A case of co-infection with malaria and chikungunya in a returning traveler from Nigeria

Rafael Ruiz Gaviria; Prashanth Santhekadur

doi:10.4103/0972-9062.325643

CASE REPORT

Year : 2021 | Volume : 58 | Issue : 2 | Page : 178-180

A case of co-infection with malaria and chikungunya in a returning traveler from Nigeria

Rafael Ruiz Gaviria, Prashanth Santhekadur
Department of Medicine, Saint Agnes Hospital, Baltimore, Maryland, USA

Date of Submission	12-Apr-2020
Date of Acceptance	07-Aug-2020
Date of Web Publication	13-Jan-2022

Correspondence Address:
Rafael Ruiz Gaviria
Department of Medicine, Saint Agnes Hospital, 900 South Caton Avenue 21229, Maryland
USA

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0972-9062.325643

Abstract

Due to globalization, physicians have to be prepared with knowledge and understanding of cases and diseases from all over the world. Vector-borne diseases are a particular group of diseases for which the clinician should be prepared, especially in the context of returning travelers with tropical fever, as the symptoms are very similar among some of the pathogens. In this report we present a case of a returning traveler from Nigeria with fever as her chief complaint and with a final diagnosis of malaria and chikungunya. We discuss how co-infection with different pathogens could change the natural history or modify the clinical course of the disease.

Keywords: Malaria; traveler; vector-borne diseases; imported cases

How to cite this article:
Gaviria RR, Santhekadur P. A case of co-infection with malaria and chikungunya in a returning traveler from Nigeria. J Vector Borne Dis 2021;58:178-80

How to cite this URL:
Gaviria RR, Santhekadur P. A case of co-infection with malaria and chikungunya in a returning traveler from Nigeria. J Vector Borne Dis [serial online] 2021 [cited 2022 Jan 22];58:178-80. Available from: https://www.jvbd.org/text.asp?2021/58/2/178/325643

Introduction

Mosquito-borne diseases are one of the most common cause of fever in the tropics with a considerable impact on the mortality and morbidity of the affected population^[1]. Nowadays, these diseases are gaining greater importance due to the epidemiological transition that is happening, which is related to environmental changes that affect the vectors that transmit these infectious agents. Among these diseases, malaria, chikungunya and dengue are the most common infections with numbers that could reach 400 million people affected per year around the world. Most cases are suspected and reported in Africa, Latin America and Asia. Therefore, strategies for managing, preventing and dealing with these conditions are incorporated in the sustainable development goals of the United Nations^[2].

Although the vectors for dengue, chikungunya, yellow fever, Zika (Aedes spp.) and malaria (Anopheles spp.) are different types of mosquitoes, cases of co-infection with these organisms have been found in the same patient with mixed presentations^[3]. Additionally, the possibility of having a triple infection in the acute setting has been described, making the already similar presentations even more difficult to diagnose, especially in cases with atypical presentations and clinical courses^[4].

We will discuss a case of a returning traveler from Nigeria who presented with a syndrome of tropical fever and in whom suspicion of malaria was the first impression. However, due to abnormalities in her bloodwork and persistence of fever despite anti-malarial treatment, further work up was performed, which showed co-infection with chikungunya.

Case

A 55-yr-old female, originally from Nigeria, came in complaining of episodes of global headache of moderate intensity associated with nausea, generalized malaise, diarrhea and increasing episodes of fever that started 6 days prior to her visit to the emergency department. She initially consulted urgent care and was prescribed anti-nausea medication. However, her fevers persisted, prompting her to go to the emergency department. The patient had a medical history significant for hypertension and a prior episode of malaria (not able to recall or obtain information regarding time, species or treatment). The patient was in Nigeria from December 2018 to July 2019, and stated that during her stay in Nigeria she did not have any symptoms and took prophylaxis for malaria in the first week of her travel. She did not have any exposure to livestock or rodents and denied any hikes or travel to lakes while she was in Nigeria or in the USA. She had a sexual encounter during her travel, but stated that she used condoms.

The patient mentioned that she had multiple episodes of mosquito bites during her travel but did not recall specific dates related to these episodes. Upon admission, she had a temperature of 101°F, heart rate of 127 beats per min with no abnormalities in her abdominal exam or skin exam. Her initial laboratories showed a platelet count of 94,000/mclt and a hemoglobin of 10.2g/dl with no electrolytes abnormalities. Thick and thin blood smear revealed ring forms compatible with Plasmodium falciparum and a PCR test confirmed the finding. Infectious disease expert was consulted and she was started on treatment with atovaquone/proguanil, as well as symptomatic treatment for fever with acetaminophen. Additional tests like blood cultures and stool cultures were negative, although ELISA HIV test was positive.

The patient’s symptoms started to improve, however, there was an increase in her parasitemia level and persistence of fever. Associated with these findings were complaints of pain located in both of her wrists and diffuse myalgia, which improved temporarily with the use of acetaminophen. Failure of anti-malaria treatment was suspected, however, parasitemia started to clear, still with episodes of fever despite parasite clearance [Table 1].

Table 1: Hospital course of temperature, parasitemia, platelets and hemoglobin

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In the interim, the patient continued to have thrombocytopenia with a nadir of 63,000 platelets. Dengue and chikungunya IgM and IgG were also sent for concern of tropical fever disease. IgM for chikungunya was positive and negative for dengue, and IgG was negative for chikungunya but positive for dengue. Fever resolved in the rest of her hospital course with no need for further doses of acetaminophen. In regards to her HIV positive test, an HIV 1 viral load was negative but the initial ELISA final result showed a possible HIV 2 infection. The patient completed her treatment course of anti-malarial medication with clearance of parasite in blood smears, increase in platelet count, as well as complete resolution of the rest of her symptoms. Laboratory results of HIV and chikungunya were discussed with the patient. She had a follow up with an infectious disease specialist and had a negative viral load of HIV 2.

Discussion

According to the literature review, the prevalence of co-infection among these infectious agents is highly variable and depends on the combination and the location. A systematic review performed by Salem et al (2018) showed that the most frequent combination is chikungunya with dengue (prevalence of 1-35%) followed by malaria with dengue and the least common was a combination of dengue/malaria and chikungunya that was only reported in Asia and Africa^[3]. These distributions of co-infections were also demonstrated in Latin America, except for the combination of the three pathogens with very low rates of malaria co-infected with dengue fever and no cases of malaria with chikungunya^[5],[6],[7].

In regards to the clinical presentation, our patient had an unexpected relapse in fever and complaints of arthralgia that could have been explained by the co-infection with chikungunya. The initial complaints and findings were lacking the common arthralgia and joint pain described with chikungunya, but then they appeared during the patient’s hospital admission while the parasitemia was already clearing. Currently, there is debate if the co-infection of these infectious agents could increase, decrease or does not have any impact on the clinical presentation and outcomes compared to only being infected by one of them^[8].

As the clinical diagnosis of these entities is very difficult due to the overlapping of a lot of the symptoms, the microbiological and molecular studies play a key role in the cases with suspicion of co-infection, as what happened in the case of our patient^[3]. The diagnosis of chikungunya was made solely with the symptoms and IgM, as they had elapsed more than 6 days since their initial presentation, and malaria was confirmed both with molecular testing and blood smear^[9]. In the case of returning travelers, the identification and recognition of countries where there is documentation of co-infection or presence of multiple vector borne diseases should make the clinician have a very low threshold for working up other tropical diseases^[2].

The presence of anemia is more frequent in the cases of malaria than in chikungunya. However, the presence of thrombocytopenia is more characteristic of infections with dengue or chikungunya, again raising the importance of keeping a high suspicion of co-infections with these pathogens in travelers coming from Asia, Africa and Latin America where all of these diseases are endemic^[5],[8],[10].

In the end, lessons from this case are that with the increasing amount of travelers from all over the world, the importance of having suspicion for these tropical fever pathogens is something that has to be kept in mind; especially if the patient is having an atypical presentation, has a change in the clinical course or has persistence of symptoms despite improvement of their laboratory values. Having a broad differential diagnosis and thinking about patients who could present with co-infections of multiple pathogens, especially if they are travelers from India, east and west Africa might become a more common daily practice with the globalization.

Ethical statement

Patient gave verbal and written consent for use of the information

Conflict of interest: None

References

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