N & Indrakumat J. Myocarditis causing severe heart failure-an unusual early manifestation of leptospirosis: a case report. BMC Research Notes. 2015; 8, 80

68. Spiri AM, Rodriguez-Campos S, Matos JM, Glaus TM, Riond B, Reusch CE et al. Clinical, serological and echocardiographic examination of healthy field dogs before and after vaccination with a commercial tetravalent leptospirosis vaccine. BCM Veterinary Research. 2017; 13 (1), 138

69. Navinan MR & Rajapakse S. Cardiac involvement in leptospirosis. Transaction of the royale society of tropical medicine and hygiene. 2012; 106 (9), 515-520

70. Von Ranke FM, Zanetti G, Escussiato DL, Hochhegger B & Marchiori E. Pulmonary leptospirosis with diffuse alveolar haemmorhage: high resolution computed tomography findings in 16 patients. J Comput Assist Tomogr. 2016; 40 (1), 91-95 71. Gendron K, Christe A, Walter S, Schweighauser A, Francey T, Doherr MG et al. Serial

CT features of pulmonary leptospirosis in 10 dog. Veterinary Record. 2014; 174 (7), 169

72. Benmansour Y, Manaf S, El Moutawakil B, Rafai MA & Slassi I. Opsoclonus- myoclonus syndrome associated with leptospirosis. Rev Neurol. 2013; 169 (6-7), 523-524

73. Landais A. Neuroleptospirose and MRI evidence of basal ganglia involvement. Médecine et maladies infectieuses. 2015; 45 (11-12), 481-483

74. Auti OB, Kansal K, Shrikanth KV & Raj V. Cardiac magnetic resonance of myocardial involvement in leptospirosis. Heart Views. 2017; 18 (4), 149-151

75. Buser FC, Schweighauser A, Hof-Gut M, Bigler B, Marti E, Mirkovitch J et al. Evaluation of C-reactive protein and its kinetics as a prognostic indicatori in canine leptospirosis. Journal of Small Animal Practice. 2019; 60 (8), 447-485

76. Cowgill L. Grading of acute kidney injury (online). 2016. Disponibile su

http://www.iris-kidney.com/pdf/4_ldc-revised-grading-of-acute-kidney-injury.pdf.

Consultato il 01/09/20

77. Perondi F, Petrescu VF, Fratini F, Brovida C, Porciello F, Ceccherini G et al. Bacterial colonization of non-permanent central venous catheters in hemodialysis dogs. Heliyon. 2020; 6 (1)

78. Tavella A. L’emodialisi intermittente nel cane: valutazione delle concentrazioni plasmatiche di omocisteina pre e post trattamento. Tesi di Laurea Magistrale in Medicina Veterinaria. Università di Pisa. AA 2016/2017

79. Andrade L, Cleto S & Seguro AC. Door-to-dialysis time and daily hemodialysis in patients with leptospirosis: impact on mortality. Clin J Am Soc Nephrol. 2007; 2 (4), 739-744

80. Smtih AM, Arruda AG, Evason MD, Weese JS, Wittum TE, Szlosek D et al. A cross- sectional study of environmental, dog, and human-related risk factors for positive canine leptospirosis PCR test results in the United States. BMC Veterinary Research. 2009; 15 (1), 412

81. Lee HS, Guptill L, Johnson AJ & Moore GE. Signalment Changes in Canine Leptospirosis between 1970 and 2009. Journal of Veterinary Internal Medicine. 2013; 28 (2), 294-299

82. Day MJ, Horzinek MC, Shultz RD & Squires RA. Linee guida per la vaccinazione del cane e del gatto (online). 2020. Disponibile su: https://wsava.org/global- guidelines/vaccination-guidelines/ . Consultato in data 04/10/20

83. Ward MP, Glickman LT & Guptill LF. Prevalence of and risk factors for leptospirosis among dogs in the United States and Canada: 677 cases (1970-1998). Journal of the American Veterinary Medical Association. 2002; 220 (1), 53-58

84. Moore G, Guptill LF, Ward MP, Glickman NW, Faun KK, Lewis HB et al. Adverse events diagnosed within three days of vaccine administration in dogs. J Am Vet Med Assoc. 2005; 227, 1102-1108

85. McGavin D & Zachary JF. Patologia generale veterinaria. 4a _{Ed. Elsevier Masson.}

2008