Chapter VI: Infectious Jaundice

DEFINITION AND SYNONYMS

=Definition.=—Infectious jaundice is a spirochaete infection, caused by _Leptospira icterohaemorrhagiae_. This spirochaete is a common parasite of rats in various parts of the world and man possibly receives his infection from this source. There is a sudden onset with rather high fever, headache and vomiting. The jaundice appears about the third or fourth day when the urine shows albumin and bile. Haemorrhages, especially epistaxis, are common and the liver rather than the spleen shows enlargement. A polymorphonuclear increase is a feature.

=Synonyms.=—Epidemic jaundice. Spirochaetosis icterohaemorrhagica. Typhus bilieux. Weil’s disease.

HISTORY AND GEOGRAPHICAL DISTRIBUTION

FIG. 47.—Showing _Leptospira_. (After Noguchi in Journal of Experimental Medicine.)

FIG. 48.—A group of _Leptospira icterohaemorrhagiae_ from a culture. (After Noguchi in Journal of Experimental Medicine.)]

=History.=—This disease was probably the form of jaundice noted in
the forces of Napoleon during the Egyptian campaign. It was first
recognized as a distinct disease by Weil, in 1886, who described
it as a peculiar form of acute infectious disease characterized by
jaundice, swelling of spleen and nephritis. Inada and his Japanese
colleagues discovered the causative spirochaete in 1915 and noted
the frequency of this parasite in rats. Infectious jaundice was an
important disease of the soldiers of the recent war.

=Geographical Distribution.=—Japan and Egypt may be considered as
the parts of the world in which the disease is most common. It is
endemic in West Africa and cases have frequently been reported from
the shores of the Mediterranean.

During the Russo-Turkish war (1877) cases of jaundice seen in
the Balkans by Sandwith were probably infectious jaundice as the
disease was frequently noted in that region during the recent war.
Cases were noted in Flanders during the war. A few cases have been
reported from the United States.

ETIOLOGY AND EPIDEMIOLOGY

=Etiology.=—The spirochaete causing infectious jaundice, _Leptospira icterohaemorrhagiae_, is the type species of a genus described by Noguchi as having minute elementary spirals running throughout the body and failing to show either flagella or undulating membrane. The caudal portion of the spirochaete is remarkably flexible and when in motion the whole body seems drawn into a straight line except for the hook formation of one or both terminal portions. Propulsion seems to occur by the rotary motion of the hook and progresses in the direction of the straight end. If both ends become curved progression ceases.

It is insoluble in 10% saponin thus differing from the other
blood spirochaetes. The constituent spirals are closely placed
and the total length may reach 15 to 20 microns. The dark-field
illumination is preferable for its demonstration although it shows
up well by various staining methods. To culture use a medium of
one part of rabbit’s serum with three parts of Ringer’s solution
inoculating with citrated plasma. The organism is found in the
blood during the first three or four days of the disease. It is
also present in the urine. Young guinea pigs are particularly
susceptible and in them we have, following injection of the blood
of a case, jaundice, albuminuria and haemorrhages. At autopsy the
spirochaetes are best demonstrated in a liver emulsion. Infection
with this spirochaete is common among rats in various parts of the
world so that it may be considered a natural infection of rats, but
they do not seem to suffer from it.

=Epidemiology.=—It is considered that the infection is transmitted through the urine of infected rats or men. The spirochaetes may gain entrance through the skin or by mouth. The fact that the spirochaetes seem to die in urine within 24 hours makes infection by the contaminated urine questionable but experiments with various arthropods have failed to indicate their connection with the transmission of the disease.

In Japan it has been noted that the disease is most common in wet
mines, disappearing when the mines are pumped dry. Before we knew
the cause of the disease attention was directed to the connection
between the infection and working about defective sewers. Trench
warfare, with the accompanying rats and wet conditions, seemed to
favor infection.

PATHOLOGY

The liver shows enlargement and fatty degeneration, but less marked than in yellow fever. The organisms are found in the liver and also in the kidneys, which latter show an intertubular congestion together with haemorrhages in this region. Haemorrhagic areas may be present in various portions of the alimentary tract and elsewhere.

SYMPTOMATOLOGY

After an incubation period of from 5 to 7 days the disease sets in abruptly with rigors, headache, muscular pains and vomiting. The patient is prostrated and has the appearance of extreme illness; the face flushed and the conjunctivae injected. There is fever of an irregular type usually running between 102° to 104°F. for the first three or four days, when it begins to fall by lysis although occasionally by crisis about the fifth day. Following a few days of moderate fever or normal temperature there is a tendency for a second rise toward the end of the second week, which continues for approximately another week when a slow convalescence sets in in favorable cases. The secondary fever shows rather marked oscillations.

Jaundice appears about the third or fourth day with marked
tenderness of the liver and slight or moderate enlargement of the
spleen. The urine is scanty and high colored showing albumin and
bile pigments. Early in the second week urine of a low specific
gravity is excreted in large amounts. The pulse is rapid at first
to become slow with the appearance of the jaundice. There is a
tendency to sleeplessness and nocturnal delirium and in unfavorable
cases the “typhoid state” comes on. Pains in the nape of the neck
and calf muscles are common features.

Haemorrhages, starting as epistaxis, are commonly observed.
Next to epistaxis intestinal haemorrhage is the most frequent.
Haematuria is rarely observed. The red cells and the haemoglobin
fall in percentage with an increase in the polymorphonuclears. The
leucocytosis runs about 15,000.

The spirochaetes may be found with the dark-field illumination
early in the disease in a blood examination and later on in the
urine.

DIAGNOSIS

It must be remembered that the causative spirochaete is very scarce in the blood of this disease which is usually not the case with relapsing fever showing jaundice. It is best to inject 2 to 4 cc. of blood into young guinea pigs intraperitoneally and after the development of the infection in the animal we find the spirochaetes rather abundantly in preparations made from liver emulsions and examined with dark-field illumination. Noguchi cultured the organism from the blood early in the disease but found it difficult. Wataguchi states that when the blood is simply diluted with water and kept at a temperature of about 25°C. growth may be obtained by the fourth day, reaching a maximum by the second week.

Agglutinins appear in the blood about the end of the first week and
cultures may be agglutinated by such serum diluted as high as 1 to
500.

Bilious remittent fever shows earlier jaundice, a more rapid pulse
rate and malarial parasites.

In yellow fever there is more marked rachialgia and earlier and
more marked albuminuria. The marked leucocytosis of Weil’s disease
should be of differentiating value.

The early jaundice and haemoglobinuria of blackwater fever should
distinguish this disease.

Prophylaxis and Treatment

=Prophylaxis.=—As the infection appears to be transmitted through the medium of the urine and faeces, sterilization of these discharges from those sick with the disease should be practised. Extermination of the rat, the host of the parasite, is the important method of eradication of the disease.

=Treatment.=—This would appear to be solely symptomatic. Arsphenamine has no effect on the infection. Hexamethylenamine has been recommended. A serum against the organism has been prepared and seems to show protective value.