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 Table of Contents  
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 143-145

Malaria and dengue coinfection

Department of Pediatrics, CMC, Ludhiana, Punjab, India

Date of Submission24-May-2021
Date of Decision16-Nov-2021
Date of Acceptance10-May-2022
Date of Web Publication20-Dec-2022

Correspondence Address:
Amandeep Kaur
Department of Pediatrics, CMC, Ludhiana, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cjhr.cjhr_62_21

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Concurrent infection of malaria and dengue may be difficult to diagnose because of overlapping signs and symptoms. An 11-year-old boy presenting in the causality with blanching rash, respiratory distress, and hypotension was initially managed as dengue shock syndrome. Due to high-grade fever and hepatosplenomegaly, peripheral blood film for malarial parasite was sent, which came out to be positive for vivax malaria. This case report emphasizes the need to consider about the possibility of dengue–malaria coinfection in the endemic areas and highlights the challenges related to management among these patients.

Keywords: Acute respiratory distress syndrome, coinfection, dengue, malaria

How to cite this article:
Kaur A, Sharma M. Malaria and dengue coinfection. CHRISMED J Health Res 2022;9:143-5

How to cite this URL:
Kaur A, Sharma M. Malaria and dengue coinfection. CHRISMED J Health Res [serial online] 2022 [cited 2023 Jan 30];9:143-5. Available from: https://www.cjhr.org/text.asp?2022/9/2/143/364534

  Introduction Top

Dengue and malarial infection is transmitted by Aedes aegypti and Anopheles stephensi mosquitoes, respectively.[1] Concurrent infection of malaria and dengue is said to occur when both the diseases occur simultaneously in an individual.[2] Probably, the first reported case of dengue–malaria coinfection was from France in 2005.[3] In a study conducted by Hati et al., in Kolkata, 1.54% had coinfection.[4] Carme et al. conducted a retrospective study in French Guiana, where coinfection was found in 1% of cases.[5]

  Case Report Top

An 11-year-old boy presented with a 3-day history of high-grade fever, body ache, vomiting, and loose stools. There was no history of chills, rigors, convulsions, jaundice, and bleeding from one any site. His vitals were heart rate of 120/min, respiratory rate 38 breaths/min, temperature 101°F, blood pressure of 80/50 mmHg, and SPO2 86% on oxygen by mask. He had blanching rash all over the body. His Glasgow Coma Scale was E3V4M4; pupils were bilateral equal and reacting to light. No meningeal signs were seen. He was also noted to have respiratory distress, reduced air entry on the right side. He had hepatomegaly and spleenomegaly of 6 cm and 5 cm below the right and left costal margins, respectively.

He was put on noninvasive ventilation and was able to maintain SPO2 of 90% on FiO2 of 100% and PEEP of 10 cm H2O. He was ventilated and started on fluid management as per the WHO dengue shock management guidelines. Chest X-ray anteroposterior view showed the right-sided mild pleural effusion. Peripheral blood smear was suggestive of Plasmodium vivax infection. Antimalarial drug artesunate (2.4 mg/kg at 0, 12, and 24 h, then once a day) was started.

In view of severe anemia, thrombocytopenia, and a deranged coagulation profile as mentioned in [Table 1], he was given 4 units of packed cell, 7 units of platelet and 3 units of Fresh frozen plasma guided by clinical and laboratory improvements.
Table 1: The laboratory reports

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His fever improved by day 3 in hospital and we could extubate him uneventfully on day 4 of hospitalization. A repeat peripheral smear exam showed no malarial parasites.

On day 4 of hospitalization, hemoglobin and platelets were 7.5 g/dl and 20,000 cells/mm3, respectively. However, as he was hemodynamically stable, no further blood or platelets were transfused.

After one uneventful day, he developed significant respiratory distress, shock, and pulmonary bleeding on day 5 and needed to be re-intubated and put on invasive ventilation. A repeat chest X-ray at this time showed the features of acute respiratory distress syndrome (ARDS) [Figure 1]. He was managed with fluid resuscitation, furosemide drip and ventilatory support, and blood transfusions. However, he had a turbulent course and expired on the 5th hospital day.
Figure 1: Chest X-ray suggestive of pulmonary hemorrhage with edema

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  Discussion Top

Our patient presented with dengue and P.vivax coinfection. Initially, we managed this patient as dengue shock syndrome, but because of high-grade fever, hepatosplenomegaly and endemicity of both infections, we investigated him for malaria. Clinically, coinfection is difficult to diagnose because of overlapping clinical features. Coinfection can lead to increase the severity of complications. Severe anemia is seen in severe malaria cases and requires blood cell transfusion.[6]

However, hemoconcentration may not have the same relevance for evaluating potential severe dengue in patients with malaria coinfection. While dengue infection alone may lead to false increase in hemoglobin report, severe anemia observed in malaria may be missed and underestimated because of plasma leakage in severe dengue fever leading to hemoconcentration.[7]

In our patient, even after repeated blood transfusion, his hemoglobin remained low. This happens because of 4 parasites hemolytic effect, invasion into erythrocytes, and effect on erythropoiesis.[8] We cannot use hemoglobin/hematocrit as a severity marker in concurrent dengue and malaria infection because both diseases impact red blood cell count through different mechanisms.[7]

Our patient was coinfected by P.vivax. Vivax has low complication rate, but ARDS is reported as a rare but fatal manifestation of P. vivax malaria.[9] Lomar et al., in their review of the malaria, described ARDS as more common in those patients with vivax malaria who traveled to endemic areas, did not take recommended antimalarial prophylaxis, and had no history of malaria.[10]

Clinical management may prove difficult in these cases because fluid overload occurs with the use of liberal amount of fluids to treat severe dengue shock, as seen in our patient. One study revealed that the mortality rate is more in coinfection as compared to malaria single infection (6.3% compared to 5.5%).[11]

We report this case to highlight the importance of looking for possibility of malaria and dengue coinfection in febrile patients in endemic areas and rainy season. One also needs to be careful to titrate the need for intravenous fluids and blood products as the disease pathophysiology affects the hemodynamics in contradictory ways.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Wiwanitkit V. Concurrent malaria and dengue infection: A brief summary and comment. Asian Pac J Trop Biomed 2011;1:326-7.  Back to cited text no. 1
Dengue: Guidelines for diagnosis, treatment, prevention and control: New edition. In: WHO Guidelines Approved by the Guidelines Review Committee. Geneva: World Health Organization; 2009.  Back to cited text no. 2
Charrel RN, Brouqui P, Foucault C, de Lamballerie X. Concurrent dengue and malaria. Emerg Infect Dis 2005;11:1153-4.  Back to cited text no. 3
Hati AK, Bhattacharjee I, Mukherjee H, Bandyopadhayay B, Bandyopadhyay D, De R, et al. Concurrent dengue and malaria in an area in Kolkata. Asian Pac J Trop Med 2012;5:315-7.  Back to cited text no. 4
Carme B, Matheus S, Donutil G, Raulin O, Nacher M, Morvan J. Concurrent dengue and malaria in Cayenne Hospital, French Guiana. Emerg Infect Dis 2009;15:668-71.  Back to cited text no. 5
Aatif S, Jamal Q, Altaf A, Salimullah. Is vivax malaria really benign? – A Karachi-based study. J Pak Med Assoc 2013;63:721-4.  Back to cited text no. 6
Magalhães BM, Alexandre MA, Siqueira AM, Melo GC, Gimaque JB, Bastos MS, et al. Clinical profile of concurrent dengue fever and Plasmodium vivax malaria in the Brazilian Amazon: Case series of 11 hospitalized patients. Am J Trop Med Hyg 2012;87:1119-24.  Back to cited text no. 7
Ru YX, Mao BY, Zheng FK, Pang TX, Zhao SX, Liu JH, et al. Invasion of erythroblasts by Plasmodium vivax: A new mechanism contributing to malarial anemia. Ultrastruct Pathol 2009;33:236-42.  Back to cited text no. 8
Mukherjee MT, Lavania BA. Acute respiratory distress syndrome due to vivax malaria. MJAFI 2008;64:365-6.  Back to cited text no. 9
Lomar AV, Vidal JE, Lomar FP, Barbas CV, de Matos GJ, Boulos M. Acute respiratory distress syndrome due to vivax malaria: Case report and literature review. Braz J Infect Dis 2005;9:425-30.  Back to cited text no. 10
Barua A, Gill N. A comparative study of concurrent dengue and malaria infection with their Monoinfection in a teaching Hospital in Mumbai. J Assoc Physicians India 2016;64:49-52.  Back to cited text no. 11


  [Figure 1]

  [Table 1]


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