Objective: Studies on concurrent infection of dengue and malaria are uncommon in India. Therefore, in this study,we compared the clinical features and outcome of concurrent infection with mono-infection of dengue and malaria.Methods: All the patients of fever within 7 days duration were investigated for dengue, malaria and other causesof fever. Patients of concurrent dengue and malaria (Group A) were compared with dengue mono-infection (GroupB) and malaria mono-infection (Group C). Biochemical and haematological investigations were done and compared.Results:  During the study period 367 patients of dengue were admitted. Concurrent infection of dengue andmalaria was found in 27 (7.4%) patients. There were 27 (5.8), 340 (72.5), and 102 (21.7%) patients in Groups A,B, and C respectively. The clinical features of concurrent infection were more like dengue than malaria. Unlikemalaria the outcome of concurrent infection is good.Conclusion: Concurrent infection of dengue and malaria is not uncommon. For the diagnosis investigations forboth the infections should be carried out routinely

M.K. Mohapatra, P. Patra & R. Agrawala

Journal of Vector Borne Diseases

Directory of Open Access Journals

J Vector Borne Dis 49, December 2012, pp. 262–265Manifestation and outcome of concurrent malaria and dengue infectionM.K. Mohapatra, P. Patra & R. AgrawalaV.S.S. Medical College, Burla, Sambalpur, IndiaABSTRACTObjective: Studies on concurrent infection of dengue and malaria are uncommon in India. Therefore, in this study,we compared the clinical features and outcome of concurrent infection with mono-infection of dengue and malaria.Methods: All the patients of fever within 7 days duration were investigated for dengue, malaria and other causesof fever. Patients of concurrent dengue and malaria (Group A) were compared with dengue mono-infection (GroupB) and malaria mono-infection (Group C). Biochemical and haematological investigations were done and compared.Results: During the study period 367 patients of dengue were admitted. Concurrent infection of dengue andmalaria was found in 27 (7.4%) patients. There were 27 (5.8), 340 (72.5), and 102 (21.7%) patients in Groups A,B, and C respectively. The clinical features of concurrent infection were more like dengue than malaria. Unlikemalaria the outcome of concurrent infection is good.Conclusion: Concurrent infection of dengue and malaria is not uncommon. For the diagnosis investigations forboth the infections should be carried out routinely.Key words Severe malaria; sub-conjuctival haemorrhage; thrombocytopeniaINTRODUCTIONMalaria and dengue are two common vector-bornediseases in India. The former is a parasitic disease trans-mitted by Anopheles mosquito and the latter is a viraldisease transmitted by Aedes mosquito. In a geographi-cal area where both the vectors co-exist, simultaneousoccurrence of malaria and dengue in an individual can-not be ruled out. But studies on concurrent infections arescarce in India and only limited to few case reports1, 2.Therefore, we have undertaken this prospective study tofind out the incidence, clinical presentations, and outcomeof dengue and malaria co-infection. The differences ofco-infection with malaria and dengue mono-infection werealso studied.MATERIAL & METHODSWe have conducted this prospective observationalstudy at V.S.S. Medical College, Burla, Odisha, India dur-ing an outbreak of dengue fever from June to September2011 after taking clearance from the Ethical Committee.During the study period all the patients who attended theoutdoor of Department of Medicine and Emergency De-partment with history of fever for <7 days were includedin the study. All the patients were investigated for den-gue and dengue positive patients were admitted for ob-servation. Dengue negative patients were investigated formalaria and other causes of fever. Patients of dengue werefurther investigated for malaria to detect dengue and ma-laria co-infection. After diagnosis, patients were groupedinto dengue and malaria co-infection (Group A), denguemono-infection (Group B) and malaria mono-infection(Group C). Differences between qualitative values weredetermined by χ2-test and quantitative values by unpaired‘t’ test. P- value <0.05 is considered as significant.The diagnosis of dengue was made with detection ofIgM antibody and NS-1 antigen by rapid diagnostic test(Advantage Dengue NS1 Ag and Ab Combi card of JMitra & Co. Pvt. Ltd., New Delhi). For diagnosis of ma-laria peripheral blood smear (thick and thin) was obtainedand stained with Giemsa stain for detection of malariaparasites.The detailed clinical history, examination, and labo-ratory investigations were done in all the cases. We col-lected blood at the time of admission for complete bloodcount (CBC), fasting blood glucose, blood urea, serumcreatinine, sodium, potassium, bilirubin, serum glutamate-oxaloacetate transaminase (SGOT), serum glutamate-pyruvate transaminase (SGPT), and alkaline phosphatase(ALP). The parasitic count made from the peripheral bloodsmear was expressed as number of asexual parasites permicro litre of blood and was calculated from the numberof parasitized cells per 200 leukocytes in a thick film, i.e.No. of parasites ‘x’ total leukocyte count/200. CBC andparasitic count were repeated every 24 h till the normal 263Mohapatra et al: Concurrent malaria and dengueisation of the platelet count and to know the parasitic clear-ance. Temperature was recorded every 12 h to assess feverclearance time. All patients were followed up for 2 wk.Patients of dengue were treated symptomatically. Pa-tients with thrombocytopenia and bleeding manifestationswere treated with platelet concentrate. Patients of dengueand malaria co-infection were considered as severe ma-laria and treated with inj. Artesunate as per WHO guide-lines3 along with treatment for dengue fever. Supportivefluid therapy was administered as per the requirement.Patients of severe malaria were treated according to theguidelines of the WHO3.RESULTSDuring the period of study, 546 patents of acute on-set of fever were admitted and 77 patients had fever dueto causes other than dengue and malaria, hence, excludedfrom analysis. Out of 469 patients, dengue and malariawas diagnosed in 367 (78.2%) and 102 (21.7%) patientsrespectively. Out of 367 patients of dengue, concurrentinfection of dengue and malaria was found in 27 (7.4%)patients. Hence, there were 27 (5.8%), 340 (72.5%), and102 (21.7%) patients in Groups A, B, and C respectively.The clinical features of Group A were continuousfever, back pain, headache, running nose, and bleedingmanifestations which were comparable with the clini-cal features of Group B (Table 1). Bleeding manifest-ations like purpuric rashes over skin, melaena with orwithout haematemesis, epistaxis, and sub-conjuctivalhaemorrhage was present in 5 (50%), 3 (30%), 1 (10%),and 1 (10%) cases of co-infection and 78 (55.7%), 47(33.5%), 10 (7.1%), and 5 (3.5%) cases of dengue mono-infection respectively. Sub-conjuctival haemorrhage(p = 0.001) was significantly different, whereas othermanifestations were not different significantly (p = 0.8),hence, comparable with dengue. A patient of co-infec-tion with sub-conjuctival haemorrhage was shown inFig. 1. Retrobulbar headache was present in 33.3% (5/15)of Group A patients compared to 48.1% (130/270) pa-tients of dengue (p <0.01). Bleeding manifestations weremore among patients with Group B (42.1%) which wassignificantly more than Group A (37.1%, p = 0.01).The clinical features of malaria were fever (100%),headache (34.3%) and associated features of severe ma-laria that included loss of consciousness (n = 90, 88.2%),jaundice (n = 60, 58.8%), oliguria (n = 54, 52.9%). Inter-mittent fever with typical paroxysm was present in 65(63.7%) cases. Multiple complications of coma, jaundice,and oliguria were found in 40 (39.2%) cases. Among thepatients of co-infection, intermittent fever with typicalparoxysm was absent in all the cases (p = 0.001). We didnot encounter complications like cerebral malaria, renalfailure, and multiple organ failure in any case with con-current dengue and malaria except one case (3.7%) withjaundice. Bleeding manifestations were absent signifi-Fig.1: Patient of dengue and falciparum malaria withsub-conjuctival haemorrhage.Table 1. Clinical features of co-infection with mono-infectionFeatures Co-infection (A) Dengue (B) Malaria (C) P-valueA ‘x’ B A ‘x’ CNo. of subjects 27 340 102Male 18 (66.7) 220 (64.7) 68 (66.6) 0.7  0.7Female 9 (33.3) 120 (35.2) 34 (33.3) 0.8 0.8Fever 27 (100) 340 (100) 102 (100) *Running nose 21 (77.8) 268 (78.9) 4 (3.9) 0.8 0.002Myalgia 16 (59.3) 204 (60) 15 (14.7) 0.7 0.001Headache 15 (55.6) 270  (79.4) 35 (34.3) 0.1 0.3Bleeding manifestations 10 (37.1) 140 (41.2)  2 (1.9) 0.01 0.001Back pain 9 (33.3) 250 (73.5) 8 (7.8) 0.02 0.001Severe malaria 1 (3.7) 0 90 (88.2) + 0.001*Same percentage, no comparison necessary; +Not comparable; Figures in parentheses indicate percentages. J Vector Borne Dis 49, December 2012264cantly (p = 0.001) among patients with Group C (1.9%)compared to Group A (37.1%). Hepatosplenomegaly wasnot found in any case of Group A and B whereas it wasfound in 62 (60.8%) cases of Group C (p = 0.001).Biochemical investigations of Groups A and B werewithin normal limits (Table 2). But among patients withmalaria mono-infection, there was abnormality of liverand renal parameters due to severe malaria (jaundice andrenal failure). Among the haematological parameters,platelet count was low in both the Groups A(58230.7 ± 5893/mm3) and Group B (48000.6 ± 9235.8/mm3), p = 0.8). Leukopenia was also found in both theGroups A and B. But comparison of haematological pa-rameters among Group A and C showed that the formerhad thrombocytopenia and leukopenia without anaemia,whereas the latter group had anaemia with normal plate-let and leukocyte count (p = 0.001). The parasitic count ofco-infection was 5098.8 ± 542.6/mm3, which was lowerthan malaria 6489.4 ± 432.8/mm3 (p = 0.01).Plasmodium falciprum, P.vivax, and mixed speciesinfection (P. falciprum + P. vivax) was found in 24(88.8%), 2 (7.4%), and 1 (3.7%) cases respectively amongco-infections. Among the patients of malaria mono-in-fection P. falciprum and mixed species infection wasfound in 98 (96%) and 4 (3.9%) patients.The mean interval of onset of fever to the hospital-ization of Groups A, B, and C patients was 2.2 ± 0.4 days,2.8 ± 0.6 days (A ‘x’ B, p = 0.8), and 5.5 ± 0.9 days (A‘x’ C, p = 0.001) respectively. All the patients of co-in-fection recovered with treatment within 7 days. There wasalso no death among the patients of concurrent infectionand dengue but 11 (10.7%) patients of malaria died.DISCUSSIONThe present study showed three notable findings.First, it showed that malaria and dengue co-infection isnot uncommon in a locality where both the vectors co-exist. Second, in concurrent infection, the clinical fea-tures of dengue fever are predominant over malaria. Third,severe malaria is uncommon among the patients with co-infection, hence, the outcome is good.The present study also showed that the incidence ofconcurrent dengue and malaria among the patients of den-gue fever was 7.4%. Out of all the cases with fever, con-current infection was 5.8%. In French Guiana, the inci-dence of co-infection among the patients of dengue feverwas 7.1% (17 of 238), which is similar to the present study.It was high in Pakistan and was found in 23.2% of cases4,5.Hence, the incidence of the co-infection may vary in dif-ferent geographical areas. As the incidence is of the hos-pitalized patients, therefore, it is not representative of acommunity or a local population. Further, vector load es-timation of a geographical area would be helpful in de-termining the concurrent infection in a locality. But wecould not determine in this study. Other studies had alsothis limitation4, 5.In the present study, P. falciparum was present inmajority of the cases (88.8%). However, P. vivax andmixed (P. vivax and P. falciparum) infection was foundin 2 and 1 cases respectively. Plasmodium vivax was thecommon species found in both French Guiana and Paki-stan. In the former study P. vivax was found in 63.9%and P. falciparum in 33.8% cases where as in the latter P.vivax was found in 96.2% (25 of 26) cases4, 5. This is dueTable 2. Haematological and biochemical parametersInvestigations Co-infection (A) Dengue (B) Malaria (C) P-valueA ‘x’ B A ‘x’ CParasitic count (No./mm3) 5098.8 ± 542.6 0 6489.4 ± 432.8 * 0.01Haemoglobin (g/dl) 10.7 ± 1 10.8 ± 2.9 6.8 ± 1.2 0.7 0.001Leukocyte count (No./mm3) 4244.4 ± 728.1 4512.8 ± 920.9 6109.6 ± 765.8 0.8 0.001Platelet count (No./mm3) 58230.7 ± 5893.0 48000.6 ± 9235.8 145000.7 ± 908.6 0.8 0.001FBS (g/dl) 88.7 ± 11.1 80.5 ± 11.7 78.9 ± 9.6 0.8 0.6B. urea (g/dl) 27.9 ± 2.9  25.8 ± 10.5 41.8 ± 6.9 0.8 0.002S. creatinine (mg/dl) 0.9 ± 0.2 1.1 ± 0.5 3.9 ± 1.2 0.9 0.001S. bilirubin (mg/dl) 0.7 ± 0.3 0.8 ± 0.3 4.8 ± 2.1 0.7 0.002SGOT (IU/l) 34 ± 5.3 32.8 ± 6.8 51.7 ± 11.2 0.5 0.001SGPT (IU/l) 32.8 ± 6.8 34.8 ± 5.6 45.9 ± 14.6 0.7 0.001Alkaline phosphatase (IU/l) 78.8 ± 9.9 87.5 ± 8.9 102.6 ± 14.7 0.8 0.001S. sodium (mEq/l) 138.5 ± 2.9 136.8 ± 3.8 135 ± 2.5 0.8 0.7S. potassium (mEq/l) 3.7 ± 0.2 3.8 ± 0.7 3.9 ± 1.2 0.7 0.8*Not comparable. 265Mohapatra et al: Concurrent malaria and dengueto the species prevalence in a particular locality.The clinical features of concurrent infection weremore like dengue mono-infection than malaria mono-in-fection. Therefore, clinically, it is difficult to diagnoseconcurrent dengue and malaria. Intermittent fever withtypical paroxysm and complications like cerebral malaria,renal failure and multi-organ failure were also absentamong the patients with concurrent infection. On the otherhand, bleeding manifestations similar to dengue werecommon among the patients with concurrent dengue andmalaria infection. Therefore, screening for malaria in pa-tients with dengue is necessary for diagnosis of such cases.Absence of severe malaria was also observed in otheravailable studies4,5. Thrombocytopenia, leukocytopenia,and anaemia have been reported in 84.6, 34.6, and 34.6%cases respectively from Pakistan5. Deranged liver func-tion was also found in that study5.It is notable that bleeding manifestations areuncommon in falciparum malaria, whereas in denguehaemorrhagic manifestations are common. However,when both the diseases can induce thrombocytopenia, itis difficult to decide which one is responsible for the cau-sation of bleeding. Therefore, malaria with bleeding mani-festations are considered as severe malaria and treatedaccordingly8. Patients without bleeding were also treatedas severe malaria because such patients may developbleeding during the hospital stay. But there is no recom-mendation for treatment of malaria in such clinical situa-tion.In the present study, irrespective of the Plasmodiumspecies infection, the outcome of concurrent dengue andmalaria is good. The benign outcome has also been ob-served in other two studies4, 5. The good outcome andabsence of severe malaria may be explained as follows.First, the patients of concurrent dengue and malaria soughtmedical treatment earlier (2.2 ± 0.4 days) than patients ofmalaria (5.5 ± 0.9 days)6, 7. Therefore, early diagnosisand treatment with antimalarial drugs was possible. Sec-ondly, low parasitic count which has been observed amongthe patients of concurrent infection may be another con-tributing factor for good outcome.REFERENCES1. Thangaratham PS, Jeevan MK, Rajendran R, Samuel PP, TyagiBK. Dual infection by dengue virus and Plasmodium vivax inAlappuzha district, Kerala, India. Jpn J Infect Dis 2006; 59 (3):211–2.2. Bhalla A. Concurrent infection with dengue and malaria. IndianJ Med Sci 2006; 60: 330–1.3. Guidelines for the treatment of malaria. Geneva: World HealthOrganization 2006; p. 1–182.4. Carme B, Matheus S, Donutil G, Raulin O, Nacher M, MorvanJ. Concurrent dengue and malaria in Cayenne Hospital, FrenchGuiana. Emerg Infect Dis 2009; 15: 668–71.5. Abbasi A, Butt N, Sheikh QH, Bhutto AR, Munir SM, AhmedSM, et al. Clinical features, diagnostic techniques and manage-ment of dual dengue and malaria infection. J Coll PhysiciansSurg Pak 2009; 19: 25–9. 6. Kaushik RM, Varma A, Kaushik R, Gaur KJ. Concurrent den-gue and malaria due to Plasmodium falciparum and P. vivax.Trans R Soc Trop Med Hyg 2007; 101: 1048–50.7. Ward DI. A case of fatal Plasmodium falciparum malaria com-plicated by acute dengue fever in East Timor. Am J Trop MedHyg 2006; 75: 182–5.8. WHO: Severe falciparum malaria. Trans R Soc Trop Med Hyg2000; 94 (Suppl 1): 1–90.Correspondence to: Dr M.K. Mohapatra, Professor of Medicine, V.S.S. Medical College, Qr. No. C/1, Doctors Colony, Burla,Sambalpur–768 017, India.E-mail: mohapatra.manoj@rediffmail.comReceived: 9 December 2011 Accepted in revised form: 20 September 2012

Manifestation and outcome of concurrent malaria and dengue infection

http://www.mrcindia.org/journal/issues/494262.pdf

Manifestation and outcome of concurrent malaria and dengue infection

Abstract

Similar works

Full text

Available Versions

Directory of Open Access Journals