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Leptospira interrogans  and Leptospira kirschneri are the dominant Leptospira species causing human leptospirosis in Central Malaysia

Leptospirosis, commonly known as rat-urine disease, is a global but endemic zoonotic disease in the tropics. Despite the historical report of leptospirosis in Malaysia, the information on human-infecting species is limited. Determining the circulating species is important to understand its epidemiol...

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Published in:PLoS neglected tropical diseases 2020-03, Vol.14 (3), p.e0008197-e0008197
Main Authors: Philip, Noraini, Bahtiar Affendy, Norliza, Ramli, Siti Nur Alia, Arif, Muhamad, Raja, Pappitha, Nagandran, Elanngovan, Renganathan, Pukunan, Taib, Niazlin Mohd, Masri, Siti Norbaya, Yuhana, Muhamad Yazli, Than, Leslie Thian Lung, Seganathirajah, Mithra, Goarant, Cyrille, Goris, Marga G A, Sekawi, Zamberi, Neela, Vasantha Kumari
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cited_by cdi_FETCH-LOGICAL-c724t-f5f985ef37f551bc4ec1ffc04e4c620f6de556eba71d73a95e62c8552862a8163
cites cdi_FETCH-LOGICAL-c724t-f5f985ef37f551bc4ec1ffc04e4c620f6de556eba71d73a95e62c8552862a8163
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container_title PLoS neglected tropical diseases
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creator Philip, Noraini
Bahtiar Affendy, Norliza
Ramli, Siti Nur Alia
Arif, Muhamad
Raja, Pappitha
Nagandran, Elanngovan
Renganathan, Pukunan
Taib, Niazlin Mohd
Masri, Siti Norbaya
Yuhana, Muhamad Yazli
Than, Leslie Thian Lung
Seganathirajah, Mithra
Goarant, Cyrille
Goris, Marga G A
Sekawi, Zamberi
Neela, Vasantha Kumari
description Leptospirosis, commonly known as rat-urine disease, is a global but endemic zoonotic disease in the tropics. Despite the historical report of leptospirosis in Malaysia, the information on human-infecting species is limited. Determining the circulating species is important to understand its epidemiology, thereby to strategize appropriate control measures through public health interventions, diagnostics, therapeutics and vaccine development. We investigated the human-infecting Leptospira species in blood and serum samples collected from clinically suspected leptospirosis patients admitted to three tertiary care hospitals in Malaysia. From a total of 165 patients, 92 (56%) were confirmed cases of leptospirosis through Microscopic Agglutination Test (MAT) (n = 43; 47%), Polymerase Chain Reaction (PCR) (n = 63; 68%) or both MAT and PCR (n = 14; 15%). The infecting Leptospira spp., determined by partial 16S rDNA (rrs) gene sequencing revealed two pathogenic species namely Leptospira interrogans (n = 44, 70%) and Leptospira kirschneri (n = 17, 27%) and one intermediate species Leptospira wolffii (n = 2, 3%). Multilocus sequence typing (MLST) identified an isolate of L. interrogans as a novel sequence type (ST 265), suggesting that this human-infecting strain has a unique genetic profile different from similar species isolated from rodents so far. Leptospira interrogans and Leptospira kirschneri were identified as the dominant Leptospira species causing human leptospirosis in Central Malaysia. The existence of novel clinically important ST 265 (infecting human), that is different from rodent L. interrogans strains cautions reservoir(s) of these Leptospira lineages are yet to be identified.
doi_str_mv 10.1371/journal.pntd.0008197
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The infecting Leptospira spp., determined by partial 16S rDNA (rrs) gene sequencing revealed two pathogenic species namely Leptospira interrogans (n = 44, 70%) and Leptospira kirschneri (n = 17, 27%) and one intermediate species Leptospira wolffii (n = 2, 3%). Multilocus sequence typing (MLST) identified an isolate of L. interrogans as a novel sequence type (ST 265), suggesting that this human-infecting strain has a unique genetic profile different from similar species isolated from rodents so far. Leptospira interrogans and Leptospira kirschneri were identified as the dominant Leptospira species causing human leptospirosis in Central Malaysia. 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Despite the historical report of leptospirosis in Malaysia, the information on human-infecting species is limited. Determining the circulating species is important to understand its epidemiology, thereby to strategize appropriate control measures through public health interventions, diagnostics, therapeutics and vaccine development. We investigated the human-infecting Leptospira species in blood and serum samples collected from clinically suspected leptospirosis patients admitted to three tertiary care hospitals in Malaysia. From a total of 165 patients, 92 (56%) were confirmed cases of leptospirosis through Microscopic Agglutination Test (MAT) (n = 43; 47%), Polymerase Chain Reaction (PCR) (n = 63; 68%) or both MAT and PCR (n = 14; 15%). The infecting Leptospira spp., determined by partial 16S rDNA (rrs) gene sequencing revealed two pathogenic species namely Leptospira interrogans (n = 44, 70%) and Leptospira kirschneri (n = 17, 27%) and one intermediate species Leptospira wolffii (n = 2, 3%). Multilocus sequence typing (MLST) identified an isolate of L. interrogans as a novel sequence type (ST 265), suggesting that this human-infecting strain has a unique genetic profile different from similar species isolated from rodents so far. Leptospira interrogans and Leptospira kirschneri were identified as the dominant Leptospira species causing human leptospirosis in Central Malaysia. The existence of novel clinically important ST 265 (infecting human), that is different from rodent L. interrogans strains cautions reservoir(s) of these Leptospira lineages are yet to be identified.</description><subject>Adult</subject><subject>Agglutination</subject><subject>Agglutination Tests</subject><subject>Animals</subject><subject>Bacteriology</subject><subject>Biology and Life Sciences</subject><subject>Causes of</subject><subject>Disease control</subject><subject>DNA</subject><subject>Dominant species</subject><subject>Drug development</subject><subject>Epidemics</subject><subject>Epidemiology</subject><subject>Female</subject><subject>Funding</subject><subject>Gene sequencing</subject><subject>Genes, Bacterial - genetics</subject><subject>Gram-negative bacteria</subject><subject>Health promotion</subject><subject>Health sciences</subject><subject>Hospitals</subject><subject>Human health and pathology</subject><subject>Humans</subject><subject>Identification</subject><subject>Identification and classification</subject><subject>Illnesses</subject><subject>Infections</subject><subject>Infectious diseases</subject><subject>Leptospira</subject><subject>Leptospira - classification</subject><subject>Leptospira - genetics</subject><subject>Leptospira - isolation &amp; purification</subject><subject>Leptospira - pathogenicity</subject><subject>Leptospira interrogans</subject><subject>Leptospira interrogans - genetics</subject><subject>Leptospira interrogans - isolation &amp; purification</subject><subject>Leptospira interrogans - pathogenicity</subject><subject>Leptospirosis</subject><subject>Leptospirosis - blood</subject><subject>Leptospirosis - epidemiology</subject><subject>Leptospirosis - microbiology</subject><subject>Leptospirosis - urine</subject><subject>Life Sciences</subject><subject>Malaysia - epidemiology</subject><subject>Male</subject><subject>Medicine</subject><subject>Medicine and Health Sciences</subject><subject>Microbiology and Parasitology</subject><subject>Middle Aged</subject><subject>Molecular Diagnostic Techniques</subject><subject>Multilocus Sequence Typing</subject><subject>Nucleotide sequence</subject><subject>Parasitology</subject><subject>Pathogens</subject><subject>Patients</subject><subject>PCR</subject><subject>People and Places</subject><subject>Polymerase Chain Reaction</subject><subject>Public health</subject><subject>Research and Analysis Methods</subject><subject>RNA, Ribosomal, 16S - genetics</subject><subject>Rodent Diseases</subject><subject>Rodentia</subject><subject>Rodents</subject><subject>rRNA 16S</subject><subject>Sequence Analysis, DNA</subject><subject>Sequencing</subject><subject>Serologic Tests</subject><subject>Serum</subject><subject>Species</subject><subject>Strains</subject><subject>Tertiary</subject><subject>Tropical diseases</subject><subject>Tropical environments</subject><subject>Vaccine development</subject><subject>Vaccines</subject><subject>Young Adult</subject><subject>Zoonoses</subject><issn>1935-2735</issn><issn>1935-2727</issn><issn>1935-2735</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2020</creationdate><recordtype>article</recordtype><sourceid>PIMPY</sourceid><sourceid>DOA</sourceid><recordid>eNptk91u0zAUxyMEYmPwBggiISG4aPFHHCc3SFUFbFIRN3BtnTrHjUtiFzuZtCfgNfYsezISmk7tNOXC0fHv_z8f8kmS15TMKZf009b3wUEz37mumhNCClrKJ8k5LbmYMcnF06P_s-RFjFtCRCkK-jw544wRLig9T_6ucNf5uLMBUus6DMFvwMW72xRclR5d_rYh6tphsHe3EDDtakwr31oHrjvm4g61xZhq6KN1m7TuW3BpcwB8tHFIlC7RdQGa9Ds0cBMtvEyeGWgivprOi-TX1y8_l5ez1Y9vV8vFaqYly7qZEaYsBBoujRB0rTPU1BhNMsx0zojJKxQixzVIWkkOpcCc6UIIVuQMCprzi-Tt3nfX-KimGUbFeEkkLbOcDMTVnqg8bNUu2BbCjfJg1f-ADxsFobO6QSWElkgzkEKvs0xCaSRnhq1lWVSCahi8Pk_Z-nWLld43fWJ6euNsrTb-WklKpczHcj_uDeoHssvFSo0xwoQkLC-v6cB-mJIF_6fH2KnWRo1NAw59P_ZYsFxIKcce3z1AH5_ERG1gaNY644ca9WiqFjlnpaCc8oGaP0INX4Wt1d6hsUP8RPD-SFAjNF0dfdN31rt4CmZ7UA_PJgY09xOgRI07cKhajTugph0YZG-Oh34vOjx6_g-w-wbK</recordid><startdate>20200301</startdate><enddate>20200301</enddate><creator>Philip, Noraini</creator><creator>Bahtiar Affendy, Norliza</creator><creator>Ramli, Siti Nur Alia</creator><creator>Arif, Muhamad</creator><creator>Raja, Pappitha</creator><creator>Nagandran, Elanngovan</creator><creator>Renganathan, Pukunan</creator><creator>Taib, Niazlin Mohd</creator><creator>Masri, Siti Norbaya</creator><creator>Yuhana, Muhamad Yazli</creator><creator>Than, Leslie Thian Lung</creator><creator>Seganathirajah, Mithra</creator><creator>Goarant, Cyrille</creator><creator>Goris, Marga G A</creator><creator>Sekawi, Zamberi</creator><creator>Neela, Vasantha Kumari</creator><general>Public Library of Science</general><general>Public Library of Science (PLoS)</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7QL</scope><scope>7SS</scope><scope>7T2</scope><scope>7T7</scope><scope>7U9</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>8C1</scope><scope>8FD</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>AZQEC</scope><scope>BENPR</scope><scope>C1K</scope><scope>CCPQU</scope><scope>DWQXO</scope><scope>F1W</scope><scope>FR3</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>H94</scope><scope>H95</scope><scope>H97</scope><scope>K9.</scope><scope>L.G</scope><scope>M0S</scope><scope>M1P</scope><scope>M7N</scope><scope>P64</scope><scope>PIMPY</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>7X8</scope><scope>1XC</scope><scope>VOOES</scope><scope>5PM</scope><scope>DOA</scope><orcidid>https://orcid.org/0000-0002-0690-9464</orcidid><orcidid>https://orcid.org/0000-0002-4076-8335</orcidid></search><sort><creationdate>20200301</creationdate><title>Leptospira interrogans  and Leptospira kirschneri are the dominant Leptospira species causing human leptospirosis in Central Malaysia</title><author>Philip, Noraini ; Bahtiar Affendy, Norliza ; Ramli, Siti Nur Alia ; Arif, Muhamad ; Raja, Pappitha ; Nagandran, Elanngovan ; Renganathan, Pukunan ; Taib, Niazlin Mohd ; Masri, Siti Norbaya ; Yuhana, Muhamad Yazli ; Than, Leslie Thian Lung ; Seganathirajah, Mithra ; Goarant, Cyrille ; Goris, Marga G A ; Sekawi, Zamberi ; Neela, Vasantha Kumari</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c724t-f5f985ef37f551bc4ec1ffc04e4c620f6de556eba71d73a95e62c8552862a8163</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2020</creationdate><topic>Adult</topic><topic>Agglutination</topic><topic>Agglutination Tests</topic><topic>Animals</topic><topic>Bacteriology</topic><topic>Biology and Life Sciences</topic><topic>Causes of</topic><topic>Disease control</topic><topic>DNA</topic><topic>Dominant species</topic><topic>Drug development</topic><topic>Epidemics</topic><topic>Epidemiology</topic><topic>Female</topic><topic>Funding</topic><topic>Gene sequencing</topic><topic>Genes, Bacterial - genetics</topic><topic>Gram-negative bacteria</topic><topic>Health promotion</topic><topic>Health sciences</topic><topic>Hospitals</topic><topic>Human health and pathology</topic><topic>Humans</topic><topic>Identification</topic><topic>Identification and classification</topic><topic>Illnesses</topic><topic>Infections</topic><topic>Infectious diseases</topic><topic>Leptospira</topic><topic>Leptospira - classification</topic><topic>Leptospira - genetics</topic><topic>Leptospira - isolation &amp; purification</topic><topic>Leptospira - pathogenicity</topic><topic>Leptospira interrogans</topic><topic>Leptospira interrogans - genetics</topic><topic>Leptospira interrogans - isolation &amp; purification</topic><topic>Leptospira interrogans - pathogenicity</topic><topic>Leptospirosis</topic><topic>Leptospirosis - blood</topic><topic>Leptospirosis - epidemiology</topic><topic>Leptospirosis - microbiology</topic><topic>Leptospirosis - urine</topic><topic>Life Sciences</topic><topic>Malaysia - epidemiology</topic><topic>Male</topic><topic>Medicine</topic><topic>Medicine and Health Sciences</topic><topic>Microbiology and Parasitology</topic><topic>Middle Aged</topic><topic>Molecular Diagnostic Techniques</topic><topic>Multilocus Sequence Typing</topic><topic>Nucleotide sequence</topic><topic>Parasitology</topic><topic>Pathogens</topic><topic>Patients</topic><topic>PCR</topic><topic>People and Places</topic><topic>Polymerase Chain Reaction</topic><topic>Public health</topic><topic>Research and Analysis Methods</topic><topic>RNA, Ribosomal, 16S - genetics</topic><topic>Rodent Diseases</topic><topic>Rodentia</topic><topic>Rodents</topic><topic>rRNA 16S</topic><topic>Sequence Analysis, DNA</topic><topic>Sequencing</topic><topic>Serologic Tests</topic><topic>Serum</topic><topic>Species</topic><topic>Strains</topic><topic>Tertiary</topic><topic>Tropical diseases</topic><topic>Tropical environments</topic><topic>Vaccine development</topic><topic>Vaccines</topic><topic>Young Adult</topic><topic>Zoonoses</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Philip, Noraini</creatorcontrib><creatorcontrib>Bahtiar Affendy, Norliza</creatorcontrib><creatorcontrib>Ramli, Siti Nur Alia</creatorcontrib><creatorcontrib>Arif, Muhamad</creatorcontrib><creatorcontrib>Raja, Pappitha</creatorcontrib><creatorcontrib>Nagandran, Elanngovan</creatorcontrib><creatorcontrib>Renganathan, Pukunan</creatorcontrib><creatorcontrib>Taib, Niazlin Mohd</creatorcontrib><creatorcontrib>Masri, Siti Norbaya</creatorcontrib><creatorcontrib>Yuhana, Muhamad Yazli</creatorcontrib><creatorcontrib>Than, Leslie Thian Lung</creatorcontrib><creatorcontrib>Seganathirajah, Mithra</creatorcontrib><creatorcontrib>Goarant, Cyrille</creatorcontrib><creatorcontrib>Goris, Marga G A</creatorcontrib><creatorcontrib>Sekawi, Zamberi</creatorcontrib><creatorcontrib>Neela, Vasantha Kumari</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Bacteriology Abstracts (Microbiology B)</collection><collection>Entomology Abstracts (Full archive)</collection><collection>Health and Safety Science Abstracts (Full archive)</collection><collection>Industrial and Applied Microbiology Abstracts (Microbiology A)</collection><collection>Virology and AIDS Abstracts</collection><collection>ProQuest Health and Medical</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>Public Health Database (Proquest)</collection><collection>Technology Research Database</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest Central</collection><collection>ProQuest Central Essentials</collection><collection>ProQuest Central</collection><collection>Environmental Sciences and Pollution Management</collection><collection>ProQuest One Community College</collection><collection>ProQuest Central</collection><collection>ASFA: Aquatic Sciences and Fisheries Abstracts</collection><collection>Engineering Research Database</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>AIDS and Cancer Research Abstracts</collection><collection>Aquatic Science &amp; Fisheries Abstracts (ASFA) 1: Biological Sciences &amp; Living Resources</collection><collection>Aquatic Science &amp; Fisheries Abstracts (ASFA) 3: Aquatic Pollution &amp; Environmental Quality</collection><collection>ProQuest Health &amp; Medical Complete (Alumni)</collection><collection>Aquatic Science &amp; Fisheries Abstracts (ASFA) Professional</collection><collection>Health &amp; Medical Collection (Alumni Edition)</collection><collection>PML(ProQuest Medical Library)</collection><collection>Algology Mycology and Protozoology Abstracts (Microbiology C)</collection><collection>Biotechnology and BioEngineering Abstracts</collection><collection>Publicly Available Content Database</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>MEDLINE - Academic</collection><collection>Hyper Article en Ligne (HAL)</collection><collection>Hyper Article en Ligne (HAL) (Open Access)</collection><collection>PubMed Central (Full Participant titles)</collection><collection>DOAJ Directory of Open Access Journals</collection><jtitle>PLoS neglected tropical diseases</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Philip, Noraini</au><au>Bahtiar Affendy, Norliza</au><au>Ramli, Siti Nur Alia</au><au>Arif, Muhamad</au><au>Raja, Pappitha</au><au>Nagandran, Elanngovan</au><au>Renganathan, Pukunan</au><au>Taib, Niazlin Mohd</au><au>Masri, Siti Norbaya</au><au>Yuhana, Muhamad Yazli</au><au>Than, Leslie Thian Lung</au><au>Seganathirajah, Mithra</au><au>Goarant, Cyrille</au><au>Goris, Marga G A</au><au>Sekawi, Zamberi</au><au>Neela, Vasantha Kumari</au><au>Munoz-Zanzi, Claudia</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Leptospira interrogans  and Leptospira kirschneri are the dominant Leptospira species causing human leptospirosis in Central Malaysia</atitle><jtitle>PLoS neglected tropical diseases</jtitle><addtitle>PLoS Negl Trop Dis</addtitle><date>2020-03-01</date><risdate>2020</risdate><volume>14</volume><issue>3</issue><spage>e0008197</spage><epage>e0008197</epage><pages>e0008197-e0008197</pages><issn>1935-2735</issn><issn>1935-2727</issn><eissn>1935-2735</eissn><abstract>Leptospirosis, commonly known as rat-urine disease, is a global but endemic zoonotic disease in the tropics. Despite the historical report of leptospirosis in Malaysia, the information on human-infecting species is limited. Determining the circulating species is important to understand its epidemiology, thereby to strategize appropriate control measures through public health interventions, diagnostics, therapeutics and vaccine development. We investigated the human-infecting Leptospira species in blood and serum samples collected from clinically suspected leptospirosis patients admitted to three tertiary care hospitals in Malaysia. From a total of 165 patients, 92 (56%) were confirmed cases of leptospirosis through Microscopic Agglutination Test (MAT) (n = 43; 47%), Polymerase Chain Reaction (PCR) (n = 63; 68%) or both MAT and PCR (n = 14; 15%). The infecting Leptospira spp., determined by partial 16S rDNA (rrs) gene sequencing revealed two pathogenic species namely Leptospira interrogans (n = 44, 70%) and Leptospira kirschneri (n = 17, 27%) and one intermediate species Leptospira wolffii (n = 2, 3%). Multilocus sequence typing (MLST) identified an isolate of L. interrogans as a novel sequence type (ST 265), suggesting that this human-infecting strain has a unique genetic profile different from similar species isolated from rodents so far. Leptospira interrogans and Leptospira kirschneri were identified as the dominant Leptospira species causing human leptospirosis in Central Malaysia. The existence of novel clinically important ST 265 (infecting human), that is different from rodent L. interrogans strains cautions reservoir(s) of these Leptospira lineages are yet to be identified.</abstract><cop>United States</cop><pub>Public Library of Science</pub><pmid>32203511</pmid><doi>10.1371/journal.pntd.0008197</doi><orcidid>https://orcid.org/0000-0002-0690-9464</orcidid><orcidid>https://orcid.org/0000-0002-4076-8335</orcidid><oa>free_for_read</oa></addata></record>
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identifier ISSN: 1935-2735
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issn 1935-2735
1935-2727
1935-2735
language eng
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source PubMed (Medline); Publicly Available Content Database
subjects Adult
Agglutination
Agglutination Tests
Animals
Bacteriology
Biology and Life Sciences
Causes of
Disease control
DNA
Dominant species
Drug development
Epidemics
Epidemiology
Female
Funding
Gene sequencing
Genes, Bacterial - genetics
Gram-negative bacteria
Health promotion
Health sciences
Hospitals
Human health and pathology
Humans
Identification
Identification and classification
Illnesses
Infections
Infectious diseases
Leptospira
Leptospira - classification
Leptospira - genetics
Leptospira - isolation & purification
Leptospira - pathogenicity
Leptospira interrogans
Leptospira interrogans - genetics
Leptospira interrogans - isolation & purification
Leptospira interrogans - pathogenicity
Leptospirosis
Leptospirosis - blood
Leptospirosis - epidemiology
Leptospirosis - microbiology
Leptospirosis - urine
Life Sciences
Malaysia - epidemiology
Male
Medicine
Medicine and Health Sciences
Microbiology and Parasitology
Middle Aged
Molecular Diagnostic Techniques
Multilocus Sequence Typing
Nucleotide sequence
Parasitology
Pathogens
Patients
PCR
People and Places
Polymerase Chain Reaction
Public health
Research and Analysis Methods
RNA, Ribosomal, 16S - genetics
Rodent Diseases
Rodentia
Rodents
rRNA 16S
Sequence Analysis, DNA
Sequencing
Serologic Tests
Serum
Species
Strains
Tertiary
Tropical diseases
Tropical environments
Vaccine development
Vaccines
Young Adult
Zoonoses
title Leptospira interrogans  and Leptospira kirschneri are the dominant Leptospira species causing human leptospirosis in Central Malaysia
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