Year : 2012 | Volume
: 1 | Issue : 3 | Page : 181--182
Concurrent malaria and dengue infection
Department of Disease Surveillance, Military Hospital Patiala (Punjab), India
Colonel Medical, HQ 1 Armoured Division, C/O 56 Army Post Office
This article reports clinical and epidemiological profiles of a case of concurrent malaria and dengue infection. The literature on the subject is briefly reviewed to high-light the significance of the concurrent infection to the clinicians practicing in geographical areas endemic to both infections.
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Malhotra V. Concurrent malaria and dengue infection.Int J Health Allied Sci 2012;1:181-182
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Malhotra V. Concurrent malaria and dengue infection. Int J Health Allied Sci [serial online] 2012 [cited 2023 Dec 10 ];1:181-182
Available from: https://www.ijhas.in/text.asp?2012/1/3/181/105083
Despite a wide overlap between the malaria and dengue-endemic areas, published reports of co-infections are scarce in literature. The first patient with concurrent malaria and dengue was reported in July 2005.  Since then, few 'case reports' ,,,,,,,,, have been published. This article reports a case of concurrent malaria and dengue infection, and briefly reviews the published literature on the issue, to highlight that clinicians in endemic regions should be vigilant of the possibility of concurrent dengue-malaria infection in a confirmed or suspected case of malaria or dengue, which has an atypical clinical presentation; unexpected laboratory reports, or shows an unsatisfactory response to treatment.
A 27-year-old male soldier reported to a Military Hospital during April 2012, with complaints of high-grade tertian fever, with rigors and chills, of one-week duration. Other symptoms were severe body ache, retrobulbar pain, headache, vomiting, and extreme tiredness. On general examination, he was febrile (temperature 38.5 degrees Celsius), heart rate was 120 beats per minute, and blood pressure was 100/65 mm of mercury. The systemic examination did not reveal any abnormality.
Laboratory findings on the day of admission were: Hemoglobin 11.7 g/dL, Total Leucocyte Count 8,700/ cmm, Differential leukocyte counts (DLC) - neutrophils 66%, lymphocytes 30%, monocytes 01%, eosinophils 03%, and platelet count of 1,85,000/cmm. The peripheral blood slide revealed trophozoites of Plasmodium vivax. The Rapid test was positive for Plasmodium vivax and negative for Plasmodium falciparum infection. Serum was positive for Ig M antibodies against dengue infection, but negative for Ig G antibodies. NS1 antigen test was positive. Serum bilirubin was 0.8 mg%, with normal liver enzymes levels. There was no evidence of hyponatremia. The widal test was negative and X-ray Chest was noncontributory. Blood culture and test for identification of dengue serotype were not requisitioned. The patient was diagnosed as a case of concurrent Malaria (Plasmodium vivax) and dengue infection, and treated with oral chloroquine, parenteral artesunate, antibiotic cover, and intravenous fluids. On day two, the patient showed satisfactory clinical response. However, his platelet count decreased to 1, 05,000/cmm with no derangement of bleeding or clotting time. Clinically there was no evidence of bleeding, and the tourniquet test was negative. The patient continued to improve satisfactorily, became afebrile from the fourth day of admission and his platelet count gradually improved to 1, 86,000/cmm. Repeated peripheral blood smears were negative for the hemoparasite. The patient made complete recovery and was discharged on the seventh day of admission.
This case was the first case of malaria in the locality for the current malaria transmission season. The locality had been dengue-free (less subclinical/undiagnosed cases) for the last two years. The patient gave no past history suggestive of malaria. Blood slide examination of close contacts revealed no case with parasitemia. An entomological survey revealed breeding of Anopheles stephensi in the locality. The Aedes index was 1.33 and Breteau index was 2.66 at his place of residence, and 2.85 and 8.57 at his place of work. There was no history of a visit to any malaria or dengue endemic areas, within the maximum incubation periods of either disease.
Concurrent infections are challenges to clinicians, more so when the diseases have overlapping clinical manifestations. In an unusual case reported by Chaudhry et al., a 28-year-old, female resident of Delhi was diagnosed with simultaneous infections due to leptospirosis, dengue, malaria, and Hepatitis E virus.  In a retrospective study, Carme et al. detected 17 (1%) cases of dengue-malaria co-infections out of 1,723 patients, who had reported to the Emergency Department of a hospital in French Guiana, with a history suggestive of malaria or dengue or both.  In a more recent longitudinal study, Hati et al., reported that 1.54% of the cases diagnosed as dengue in Kolkota had also concurrent Plasmodium infection. 
Thus, there is a need for clinicians serving in geographical areas that are endemic to both malaria and dengue to be vigilant of co-infection, especially when the patient presents with atypical or abnormally severe symptoms, laboratory reports are unexpected (example thrombocytopenia in a case of malaria), or the response to treatment is unsatisfactory. The clinical significance of the concurrent infection has gained added significance as concurrent dengue-malaria infection has higher morbidity than either of the infections alone. 
Co-infection with a protozoan and a virus, both having different mean incubation periods, and transmitted by different vector mosquitoes, each having unique vector bionomics is intriguing to an epidemiologist. Concurrent infection can occur only if both vectors infected with the respective pathogens interact with a host susceptible to both infections, within a limited time frame, to produce simultaneous symptoms. Of interest, the vector for malaria has its main habitat in forest/rural areas, while Aedes is more urbanized. Obviously, the concurrent infection requires either overlapping of geographical areas and transmission periods for dengue and malaria, or the movement of a susceptible (for both infections) host between two locations (say urban to rural/forested), in a time frame highlighted earlier. There are too many 'ifs', but is 'the truth not stranger than fiction'?
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