A Case Report of Plasmodium Vivax, Plasmodium Falciparum and Dengue Co-Infection in a 6 Months Pregnancy
A 25-year-old 6 months pregnant lady from a rural background was admitted to a private tertiary care hospital in north India with complaints of fever with chills since 4 days. The patient had a BP = 100/60 mm of Hg, pulse = 112 bpm, RR = 22/min, temperature = 101°F, and was maintaining a saturation of 96% with oxygen support at 2 l/min. The patient was dyspneic, had a blanching erythematous rash, pallor (+++) and the fetal heart sounds could be heard. The cardiovascular and neurological examination was, however, normal. A complete blood count with peripheral smear, ELISA for immunoglobulin G (IgG) and immunoglobulin M (IgM) for dengue, were sent along with the routine blood examinations. The patient was managed symptomatically and was given supportive treatment.\nThe patient had Hb = 4.1 gm/dl, TLC = 5000/mm3, DLC = P68%, L32%, E0, B0, Platelets = 50,000/mm3, blood urea = 58.8 mg/dl, Sr.creatinine = 1.8 mg/dl, Sr.Na+ = 145 meq/L, Sr.K+ = 4.3 meq/L, total bilirubin = 0.8 mg/dl with a direct bilirubin = 0.7 mg/dl and an indirect bilirubin = 0.1 mg/dl, total serum protein = 3.9 g/dl, Sr.albumin = 2.2 g/dl, Sr.globulin = 1.7 g/dl, Aspartate Amino transferase (AST) = 60 U/L, Alanine Aminotransferase (ALT) =13 U/L, Sr.Alkaline Phosphatase = 113 U/L. Dengue duo Nonprotein Surface (NS1) antigen combo kit manufactured by standardia using one step rapid immunochromatograpic test for detection of NS1 Antigen and IgG and IgM were employed for the detection of dengue infection. Peripheral smear examination revealed presence of gametocytes of P. vivax and P. falciparum. The histidine rich protein-2 card test was also positive for P. vivax and P. falciparum. A general blood picture was that of markedly reduced red cell mass, red blood cells were microcytic and hypochromic along with anisopoikilocytosis in the form of tear drop cells, target cells and helmet cells. The treatment was accordingly modified and anti-malarials were started in the form of artisunate based combination therapy. Paracetamol in divided doses was given to control the fever and proper care was taken for fetal well-being by fetal sonography. During fetal sonography the amount of amniotic fluid, blood flow through the Doppler study, fetal activity, placenta and cervix were examined to ensure that there was no fetal compromise. The patient was given four units of packed red blood cell transfusion and was discharged after 7 days of in-patient treatment with a live fetus and is on a regular follow-up.