CO-INFECTION OF MALARIA CO-INFECTION OF MALARIA

AND LEPTOSPIROSISAND LEPTOSPIROSIS PROF.S.SHIVAKUMAR’S PROF.S.SHIVAKUMAR’S

UNITUNIT

N.LOGANATHANN.LOGANATHANMD POSTGRADUATEMD POSTGRADUATE

Case ICase I

Mr.Anthony, 28 yr old male Mr.Anthony, 28 yr old male admitted with H/o fever for 20 admitted with H/o fever for 20 days,high grade, continuous with days,high grade, continuous with chills & rigor, headache, vomiting chills & rigor, headache, vomiting and myalgia. No H/o chestpain, and myalgia. No H/o chestpain, dyspnoea, cough, joint pain, skin dyspnoea, cough, joint pain, skin rashes, jaundice, dysuria, abdominal rashes, jaundice, dysuria, abdominal pain or altered bowel habits. pain or altered bowel habits.

On Examination…On Examination…• Conscious, oriented,febrile, otherwise Conscious, oriented,febrile, otherwise

general examination was normalgeneral examination was normal

• Vitals stableVitals stable

SYSTEMIC EXAMINATIONCVS

RS

ABDOMEN

CNS

CLINICALLY NORMAL

CASE IICASE II

Mr.Sridharan, 17 yr old Mr.Sridharan, 17 yr old young adult was admitted with young adult was admitted with H/o fever for 3 days, chills & H/o fever for 3 days, chills & rigor, headache,jaundice,cough rigor, headache,jaundice,cough and altered sensorium. No H/o and altered sensorium. No H/o trauma, joint pain, skin trauma, joint pain, skin rashes,ear discharge,dyspnoea, rashes,ear discharge,dyspnoea, chestpain,altered bowel habits, chestpain,altered bowel habits, vomiting. No other complaints. vomiting. No other complaints.

On Examination….On Examination….• Drowsy, febrile,jaundiced, otherwise Drowsy, febrile,jaundiced, otherwise

general examination was normalgeneral examination was normal

• Vitals stableVitals stable

SYSTEMIC EXAMINATIONCVS

RS

ABDOMEN

CLINICALLY NORMAL

CNS Drowsy. No cranial / motor deficits. No meningeal signs

INVESTIGATIONSINVESTIGATIONSInvestigations

Case I Case II

Hb %Hb % 11.6 11.6 gmsgms

9.0 gms9.0 gms

TCTC 60006000 70007000

DCDC P68 L30 P68 L30 E2E2

P60 L38 P60 L38 E2E2

ESRESR 3/73/7 30/65 30/65

PlateletsPlatelets 1.8 L1.8 L 1.7 L1.7 L

Urine R/EUrine R/E NormalNormal NormalNormal

RBSRBS 130 mg 130 mg 116 mg116 mg

UreaUrea 24 mg24 mg 28 mg28 mg

S.CreatinineS.Creatinine 0.9mg0.9mg 0.9mg0.9mg

InvestigatioInvestigationsns

Case ICase I Case IICase II

TBTB 0.9mg0.9mg 7.6 mg7.6 mg

DB DB 0.5 mg0.5 mg 4.3 mg4.3 mg

SGOT SGOT 59 IU/L59 IU/L 61 IU/L61 IU/L

SGPTSGPT 129 IU/L129 IU/L 4O IU/L4O IU/L

SAPSAP 4O IU/L4O IU/L 80 IU/L80 IU/L

Na +Na + 128meq/128meq/LL

136meq/L136meq/L

K +K + 3.5 3.5 meq/L meq/L

3.8 meq/L3.8 meq/L

ECGECG WNLWNL WNLWNL

InvestigationsInvestigations Case ICase I Case IICase II

CXRCXR NormalNormal NormalNormal

USGUSG NormalNormal NormalNormal

QBC- MP QBC- MP P.Vivax +P.Vivax + P.Vivax +P.Vivax +

MSATMSAT

MATMAT 2 +2 +

1:160, 1:160, patoc patoc

3+,2+3+,2+

1:80, 1:80, semarangasemaranga

DISCUSSIONDISCUSSIONBoth Case I and Case II were Both Case I and Case II were tested positive for malaria tested positive for malaria ( P.V ) & Leptospirosis. The ( P.V ) & Leptospirosis. The Case II in addition had altered Case II in addition had altered sensorium & Hepatic sensorium & Hepatic dysfunction.dysfunction.

Case I is treated with Case I is treated with Chloroquine & DoxycyclineChloroquine & Doxycycline

Case II is treated with Quinine Case II is treated with Quinine & Doxycycline & Doxycycline

REVIEW OF LITERATURE…

CO-INFECTION WITH MALARIA AND LEPTOSPIROSIS

CHANSUDA WONGSRICHANALAI, CLINTON K. MURRAY, MICHAEL GRAY, R. SCOTT MILLER, PHILIP MCDANIEL, WILSON J. LIAO, AMY L. PICKARD, AND

ALAN J. MAGILL Armed Forces Research Institute of Medical Sciences,

Bangkok, Thailand; Brooke Army Medical Center, Fort Sam Houston, San Antonio, Texas: Veterinary Command Food Analysis and Diagnostic Laboratory, Fort Sam Houston,

San Antonio, Texas; Kwai River Christian Hospital, Sangkhlaburi, Kanchanaburi, Thailand; Walter Reed Army

Institute of Research, Silver Spring, Maryland

Malaria and leptospirosis are both common in the tropics. Simultaneous infections are possible, although not previously reported. We report cases of malaria from an area of Thailand on the Thailand-Myanmar border with compelling serologic evidence of simultaneous acute leptospirosis.

STUDY ABSTRACT:

One was a case of infection with Plasmodium falciparum with acute and convalescent microscopic agglutination test (MAT) titers for Leptospira serovar icterohaemorrhagiae of 1:200 and 1:1,600, respectively. The other was a case of infection with P. vivax that seroconverted to a titer of 1:3,200 for Leptospira serovar bataviae. Additionally, there were probable cases of leptospirosis with malaria detected.

Cont…

Management of dual infections is complicated by their similar clinical presentations, and because the confirmatory diagnosis of malaria is readily available as opposed to that of leptospirosis. Treatment focusing on malaria mono-infections instead of dual infections could result in a delay of specific therapy for leptospirosis and possible consequences of serious complications.

Cont..

Confirmation of co-infections with leptospirosis and malaria warrants careful diagnostic evaluation and presents a therapeutic dilemma among febrile patients in Sangkhlaburi. In the case of P. falciparum, artesunate-doxycycline therapy, one of the regimens of choice for this region of Thailand known for its high prevalence of multidrug-resistant malaria, will cover both diseases. For P. vivax, and in places where doxycycline is not routinely used for the treatment of P. falciparum malaria, prescription of doxycycline for a case with any index of suspicion should be considered

DISCUSSION

OUR STUDIES AT GOVT. STANLEY MEDICAL COLLEGE HOSPITAL…

CO-INFECTION OF MALARIA AND LEPTOSPIROSIS- A STUDY 48 CASES

TOTAL NO. MALARIA – 220CO-INFECTED WITH LEPTO - 48(22%)

PV - 39PF - 12PV & PF - 03

Co infection of Leptospirosis occurred in significant ( 22% ) number of patients with Malaria.

STUDY OF 180 CASES OF STUDY OF 180 CASES OF FEVER ADMITTED TO FEVER ADMITTED TO MEDICAL WARD - SMCMEDICAL WARD - SMC

• MALARIA MALARIA -58 (32%)-58 (32%)

• LEPTO LEPTO - 27 (15%)- 27 (15%)

• OTHERS - 95 (53 %)OTHERS - 95 (53 %)

OUT OF 58 CASES OF MALARIA 10 (17 %) WERE FOUND TO BE +VE FOR LEPTO

IMMUNOLOGY-Hypoimmune IMMUNOLOGY-Hypoimmune statestate

B CELL T CELL

CD4 CD8

POLYCLONAL ACTIVATION

MACROPHAGEHUMORAL CMI

KILLS INFECTED RBCSRBC LACKS HLA I AGPOLYCLONAL AB BLOCKS CMI

INFECTIONS

URINARY TRACT INFECTION RESPIRATORY INFECTIONSALMONELLA BACTREMIA ? CAN THIS PRE-DISPOSE TO

LEPTO SPIROSIS

Malaria & Lepto Malaria & Lepto Coinfection:Coinfection:• North chennai is endemic for North chennai is endemic for

both malaria & Leptospirosisboth malaria & Leptospirosis

• It is essential to treat the dual It is essential to treat the dual infections when an index case is infections when an index case is suspected esp.in endemic areasuspected esp.in endemic area

Co InfectionMalaria Leptospirosis

Symptomatic

Asymptomatic

symptomatic

Symptomatic

Symptomatic

asymptomatic

1.DOXYCYCLINE is effective against both Malaria and leptospirosis. So adding Doxycycline with Chloroquine or Quinine will be effective in treatment of both illness simultaneously

2. In endemic areas of Malaria and Leptospirosis identifying and treating co infection is essential for rapid recovery and to prevent complications.

CONCLUSION