Dégallier, Nicolas

Travassos da Rosa, A.P.A.

Travassos da Rosa, J.F.S.

Vasconcelos, P.F.C.

Horizon / Pleins textes

Concomitant Infections by Malaria and kboviruses in 
PEDRO FERNANDO DA COSTA VASCONCELOS*, AMELIA PAES DE ANDRADE TKAVASSOS DA F~osA*, 
JORGE FERNANDO SOARES TRAVASSOS DA ROSA* Pc NICOLAS DEGALLIER*" 
"Laboratorio de arbovirus, Seção de Virus, Evandro Chagas Institi:te, SEW Foundation, Av. 
Alniirante Barroso 492, CP 1128,66050, Belém, Pará, Brazil.** ORSTOIM, CP 75,66050, 
Belém, Pará, Brazil .& Instituto Evandro Chagas. 
VASCONCELOS DA COWA P.F.; .A. P.A. TRAVASSOS DA ROSA; J.F. S. 
TRAVASOS DA ROSA N. DEGALLIER. Concomitant Infections by 
Malaria and Arboviruses in the Brazilian Amazon Region. Rev. Laf- 
amer. Microbid 32: 291-294,1990. . .  
A~SIRAC~: Six casks, in which infectipns of arboviruses and malaria 
were observed in the same patient and at the same time, in the Amazon 
Region of Brazil. The arboviruses isolated are included in family Bunya- 
viridae, genus Bunyavhs. Plasrnodiunr falcipamm (diagnosed by thick 
and thin smears) was associated with the following arboviruses: Guama 
(California serogroup) 3 times; Tacaiuma (Anopheles A serogroup) 
twice; Catu (Guama serogroup) once. The latterwas also infected byP. 
vivar 
old or more. None were boni in Par6 State, although all were living 
there. The fatnalewas a domestic helper,while four men were agricultu- 
s k; 
Five patients were male and one female. AI1 were seventeen years . 
. rat workers and one was a commercial traveler. 
The main clinical history of disease was kver with headache, chills, 
myalgia and arthralgia. Sometimes we noted abdominal pain, nausea, 
vomiting and dizziness. Jaundicewas recorded in two cases ofP. fuZcipu- 
mm in association with Tacaiuma. The typical periodic fever associated 
with malaria was not observed. It was continuous. Patients were treated 
by SUCAM with chloroquine, primaquine, quinine, or other drugs when 
necessary. Five recovered quickly, but one died. 
These cases are important because in  Amazonia thousands of peo- 
ple are diagnosed and treated for malaria. About 10% of the :strains o f ,  
P. falcipunrm are considered to be drug resistant. The possibility (pro- 
bably much undemtimated) ofconcoi:?itant infectionswith arboviruses 
may obscure the effectiveness of the treatment, or may le,ad to an 
erroneus diagnosis. 
It is proposed thai the joint infections with malaria and Guama or 
Tacaiuma viruses were due to the fact that in Amazoaia, boih agents 
share the same mosquito vectors in forested areas, either Anopilelu 
nunezovan or A. hiannulatus. 
' 
, 
. 
INTRODUC'IJON . 
, Every year thousands of cases of malaria are diag- 
nosed in Brazil and more :laan 90% of them, occur in the 
Amazon Region. At the time of these studies, malaria in 
Brazil w g . q . ~ s e d  by both Plasmodiuni fcllcipahtm and P. 
vivox ahd the incidence of each parasite was about equal. 
111 the Amazon Basin however, we have a great number of 
arboviruses capable of causing disease in man. In the 
forest, P. falc@awni, P. v i v a  and some arboviruses have 
the same potential vectors, mosquitoes of the group 
' Anopheles (Nyssorhynchus) mainly A. (N) m-annulotus 
and A. (N.) nuneztovan'. Six cases of fever of unknown 
origin, were after several examinations diagnosed as. 
malaria, which is the most frequent tropical disease 
present in the .Amazon Region of Brazil. Despite treat- , 
iu 
* 
* Work done with joint funding by SESP. FoundationlCNP 
q/ORSTOM. 
ment, the symptoms reainined, In these six cases, another 
agent was found at  the same time, and all were ar- 
boviruses of the family Bunyaviridae. 
MATERIAL Y METHODS 
20 ml blood samples were lakm from each patient by 
venopuncture. Thick and thin smears were made to look 
for hemoparasites. 0.02 ml of a 1: lO of blood diluted in 
fresh boratesaline solution of hovine albumin (fraction 
V) 0.75% and antibiotics, were inoculated intracerebral- 
ly (ic) in suckling mice for virus isolation7. Serum 
samples were tested by the Heniagglutination Inhibition 
test (HI), to detect antibodies to awobiruses6. When in- 
dicated, Complement Fixation Test (CF) was also used, 
mainly to determine the spccilïc scroiypcs, using the pla- 
que method2. 
All patients with malaria were treated by the Superin.. 
tendencia de  Campanhas de  Saúde Pública (SUCAM), 
4 
b 292 VASCONCELOS DA COSA PEDRO FERNANDO, AMELIA PAES DE ANDRADE TRAVASSOS DA ROSA; JORGE FERNANDO S ARES TRAV~\SSOS . DA KOM AND NICOLAS DEGALUER. Concomitant Infections by Malaria and Arboviruses in the Brazilian Amazon Region.&+" 
I I 
. .  i 
Fig.1: MA? OF THE AMAZON REGION,SHOWING THE PLACES WHERE CONCOMITANT INFECTIONS OCCURRED. 
I J I 
Fig. 1: Map of the Amazon region, showing the places where concomitant infections occurced 
' Ministry of Health of Brazil, who are responsible for the 
treatment of malaria in Brazil. The drugs used in-the 
specifictreatment were Chloroquine (600 mg 1st day, 450 
mg 2nd and 3rd days) and Primaquine (15 mg per day/l4 
days). JXIC patient remained positive after treatment for 
malaria, other schedules were used, as for example an 
association of either Quinine (1500 mg per day/3-5 days) 
plus TetraLycline (1000-2000 mg per dayn-10 days) or 
Sulfaxodine (500 mg per day) plus pyrimethamine (25 mg 
per day) for 3 days. 
Non-specific symptoms were treated with Aspirine 
(1000-2000 mg daily) or other drugs. 
RESULTS 
Diagnosis. Guaroa virus (California serogroup) was 
isolated three times, Tacaiuma virus (Anopheles A sero- 
group) twice and Catu virus (Guama serogroup) once. 
All patients had active P. .<ifciparun1 infections and the 
patient with Catu virus, was also positive for P. vivpx. 
Unfortunately, convalescent sera from the patients were 
. not obtained, because these patients lived, either in or, 
near forested areas which were a long way away from.our 
laboratory in Bel6m (Figure 1). 
TABLE 1 
IMFECTIONS WITH FARASITES AND 
ARBOVIRUSES 1N AMAZON REGION O F .  
I 
DISTRIBUTION OE; 6 CASES OF CoNcoMrrm 
B W I L "  
RECORD PLACE* P A M I T E  VIRUSYEAR 
H 210353 Paragominas P. falciparum Guaroa 1971 
H 260330 Altamira P. f¿zlc¿$arum Catu 1974 
P. v i v a  
H 372559 Al tamira P. fakiparum Tacaiuma 1979 
H 411 166 Altamira P. folcipanlm Taciuma 1983 
H 428895 Tilcurui P. fufc@ansm Guaroa 1984 
H 467925 Tucurui P. falciparunr Guaroa 1987 
P- 
-~ 
* All cities are in areas of Para State . 
Table 1, lists the places from which thc: patients came, 
parasites detected and arbovirus diagnosed, as well as the 
year in which they occurred. 
Cfinical aspects, Patients were 17 to 37 years Gld, five 
were male and one female. The symptoms referred to by 
. 
. 
VASCONCEL~S DA COSA PEDRO FERNANDO, AMELIA PAES DE ANDRADE TRAVASSOS DA ROSA; JORGE FERNANDO S ARES I'RAVASSOS 
DA ROSA AND NICOUS DEGALLIER. Concomitant Infections by Malaria and Arboviruses in the Brazilian Amazon Region. Rev. 
293 
Lol-am~. MiEmbid 32 291-294.19!N0. 
.. 
all were fever, chills, headache and myalgia. Other 
symptoms presented by some were vomiting (S), dizzi- 
ness (4), arthralgia (3), abdominal pain (2), anorexia (2), 
jaundice, (Z), photophobia (2) and lymphadenopathy (1). 
The two cases of jaundice occurred in patients with P. 
fulcipanim infections anil Tacaiuma. One of them, 
developed coma, renal and hepatic failures as well as 
hemolysis (erythiokytes = 1,9OO,OOO), anaemia 
(haemoglobin = 5.0%) anti seven days after onset of the 
disease she died, despite treatment. In the other case, the 
jaundice decreased and the patient recovered both renal 
and hepatic functions. 
Futhermore, in the other patients, the fever remained 
until the viral cycle had been completed. On an average, 
the disease persisted for five days after treatment and; 
only two patients (both with jaundice) were hospitalized. 
D~SCLJSSION 
* i  
.i 
Concomitance of' cases. It is very interesting, that we 
found two different agents in the same patient a t  the 
same time; one being a parasite and the other an ar- 
bovirus. Malaria caused by P. fakiparum was detected six 
times in association with arboviruses; three times with 
Guaroa, twice with Tacaiuma and once withCatu. The 
latter patient was also infected with P. v i v a  
Thê concomitance of Tacaiuma and Guaroa must be 
more frequent than detected. In effect, the potential vec- 
tor of both are the mosquitoes A. nuneztovarì and A. 
niannulutus5. These arthropods have been found fre-' 
quently infected with sporozoites of Plasmodium, spe- 
cially P. vivm and nowadays are playing an important 
role in the transmission of malaria in the villages and 
small towns of northern Brazill. TodayA. nuneztovari is 
considered a major vector of malaria in certain areas of 
the Amqzpn Region such as Northern Venezuela3 and 
The occurrence of Catu and malaria appears to be 
merely incidental, because this arbovirus has as vectors 
. Culex mosquitoes8 which are not considered to be vectors 
of malaria, 
The small number of mixed cases diagnosed, is possib- 
ly because specific diagnosis of arbovirus infections is 
only made in our laboratory. Once a smear is positive to 
malaria, nobody normally searches for another pathogen 
as the causative agent of the disease. It is very dificult to 
' 
m S o u t h h t  Colombiad. 
. 
isolate arboviruses, because the blood sample has to be 
collected, when the viremia is occurring, which. means 
during the first days of disease. Events normally take 
place in the isolated rural areas of Amazonia and it is 
difficult to obtain, suitable samples for attempted isola- 
tion, because of the necessity of special storage con- 
tainers to transport the specimens to the laboratory. 
Clinical @mptoms. The symptoms presented by the 
patients with malaria (P. fafcipurum) were the same as 
had been described. It is intriguing that only the two 
patients with malaria and Tacaiuma had jaundice. 
Tacaiuma had been isolated on  other occasions, but the i clinical picture presented by the patients was a febrile , disease for no more than five days. The patients I 
reavered without apparent sequelae. Further studies in 
monkeys must be made, to  determine if the concomitant 
infection is iesponsible either for an increase in the 
severity of symptoms or is only related to the strain of P. 
falcipamm. 
Finally, it is important to remember that the typical 
periodic fevers associated with both types of inalarial 
parasites are masked by the continuous fever caused in 
the arbovirus infection. 
Treatment implications. Many cases of febrile disease 
are diagnosed each year and treated as malaria. After 
treatment some of them continued to have fever and with 
such cases either the treatment failed or an arbovirus 
could be associated, In the case of mixed infection of 
arboviruses and malaria if the fever continues and the 
blood smears are negative then the specifc treatment for 
malaria should not be repeated, since 'ther fever or 
other symptoms may be caused by an arb i virus and not 
malaria, as was seen in the present cases. 
In the last instance, without a specific laboratory diag- 
nosis of malaria, it is not advisable to treat patients just 
because they have fever and live in endemic malarious 
areas. 
Acmo WLEDGEMENTS 
We are grateful to Drs. Agostinho A. Arau'o of 
ros Barreto for their help in the treatment of malaria, as 
well as, to Dr. Jeffrey J. Shaw for his criticism and reading 
of manuscript. 
SUCAM and Benedito Helio S. Queiroz of Hospita 1 Bar- 
VASCONCELOS DA COSA F.F.; AP. TRAVASSOS DA ROSA; J.F. S. 
TRAVASSOS DA ROSA & N. DEGALLIER. Infe@es concomitantes por 
malaria e arbovirus na'região amazdnica brasileira. Rev. Lutamer. 
Micr&Ìd 32: 291-294,1990. 
RESUMO: Seis casos nos quais infecções por arbovirus e malaria 
foram observadas no mesmo e ao mesmo tempo. O diagnostico foi feito 
por isolamento de virus. Os arbovirus isolados estgo incluidos na familia 
Bunyavindae, genero Buyavirus. Plmnodium fakiparum (diagnostica- 
do por gota espessa e esfregaç0 sanguineo) foi associado com os seguin- 
. 
~ - __ - ~ 
tes arbovirus: Guaroa (grupo California) 3 veza; Tacaiuma (grupo 
Anopheles A) 2vaes e Catu (grupo Guama) uma vez. O dltinio pacien- 
te estava t a m b h  infectado por P. v i v u  
. Dos seis pacientes cinco eram homens e um mulher. Todos apresen- 
tavam 17 años de idade ou mais. Embora morassem no Estado do Fad,  
nenhum nasceu no mesmo. A mulher era domestica, 4 homens trabalha- 
dores rurais e um comerciante ambulante. 
A hist6ria cllrlica principal de doença consistiu de febre com cefalea, 
calefrios, mialgias e artralgias. Em alguns, observouse dor abdominal, 
' nauseas, vdmitos e tontura. Ictericia foi registrada em dois casos de P. 
I I  
294 VASCONCELOS DA COSTA PEDRO FERNANDO, AMELLA PAES DE ANDRADE TRAVASSOS DA ROSA; JORGE FERNANDO SOARES TIUVASSOS 
DA ROSA AND NICOLAS DECALLIER. Concomitant Infections by Malaria and Arboviruses in the Brazilian Amazon Region. ì?eV. 
. Lat-amer.,MicmbioL 32 h?1-294,1990. 
- ,  - 
fulciparwn em associação com Tacaiuma. A febre era contlnua e não cos. A possibilidades [provavelmente subestimada) de infecçba conco- 
peri6dica, que e tlpica da malaria. Os pacientes foram tratados pela , mitantes com arboviroses, pode mascarar ou alterar a cfidcia do trata- 
S U W  con cloiuquina, primaquine, quinino, ou outras drogas, quan- mento ou levar a falsos diagn6sticos. 
do neceskrio. Cinco deles recuperaram sem sequelas e um morreu. fi possfve! que casos de infecges simultrSneas de inalaria e Quaroa 
Esses casos d o  importantes porque na Amazbnia milhares de casos ou Tacaiuma, sejam devidas, na Amazdnia, ao fato de que osvetores em 
d o  diagnosticados e trabdas como malaria. Um nfímero consideravel ambos os casos em ireas da floresta, são os mosquitosknophelarnu~~- 
das c e p s  de P. fufcipunun doconsideradas resistentes aos antimalAn- fovun'eA. triunnulutus. 
REFERENCES 
1,  ARRUDA, M.; M.B. CARVALHO; R.S. NUSSENZWEIG; M. hlARACIC; 5. 
A.W. FERREIRA a AH. COCHRANE, 1986. Potential vectors of 
malaria and their different susceptibility to Plasmodium f~lcipa- 
m and Plmnwdium vivar in Northern Brazil identified by immu- 
n0assay.h 1. Trop. A4cd Hx. 35(5):873-881. 
2 FULTON, F. 6( KIR. DUIV~EELL, 1946. The serological comparison of 
strains of Influenza vims. J.  Gm Microbio1 397-111. 
3. I GABALDON, A. 8 L. GIJEKRERO, 1959. An attempt to eradicate 
malaria by weekly administration of .Pyrimethamine in areas of 
out-of-doors transmission in Venemela. A m  J. Trop. Med Hm 
E433-439. 
HAMON, JJ.; J. RfOUCt.ll?~ J. BRENGUES & G. CI3AUVEI', 1970. 
Problems Facing anopheline vector control. Vector ecology and 
behavior, during, and after application of control measures. Mkc. 
Puhi Entomol. Soc. A m  7:28-41. 
6. 
7. 
4. 
8. 
KARABATSOS, N.(Ed.), 198% International Catalogue of hbovi- 
ruses incliiding certain other viruses of vertebrates, 3rd ed. The 
Amen'can Society of Tropical Medicine and Hygiene, San Antonio 
Texas, USA. 8 .  
\ 
SHPOPE , R.E. 8 O.R. CAUSEY, 1962. Further studies on  lhe sero- 
logical relationships of group C arthropod-borne viruses and the 
application of these relationships to rapid identification of types. 
Am. 1. Trop. Mea! Hyg. 11(2):283-290. 
SHOPF, R.E. & G.E. SATHER, 1979. Arboviruses Fag. 767-814. In E. 
H. LENNEITE & N.J. SCHMIDT (Ed.), l>iagnostic procedures for 
Viral, Rickettsial and Chlamydial Inleclions 5th edition,..i~nm'cun 
Public ffeulrh Asociudon, Wasliington, USA 
WOODALL, J.P., 1967. Virus research in Amazonia. In Atas Shpo- 
$io sobre u BiotuAmJranicu 6 (Paldog¡a):31-63. 
. __- - -.-.--,a. 


Concomitant infections by malaria and arboviruses in the Brazilian Amazon region

Abstract

Similar works

Full text

Available Versions

Horizon / Pleins textes