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ORIGINAL RESEARCH ARTICLE
ISSN - Print: 2277 – 1522, Online: 2277 - 3517
Co -Infection of Malaria and Leptospirosis - A Hospital Based Study from South India
Loganathan N1, Sudha Ramalingam 2, Ravishankar D3, Shivakumar S4 Date of Submission: 16.03.2012 Date of Acceptance: 28.0.2012 Abstract:
Introduction: Co-infection of Malaria and Leptospirosis is common in the regions where both diseases are endemic.
As the clinical features are non-specific and similar it is difficult to differentiate either of these illnesses. Also, both these illness can present with similar complications such as jaundice & renal failure. Aim: To assess the prevalence of
co-infection of Leptospirosis and Malaria in patients admitted with fever. Methods: Patients with fever admitted to a
Government facility in South India who tested positive for Plasmodium vivax / falciparum by Peripheral Smear / Quantitative Buffy coat (QBC) were investigated for co- infection with Leptospirosis utilizing MSAT (Macroscopic slide agglutination test- 2+ and above). All patients tested positive by MSAT were further confirmed by Microscopic Slide Agglutination Test (MAT) (titers of 1:80 and above). Patients positive for both malaria and Leptospirosis were t aken up for the study and were evaluated for relevant clinical features and Lab profile. Results and Discussion: 220
Patients with malaria were analyzed and 48 (22 %) were found to be positive for Leptospirosis. Vivax malaria
occurred in 36 patients, Falciparum malaria in 9 patients and 3 patients had both vivax and falciparum malaria in the 48 patients with leptospirosis co-infection group. Fever, Headache, Myalgia were the common symptoms of our Co- infection group & 19 % had Jaundice, 12 % had CNS manifestations, 10 % had Anemia, 4 % had Renal Failure. Uncomplicated Malaria & Leptospirosis were treated by Chloroquine and Doxycycline & Severe Malaria / Leptospirosis were treated by I.V Quinine / I.V Penicillin. This study had revealed that it is essential to evaluate for Leptospirosis in all patients with fever especially in endemic areas as Co-infection is common. Key words: Malaria, Leptospirosis, Co-Infection
Introduction
Co-infection of Malaria and Leptospirosis is
these illnesses. Both these illness can present with common in the regions where both diseases are similar complications such as jaundice & renal endemic1. As the clinical features are non specific failure. Chennai is an important coastal metropolis in and similar it is difficult to differentiate either of South India in the state of Tamil Nadu and has a land area of 172 Km2 with a population around 6 1Department of Medicine, PSG Institute of Medical Sciences millions. This study has been undertaken at a and Research, Coimbatore. 2Department of Community Government teaching hospital in North Chennai, Medicine, PSG Institute of Medical Sciences and Research, Tamil Nadu to evaluate the prevalence of co- Coimbatore. 3Consultant Physician, Manipal Hospital, Salem 4Professor and Head (Retired), Department of Medicine Methods:
All cases that fulfill the following criteria were Corresponding author: Dr. N. Loganathan, Assistant
admitted. a) Fever more than 5 days and /or b) Fever Professor, Department of Medicine, PSG Institute of Medical Sciences with any associated organ dysfunction. All these patients are investigated for malaria, leptospirosis, tuberculosis, enteric fever, pneumonia and other Table 2: Types of complications in the study
population
Patient’s positive for both malaria and Leptospirosis were taken up for the study and were evaluated for Complications relevant clinical features and Lab profile. Patients with fever who tested positive for Plasmodium vivax / falciparum by peripheral smear study / QBC were Anemia investigated for co- infection with Leptospirosis utilizing MSAT ( Macroscopic slide agglutination test- Jaundice 2+ and above ) .We have utilized a simple and Serum Total Bilirubin sensitive MSAT for early detection of Leptospirosis and utilized Modified Faine’s score of > 25 for SGOT(IU/L) diagnosis of leptospirosis2. All patients tested positive by MSAT were further confirmed by MAT (titers of A total of 220 Patients with malaria (183 vivax malaria & 37 falciparum malaria) were analyzed of Cerebral Malaria which 48 patients (22 %) were found to be positive for (Fits&Altered Sensorium) leptospirosis. There were 22 males & 26 females and the mean age was 29 years. In the co-infection group 36 patients had vivax malaria, 9 patients had There were no complications noted in the 3 patients falciparum malaria and 3 patients had both vivax and who had both vivax & falciparum malaria with falciparum malaria. Fevers, Headache, Myalgia were leptospirosis co-infection. the common symptoms of our co-infection group. Uncomplicated malaria and leptospirosis were treated Clinical features of our study group is shown in by Chloroquine and Doxycycline and severe malaria / Table:1. leptospirosis were treated by I.V Quinine / I.V Penicillin. All patients survived. This study had Table:1 Presenting clinical features of the study
revealed that it is essential to evaluate for Leptospirosis population
in all patients with fever especially in endemic areas as co-infection is common. A study from Thailand has revealed co-infection is an important problem in endemic areas. They reported seven cases of co- infection of leptospirosis and malaria who presented with fever, headache and myalgia1 . A case report from Chandigarh, India has revealed co-infection of malaria Simultaneous infection of malaria with filariasis, salmonella, dengue, retroviral infections and borrelia have been reported1 .Malaria induces a hypoimmune state & therefore the host is vulnerable to other infections. Data on co-infection with leptospirosis are limited. Leptospirosis is difficult to diagnose as Complications of vivax and falciparum malaria with diagnostic tools are unavailable in remote areas. It is leptospirosis co-infection is shown in the table 2. common practice in a malaria endemic area that if an acutely febrile patient is found to be malaria-positive, malaria is assumed as the sole cause of fever. Failure to 2. Shivakumar S, Shareek PS. Diagnosis of recognize acute leptospirosis co-infection may delay Leptospirosis utilizing Modified Faine’s Criteria. the initiation of proper therapy and possibly ensure J.Assoc Phys India 2004, 52:678-679. severe complications of leptospirosis like hepatic & renal dysfunction. Doxycycline is effective against 3. Srinivas R, Agarwal R, Gupta D. Severe sepsis due both malaria and leptospirosis. So adding Doxycycline to severe falciparum malaria and leptospirosis co-with Chloroquine or Quinine will be effective in infection treated with activated protein C.Malaria treatment of both illness simultaneously. So treatment Journal 2007,6:42. of both infections instead of malaria monotherapy will result serious Conflict of Interest: Nil
complications in endemic areas where both illnesses
are common.
Discussion
To conclude, co- infection of Leptospirosis occurred
in significant (22%) number of patients with
Malaria in our study. In endemic areas of malaria
and leptospirosis identifying and treating co-
infection is essential for rapid recovery and to
prevent complications. Chloroquine / Doxycycline or
Quinine & Doxycycline (or Artemisinin group) /
Penicillin combination is recommended for treatment
of co-infection of leptospirosis and malaria. If
diagnostic facilities for leptospirosis are not available
it is beneficial to treat the co-infection by addition
of Doxycycline to anti-malarial treatment. Modified
Faine’s Criteria can be utilized for diagnosis of
current leptospirosis infection. This criterian is
valuable only if diagnostic facilities for leptospirosis
are available especially in co-infection. It is essential
that a simple diagnostic tests for leptospirosis is
made available in rural areas where both Malaria and
Leptospirosis are commonly seen.
This is one of the few studies which have reported
the largest number of Malaria and Leptospirosis co
infection. This underscores the need to evaluate all
patients who present with fever for Malaria and
Leptospirosis co infection especially in endemic
areas.
References:
1. Wongsrichanalai C, Murray C, Gray M et al. Co-
Infection
Am.J.Trop.Med.Hyg., 68(5),2003,pp.583-585.

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