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| LETTERS TO EDITOR |
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| Year : 2022 | Volume
: 12
| Issue : 2 | Page : 131-132 |
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Triple infection with dengue, chikungunya and malaria
Atul Goel1, Rohit Bansal2, Priya Bansal1
1 Department of Medicine, Lady Hardinge Medical College, New Delhi, India
2 Department of Medicine, Dr. RML Hospital, New Delhi, India
| Date of Submission | 17-Feb-2021 |
| Date of Decision | 23-Feb-2021 |
| Date of Acceptance | 24-May-2021 |
| Date of Web Publication | 24-Nov-2022 |
Correspondence Address:
Priya Bansal
Department of Medicine, Lady Hardinge Medical College, New Delhi
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/tp.tp_9_21
How to cite this article:
Goel A, Bansal R, Bansal P. Triple infection with dengue, chikungunya and malaria. Trop Parasitol 2022;12:131-2 |
Sir,
Vector-borne diseases, malaria, dengue (DENV), chikungunya (CHIKV), filariasis, yellow fever, and Japanese encephalitis being the common ones, account for >17% of all infections globally, causing close to 700,000 deaths per annum.[1] In the tropics, febrile illness may result from co-infection with multiple arthropod-borne organisms. The illness seen in co-infections often manifests with overlapping signs and symptoms such as prolonged fever, rashes, vomiting, abdominal pain, and arthralgia, making diagnosis and treatment difficult for the clinician, and it is advisable to test for all the arthropod-borne organisms in areas where they co-circulate. While standard protocols are followed in the management, little can be done to salvage patients with co-infections.
We encountered a case of triple infection of malaria, dengue, and chikungunya in a 28-year-old nonpregnant female with no known comorbidities who presented with fever and epistaxis for 5 days. On examination, the patient had high grade fever, tachycardia, and a blood pressure of 80/50 mmHg. She had mild icterus. There was no organomegaly and chest was clear at presentation. Preliminary investigations revealed a hemoglobin of 13.3 g/dL, total leukocyte count was 15,200/cu.mm and platelets 30,000/cumm. Her kidney function tests reflected prerenal acute kidney injury, and liver function tests showed a total bilirubin of 3.2 mg/dL with mild serum transaminitis. The peripheral smear showed trophozoites and schizonts of Plasmodium vivax malaria. She was diagnosed to have complicated vivax malaria with sepsis and multi-organ dysfunction. She was treated with fluids, inotropic support, parenteral anti-malarials, and platelet transfusion. On day 2 of her admission, the patient developed hemoptysis and tachypnea. Chest examination revealed bilateral diffuse coarse crepitations. Chest-X-ray showed bilateral diffuse opacities [Figure 1]. Arterial blood gas analysis showed pH of 7.44, HCO3 was 15 mEq/l, PaO2 was 44.5 mmHg, and PaCO2 was 16 mmHg (PaO2/FiO2 <100). The patient's hemoglobin had decreased to 10.5 mg/dL. The patient was shifted to intensive care unit with a provisional diagnosis of diffuse alveolar hemorrhage and started on oxygen inhalation. On day 3 of admission, the illness worsened and she was put on mechanical ventilation and intravenous steroids. Blood culture and urine culture were negative. Ultrasonography of the abdomen was suggestive of polyserositis with moderate ascites and minimal bilateral pleural effusion. Dengue NS1ag and Chikungunya IgM sent as part of workup of acute febrile illness came positive (confirmed by reverse transcription polymerase chain reaction for both). The patient eventually succumbed to co-infection with malaria, dengue (DENV), and chikungunya (CHIKV) on day 4 in spite of best efforts.
Co-infection of malaria with chikungunya and dengue has been previously reported as highlighted in [Table 1]. | Table 1: Case reports of mixed malaria, dengue, and chikungunya co-infections reported in literature
Click here to view |
In a study of febrile patients in Nigeria, the prevalence of co-infections with multiple organisms was widespread, with 29.8% testing positive for more than one arbovirus in the presence of malaria infection.[8] Dual infection with CHIKV/DENV was most commonly observed co-infection (17.8%) in patients with malaria.[8] Another study from India by Mørch et al. reported two cases of the triple co-infection from among 1564 patients of acute undifferentiated fever,[9] while a study of 1795 cases of acute febrile illness in Sierra Leone, rapid diagnostic test results in 1260 samples revealed four cases positive for all the three vector-borne infections.[10]
Individuals infected with arboviruses and malaria are infected by more than one infected mosquito. The opportunities for co-infections are increased by the feeding behavior of the vectors, poor socioeconomic conditions, and overcrowding. Co-infections provide an opportunity for genetic exchange between the various organisms, allow for mutations, and potentially result in a change in clinical severity.[8] While, thrombocytopenia and fluid leakage are manifestations of dengue, splenomegaly and liver dysfunction are more common in malaria.[7] The present patient had malarial hepatopathy and dengue-related polyserositis and likely succumbed to diffuse alveolar hemorrhage. Delay or failure to recognize coincidence of infections, especially with malaria, may result in an increase in morbidity, and even mortality, as was seen in our patient.
In conclusion, there is a continual need to deliver and improve public-health initiatives to reduce arthropod-borne infections and watch for mixed infections.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
 References | |  |
| 1. | |
| 2. | Raut CG, Rao NM, Sinha DP, Hanumaiah H, Manjunatha MJ. Chikungunya, dengue, and malaria co-infection after travel to Nigeria, India. Emerg Infect Dis 2015;21:908-9.  |
| 3. | Hati AK, Chandra G, Mukherjee H, Mondal R, Talukar, Bhattacharyya N. Concurrent infections of three mosquito borne diseases-Dengue, chikungunya and malaria. J Mosq Res 2016;6:1-3. |
| 4. | Tazeen A, Abdullah M, Hisamuddin M, Ali S, Naqvi IH, Verma HN, et al. Concurrent infection with Plasmodium vivax and the dengue and chikungunya viruses in a paediatric patient from New Delhi, India in 2016. Intervirology 2017;60:48-52. |
| 5. | Gupta N, Gupta C, Gomber A. Concurrent mosquito-borne triple infections of dengue, malaria and chikungunya: A case report. J Vector Borne Dis 2017;54:191-3. [ PUBMED] [Full text] |
| 6. | Abdullah M, Tazeen A, Hisamuddin M, Naqvi IH, Verma HN, Ahmed A, et al. A clinical report on mixed infection of malaria, dengue and chikungunya from New Delhi, India. Virusdisease 2017;28:422-4. |
| 7. | Dev N. An infection cocktail: Malaria, dengue, chikungunya and Japanese encephalitis. Trop Doct 2019;49:42-3. |
| 8. | Baba M, Logue CH, Oderinde B, Abdulmaleek H, Williams J, Lewis J, et al. Evidence of arbovirus co-infection in suspected febrile malaria and typhoid patients in Nigeria. J Infect Dev Ctries 2013;7:51-9. |
| 9. | Mørch K, Manoharan A, Chandy S, Chacko N, Alvarez-Uria G, Patil S, et al. Acute undifferentiated fever in India: A multicentre study of aetiology and diagnostic accuracy. BMC Infect Dis 2017;17:665. |
| 10. | Dariano DF, Taitt CR, Jacobsen KH, Bangura U, Bockarie AS, Bockarie MJ, et al. Surveillance of vector-borne infections (chikungunya, dengue, and malaria) in Bo, Sierra Leone, 2012-2013. Am J Trop Med Hyg 2017;97:1151-4. |
[Figure 1]
[Table 1]
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