1. CO-INFECTION OF MALARIA AND LEPTOSPIROSIS PROF.S.SHIVAKUMAR’S UNIT N.LOGANATHAN MD POSTGRADUATE

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

3. On Examination… Conscious, oriented,febrile, otherwise general examination was normal Conscious, oriented,febrile, otherwise general examination was normal Vitals stable Vitals stable SYSTEMIC EXAMINATION CVS RS ABDOMEN CNS CLINICALLY NORMAL

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

5. On Examination…. Drowsy, febrile,jaundiced, otherwise general examination was normal Drowsy, febrile,jaundiced, otherwise general examination was normal Vitals stable Vitals stable SYSTEMIC EXAMINATION CVS RS ABDOMEN CLINICALLY NORMAL CNS Drowsy. No cranial / motor deficits. No meningeal signs

6. INVESTIGATIONS Investigations Case ICase II Hb % 11.6 gms 11.6 gms 9.0 gms 9.0 gms TC 6000 6000 7000 7000 DC P68 L30 E2 P68 L30 E2 P60 L38 E2 P60 L38 E2 ESR 3/7 3/7 30/65 30/65 Platelets 1.8 L 1.8 L 1.7 L 1.7 L Urine R/E Normal Normal RBS 130 mg 130 mg 116 mg 116 mg Urea 24 mg 24 mg 28 mg 28 mg S.Creatinine 0.9mg 0.9mg

7. Investigations Case I Case I Case II Case II TB TB 0.9mg 0.9mg 7.6 mg 7.6 mg DB DB 0.5 mg 0.5 mg 4.3 mg 4.3 mg SGOT SGOT 59 IU/L 59 IU/L 61 IU/L 61 IU/L SGPT SGPT 129 IU/L 129 IU/L 4O IU/L 4O IU/L SAP SAP 4O IU/L 4O IU/L 80 IU/L 80 IU/L Na + Na + 128meq/L 128meq/L 136meq/L 136meq/L K + K + 3.5 meq/L 3.5 meq/L 3.8 meq/L 3.8 meq/L ECG ECG WNL WNL

8. Investigations Case I Case I Case II Case II CXR CXR Normal Normal USG USG Normal Normal QBC- MP QBC- MP P.Vivax + P.Vivax + MSATMAT 2 + 2 + 1:160, patoc 1:160, patoc 3+,2+ 3+,2+ 1:80, semaranga

9. DISCUSSION  Both Case I and Case II were tested positive for malaria ( P.V ) & Leptospirosis. The Case II in addition had altered sensorium & Hepatic dysfunction.  Case I is treated with Chloroquine & Doxycycline  Case II is treated with Quinine & Doxycycline

10. REVIEW OF LITERATURE…

11. 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

12. 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:

13. 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…

14. 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..

15. 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

16. OUR STUDIES AT GOVT. STANLEY MEDICAL COLLEGE HOSPITAL…

17. CO-INFECTION OF MALARIA AND LEPTOSPIROSIS- A STUDY 48 CASES TOTAL NO. MALARIA – 220 CO-INFECTED WITH LEPTO- 48(22%) PV - 39 PF - 12 PV & PF - 03 Co infection of Leptospirosis occurred in significant ( 22% ) number of patients with Malaria.

18. STUDY OF 180 CASES OF FEVER ADMITTED TO MEDICAL WARD - SMC MALARIA -58 (32%) MALARIA -58 (32%) LEPTO - 27 (15%) LEPTO - 27 (15%) OTHERS - 95 (53 %) OTHERS - 95 (53 %) OUT OF 58 CASES OF MALARIA 10 (17 %) WERE FOUND TO BE +VE FOR LEPTO

19. IMMUNOLOGY-Hypoimmune state B CELL T CELL CD4 CD8 POLYCLONAL ACTIVATION MACROPHAGE HUMORAL CMI KILLS INFECTED RBCS RBC LACKS HLA I AG POLYCLONAL AB BLOCKS CMI INFECTIONS URINARY TRACT INFECTION RESPIRATORY INFECTION SALMONELLA BACTREMIA ? CAN THIS PRE-DISPOSE TO LEPTO SPIROSIS

20. Malaria & Lepto Coinfection: North chennai is endemic for both malaria & Leptospirosis North chennai is endemic for both malaria & Leptospirosis It is essential to treat the dual infections when an index case is suspected esp.in endemic area It is essential to treat the dual infections when an index case is suspected esp.in endemic area Co Infection Malaria Leptospirosis Symptomatic Asymptomatic symptomatic Symptomatic asymptomatic

21. 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