Leptospirosis Case Report

COPY 1 - Health Department
Department of Health and
Human Services
Centers for Disease Control
and Prevention
Atlanta, GA 30333

Reset Form

Leptospirosis Case Report Form

Form Approved
OMB 0920-0009
Exp. 4/30/2016

Visit www.cdc.gov/leptospirosis for a fillable PDF version of this Case Report

Patient's Name

Date Submitted to CDC

Address

State Case ID

City

Clinician's Name

Clinician's Phone

Demographics
State of Residence

Race

Zip Code

Alaska Native or
American Indian
Asian

County of Residence

Sex

Date of Birth

Black/African American

White

Native Hawaiian or
Other Pacific Islander

Not Specified

Age

days
months
years

Hispanic or Latino
Not Hispanic or Latino
Unknown

Ethnicity

Clinical Presentation
Was the patient symptomatic?

If yes, Date of Onset

Select all clinical manifestations the patient experienced:
Fever

Conjunctival suffusion

Jaundice

Pulmonary complications

Gastrointestinal involvement

Myalgia

Thrombocytopenia

Hepatitis

Cardiac involvement

Rash (petechial or maculopapular)

Headache

Aseptic meningitis

Hemorrhage

Renal insufficiency/failure

Other, specify:

Outcome
Was the patient hospitalized?

If yes, date admitted

Was antimicrobial treatment given for this infection?
Which drugs (select all that apply)?
Clinical Outcome

Number of days hospitalized
If yes, date started

Doxycycline

Penicillin

Other, specify:

Date of discharge

Date of death

Laboratory Results
Culture

Specimen Type

Collection date

Positive

Negative

Not done

PCR

Specimen Type

Collection date

Positive

Negative

Not done

MAT
(≥7 days)

Acute (highest titer)
Date

Convalescent (≥ 2 weeks later, highest titer)
Titer

Date

Titer

4-fold rise in titer
Single titer ≥ 800

Other test

Choose ELISA

Positive

Negative

Other test

Choose ELISA

Positive

Negative

Leptospira serovar^

^identified by PFGE or MLST or other molecular typing method

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR
Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0009).

Page 1 of 4

COPY 1 - Health Department
Department of Health and
Human Services
Centers for Disease Control
and Prevention
Atlanta, GA 30333

Leptospirosis Case Report Form

Form Approved
OMB 0920-0009
Exp. 4/30/2016

Visit www.cdc.gov/leptospirosis for a fillable PDF version of this Case Report

Exposures in 30 days prior to illness onset, specify if the patient had:
Contact with
animals
(select all
that apply)

Farm livestock

Rodents

Dogs

Other

No known contact

Unknown

Specify animal:
Where did animal contact(s) occur (eg, at home)?

Contact with
water
(select all
that apply)

Wildlife

River/stream

Standing fresh water (eg, lake, pond)
Other

Unknown

No known contact

Wet soil

Flood water, run-off

Sewage

Specify water:

Where did water contact(s) occur (specify location)?

If the patient had contact with animals or water, select the type of contact:
Occupational

Avocational

Recreational

Farmer (Land)
Other

Pet Ownership

Unknown

Unknown

If Other,Specify:

Swimming
Other

Fish worker

If Other, Specify:

Gardening
Other

Farmer (Animals)

Outdoor competition

Boating

Camping/hiking

Hunting

Unknown

If Other, Specify:

Other (Specify):

In the 30 days prior to illness onset,
Did the patient stay in housing with evidence of rodents?

Did the patient stay in a rural area?

Did the patient travel outside of county, state, or country?

Travel destination(s)

Was there heavy rainfall near the patient's place of residence, work site, activities, or travel?
Was there flooding near the patient's place of residence, work site, activities, or travel?
Did the patient have similar exposures as a contact diagnosed with leptospirosis in the 30 day period?
Has the patient ever had leptospirosis?
Is this patient part of an outbreak?

If yes, describe
outbreak

Classify case based on the CSTE/CDC case definition (see criteria below)
Investigator Name

Confirmed

Probable

Phone Number

Comments
Send completed pages 3-4 to: CDC/ Bacterial Special Pathogens Branch, 1600 Clifton Road NE, MS-A30, Atlanta, GA 30333,
by fax to (404) 929-1590, or by encrypted e-mail to bspb@cdc.gov.
Call (404) 639-1711 or e-mail bspb@cdc.gov with questions about a case, lab testing, or the form.
Confirmed: Isolation of Leptospira from a clinical specimen, OR fourfold or greater increase in Leptospira agglutination titer between acute- and convalescentphase serum specimens studied at the same laboratory, OR demonstration of Leptospira in tissue by direct immunofluorescence, OR Leptospira agglutination
titer of ≥ 800 by Microscopic Agglutination Test (MAT) in one or more serum specimens, OR detection of pathogenic Leptospira DNA (e.g., by PCR) from a
clinical specimen.
Probable: A clinically compatible case with involvement in an exposure event (e.g., adventure race, triathlon, flooding) with known associated cases, OR
Leptospira agglutination titer of ≥ 200 but < 800 by Microscopic Agglutination Test (MAT) in one or more serum specimens, OR demonstration of antiLeptospira antibodies in a clinical specimen by indirect immunofluorescence, OR demonstration of Leptospira in a clinical specimen by darkfield microscopy,
OR detection of IgM antibodies against Leptospira in an in acute phase serum specimen, but without confirmatory laboratory evidence of Leptospira infection.

Retrieve Data

Print Form

Page 2 of 4

Email Form

COPY 2 - CDC
Department of Health and
Human Services
Centers for Disease Control
and Prevention
Atlanta, GA 30333

Reset Form

Leptospirosis Case Report Form

Form Approved
OMB 0920-0009
Exp. 4/30/2016

Visit www.cdc.gov/leptospirosis for a fillable PDF version of this Case Report

CDC ID

Date Submitted to CDC
State Case ID
Clinician's Name

Clinician's Phone

Demographics
State of Residence

Race

Zip Code

Alaska Native or
American Indian
Asian

County of Residence

Sex

Date of Birth

Black/African American

White

Native Hawaiian or
Other Pacific Islander

Not Specified

Age

days
months
years

Hispanic or Latino
Not Hispanic or Latino
Unknown

Ethnicity

Clinical Presentation
Was the patient symptomatic?

If yes, Date of Onset

Select all clinical manifestations the patient experienced:
Fever

Conjunctival suffusion

Jaundice

Pulmonary complications

Gastrointestinal involvement

Myalgia

Thrombocytopenia

Hepatitis

Cardiac involvement

Rash (petechial or maculopapular)

Headache

Aseptic meningitis

Hemorrhage

Renal insufficiency/failure

Other, specify:

Outcome
Was the patient hospitalized?

If yes, date admitted

Was antimicrobial treatment given for this infection?
Which drugs (select all that apply)?
Clinical Outcome

Number of days hospitalized
If yes, date started

Doxycycline

Penicillin

Other, specify:

Date of discharge

Date of death

Laboratory Results
Culture

Specimen Type

Collection date

Positive

Negative

Not done

PCR

Specimen Type

Collection date

Positive

Negative

Not done

MAT
(≥7 days)

Acute (highest titer)
Date

Convalescent (≥ 2 weeks later, highest titer)
Titer

Date

Titer

4-fold rise in titer
Single titer ≥ 800

Other test

Choose ELISA

Positive

Negative

Other test

Choose ELISA

Positive

Negative

Leptospira serovar^

^identified by PFGE or MLST or other molecular typing method

Page 3 of 4

COPY 2 - CDC
Department of Health and
Human Services
Centers for Disease Control
and Prevention
Atlanta, GA 30333

Leptospirosis Case Report Form

Form Approved
OMB 0920-0009
Exp. 4/30/2016

Visit www.cdc.gov/leptospirosis for a fillable PDF version of this Case Report

Exposures in 30 days prior to illness onset, specify if the patient had:
Contact with
animals
(select all
that apply)

Farm livestock

Rodents

Dogs

Other

No known contact

Unknown

Specify animal:
Where did animal contact(s) occur (eg, at home)?

Contact with
water
(select all
that apply)

Wildlife

River/stream

Standing fresh water (eg, lake, pond)
Other

Unknown

No known contact

Wet soil

Flood water, run-off

Sewage

Specify water:

Where did water contact(s) occur (specify location)?

If the patient had contact with animals or water, select the type of contact:
Occupational

Avocational

Recreational

Farmer (Land)
Other

Pet Ownership

Unknown

Unknown

If Other,Specify:

Swimming
Other

Fish worker

If Other, Specify:

Gardening
Other

Farmer (Animals)

Outdoor competition

Boating

Camping/hiking

Hunting

Unknown

If Other, Specify:

Other (Specify):

In the 30 days prior to illness onset,
Did the patient stay in housing with evidence of rodents?

Did the patient stay in a rural area?

Did the patient travel outside of county, state, or country?

Travel destination(s)

Was there heavy rainfall near the patient's place of residence, work site, activities, or travel?
Was there flooding near the patient's place of residence, work site, activities, or travel?
Did the patient have similar exposures as a contact diagnosed with leptospirosis in the 30 day period?
Has the patient ever had leptospirosis?
Is this patient part of an outbreak?

If yes, describe
outbreak

Classify case based on the CSTE/CDC case definition (see criteria below)
Investigator Name

Confirmed

Probable

Phone Number

Comments
Send completed pages 3-4 to: CDC/ Bacterial Special Pathogens Branch, 1600 Clifton Road NE, MS-A30, Atlanta, GA 30333,
by fax to (404) 929-1590, or by encrypted e-mail to bspb@cdc.gov.
Call (404) 639-1711 or e-mail bspb@cdc.gov with questions about a case, lab testing, or the form.
Confirmed: Isolation of Leptospira from a clinical specimen, OR fourfold or greater increase in Leptospira agglutination titer between acute- and convalescentphase serum specimens studied at the same laboratory, OR demonstration of Leptospira in tissue by direct immunofluorescence, OR Leptospira agglutination
titer of ≥ 800 by Microscopic Agglutination Test (MAT) in one or more serum specimens, OR detection of pathogenic Leptospira DNA (e.g., by PCR) from a
clinical specimen.
Probable: A clinically compatible case with involvement in an exposure event (e.g., adventure race, triathlon, flooding) with known associated cases, OR
Leptospira agglutination titer of ≥ 200 but < 800 by Microscopic Agglutination Test (MAT) in one or more serum specimens, OR demonstration of antiLeptospira antibodies in a clinical specimen by indirect immunofluorescence, OR demonstration of Leptospira in a clinical specimen by darkfield microscopy,
OR detection of IgM antibodies against Leptospira in an in acute phase serum specimen, but without confirmatory laboratory evidence of Leptospira infection.

Retrieve Data

Print Form

Page 4 of 4

Email Form