Malaria Dengue Chikungunya
Agent Plasmodium parasites: P. Dengue virus 1, 2, 3, and 4.
falciparum (common and Part of the Flaviviridae
severe, 50%), P. vivax family.
(43%), P. ovale, and P.
malariae.
Transmissi
on
Female Anopheles
mosquito (more Female Aedes aegypti (most
prevalent during the common), A. albopictus, A.
night, dawn, and dusk) polynesiensis, and A.
scutellaris mosquitoes
Incubation 2 weeks, other sources: 3 to 4 days
10-21+ days
Natural  Febrile phase: High
course fever, nausea, myalgia,
rash, flushed face for 2-
7 days.
 Critical phase: Plasma
leakage, abdominal
pain, hypotension, liver
tenderness for 24-48
hours.
 Convalescent phase:
Increased appetite,
rash, normotension,
bradycardia, decreased
Hct.
Leptospirosis
Alphavirus Leptospira bacteria. 13 out of 21
Female Aedes aegypti (more
prevalent during the day) and
Aedes albopictus mosquitoes
1 to 12 days
 Acute infection phase (1-
14 days): High grade fever
for 3-5 days.
Polyarthralgia (10+ joints)
begins 2-5 days after
onset of fever.
 Persistent symptoms
phase: Skin manifestation
(40-75%) macular or
maculopapular rash. The
polyarthralgia becomes
more severe and can
become polyarthritis,
sometimes with
tenosynovitis and carpal
tunnel syndrome. May
complicate to Raynaud's
phenomenon (20%).
Hepatitis B
Hepatitis B virus. Part of the
species are pathogenic.
Urine of rats and other mammals,
swallowed or via eyes, nose, or
cuts. Not airborne or human-to-
human.
7 to 12 days
 1st phase (aka acute or
septicemic phase): 3–7 days.
 Asymptomatic phase: 3-4
days. Symptoms disappear.
Bacteria in blood. Leptospira
antibodies appear.
 2nd phase: Fever returns.
Hallmark: meningitis.
 Severe phase (10%): Liver
damage (causing jaundice),
kidney failure, and bleeding
(aka Weil's disease).
 Can complicate to severe
pulmonary haemorrhage
syndrome, which is fatal in
50% despite treatment.
Typhoid
Salmonella bacteria: S. typhi
Hepadnaviridae family.
Body fluids/blood. Vaginal/anal
sex. Needle-sharing. Vertically,
pregnant mother to child.
40 to 160 days, average 60 to 90
days. Other source: 2 to 24
weeks.
 Usually starts insidiously -
with anorexia and nausea
and ache in the right upper
abdomen.
 Majority asymptomatic.
Indefinite nausea, vomiting,
diarrhea, anorexia. More
symptoms appear with
severity.
 With or without symptoms
(HBsAg +) for >6 months,
considered chronic (5-10%),
can lead to cirrhosis or liver
cancer (25-40%).
 Rarely (0.1-0.5%), leads to
(very fatal) fulminant
hepatitis.
(common and severe, 83%) and
S. paratyphi (less severe).
Consuming food/water
contaminated with feces of an
infected person.
6 to 30 days
 1st week: Relative
bradycardia. Malaise,
headache, cough.
Leukopenia, eosinopenia,
relative lymphocytosis.
Blood cultures (+) for S.
typhi. Typhidot (+).
 2nd week: Relative
bradycardia. Delirium,
agitation. Rose spots
(33%). Rhonchi in lung
bases.
Hepatosplenomegaly.
Smelly pea-soup diarrhea.
Transaminase elevation.
Widal (+).
 3rd week: Complications:
intestinal haemorrhage,
dehydration, respiratory
diseases. Platelets low.
 4th week: Fever subsides.
 Signs and Symptoms / Physical Exam Findings
Malaria Dengue Chikungunya Leptospirosis Hepatitis B Typhoid
Skin Indefinite rash usually during
incubation period. Acute urticaria
(20%-30%). Pruritis, especially if
jaundice prolonged.
Uncommonly, and in chronic:
bullous pemphigoid, lichen
planus, Gianotti-Crosti syndrome,
porphyria cutanea tarda.

Sweating
Rose spots (maculopapular
rash) (25%), less visible in dark
Over face, chest from day 1-3 skinned people, on anterior
for 3-7 days, non-hemorrhagic. trunk: these 2-4 mm sized,
A maculopapular or macular Maculopapular rash, similar to salmon-colored, raised,
Usually over legs, from day 4-6, blanching spots usually number
confluent rash over the face, dengue. Occurs early in illness.
hemorrhagic. 5-12, and fade after 3-4 days.
thorax, and flexor surfaces, 40-75%.
with islands of skin sparing.
Petechiae spots on full body
except face, from day 3-4.
May turn hemorrhagic. Rash
disappears under pressure.
Fever With or without chills. Sudden onset and Sudden onset of high fever (up With chills. 4-7 days, remission for Mild (<39°C), during incubation  1st week: Gradual
 Recurrent (36-48 occasionally biphasic pattern. to 40°C) for 1-2 days, remission 1-2 days, and relapse. period. increase in temperature.
hrs) or continuous 1-2 days of fever, remission for 1-2 days (defervescence), (Stepladder fever in
fever in P. for 1-2 days, relapse for 1-2 relapse for 1-2 days. With <12%).
falciparum. days. aka "breakbone fever" chills.  2nd week: High in
 Tertian fever (every due to accompanying joint afternoons.
and muscle pain.
2 days) in P. vivax  3rd week: Constantly
and P. ovale. high, reaching 40°C.
 Quartan fever  4th week: Subsides.
(every 3 days) for P.
malariae.
Jaundice Mild and rare. Due to Only 2% of DSS patients. Mild. Only in severe leptospirosis (Weil's In 10% of younger children, 30-
intravascular hemolysis disease). 50% of adults. Accompanied by
(most common), darker urine and lighter feces.
disseminated
intravascular
coagulation, and, rarely,
malarial hepatitis.
Arthralgia No joint pain. Mild joint pain, specially in Severe small joint pain and Mild joint pain. Not common. Indefinite. Acute and symmetric,
febrile phase. Usually of the arthritis (joint swelling), morning stiffness.
knees and shoulders. polyarticular, bilateral, and
symmetric. Begins two to five
days after onset of fever. 80%+.
Myalgia Body aches. Severe muscular pain, Severe muscular pain. Severe muscular pain. Indefinite, accompanied by
especially of the lower back, fatigue.
 arms, and legs. And
especially in febrile phase.
Headache Mild to severe Common. Retro-orbital pain. Common Severe and common (75-100%) Indefinite.
Nausea Yes. 50% Yes.
Other Enlarged spleen as a Mild hemorrhagic Conjunctival suffusion (55%).
findings result of hemolysis. manifestations (eg, Muscle tenderness, splenomegaly,
Enlargement of the liver. petechiae, bleeding gums, lymphadenopathy, pharyngitis,
epistaxis, menorrhagia, hepatomegaly, muscle rigidity,
hematuria). Altered taste abnormal respiratory auscultation,
sensation. Anorexia. or skin rash occur in 7-40%. Aseptic
Lymphadenopathy. meningitis in 50-85% if
cerebrospinal fluid is examined
after seven days of illness.
Lab Findings
Malaria Dengue Chikungunya Leptospirosis Hepatitis B Typhoid
Hemoglobi Low (25%, more in
n children)
Lymphocyt Lymphopenia. Atypical Lymphopenia Lymphopenia
es lymphocytes.
Thromboc Thrombocytopenia (50- Thrombocytopenia (platelet Thrombocytopenia Thrombocytopenia (39%)
ytes 68%) count < 100 x 109/L)
Leukocyte Leukocytosis (<5%) Leukopenia Peripheral leukocytosis (3,000-
s 26,000 x 109/L) with a left shift.
Neutrophil Neutropenia
s
ESR Elevated in acute phase
Liver Mild to moderate elevation Minimal to moderate elevation AST/ALT may be elevated (up to
Enzymes of AST and ALT. (40%) of AST, ALT, and GGT. 2000 IU/L), in acute phase and
with ALT>AST.
Other Triad of PCR to detect viral genomic Serology is the primary tool for Hyponatremia is common in severe Prothrombin time is the best
thrombocytopenia, sequences. Fourfold or diagnosis in the clinical setting. leptospirosis. Urinalysis frequently indicator of prognosis. Hepatitis
elevated lactate greater change in reciprocal Immunoglobulin M (IgM) anti- shows proteinuria, pyuria, granular B surface antigen (HBsAg) is the
dehydrogenase (LDH) IgG or IgM antibody titers to chikungunya virus antibodies casts, and occasionally microscopic serologic hallmark, and can be
levels, and atypical one or more dengue virus (detected by direct enzyme- hematuria. Elevated creatine kinase detected by radioimmunoassays
lymphocytes. These antigens. Isolation of the linked immunosorbent assay is observed in approximately 50% (RIA) or enzyme immunoassays
findings should prompt dengue virus from serum, [ELISA]) are present starting of patients and may be a useful (EIA). HBsAg appears in serum 1
obtaining malarial plasma, leukocytes, or about five days (range 1 to 12 clue. Gold standard is molecular to 10 weeks after an acute
smears of thick and thin autopsy samples. In DHF, days) following onset of agglutination test (MAT). A exposure, before symptoms and
(to know species) blood. blood coagulation test: PT symptoms and persist for combination of blood culture and liver enzyme elevation.
Mild coagulopathy, and prolonged, APTT prolonged, several weeks to three months. MAT has sensitivity of only 55.5%,
elevated blood urea fibrinogen low. Immunoglobulin G (IgG) but specificity is 98.8%. MAT
nitrogen (BUN), and antibodies begin to appear requires high expertise and is only
creatinine may also be about two weeks following done in top labs. (Ig)M ELISA tests
found. onset of symptoms and persist are done in clinical settings instead.
for years.
Management
Malaria Dengue Chikungunya Leptospirosis Hepatitis B Typhoid
Preventio Avoid exposure to There is no vaccine. No Doxycycline once a week can be A typhoid vaccine, recommended
n mosquitoes by not going antiviral agents have been used as chemoprophylaxis to for high risk people or those
 out at feeding times, proven to be effective. minimize infections during traveling to endemic zones, can
using mosquito nets, Minimize mosquito exposure. outbreaks in endemic regions. prevent 30-70% of cases during
long-sleeved clothing, Clean water and rat control can the first two years and remain
and insect repellent. help. Human and animal vaccines partially effective for up to 7
Chemoprophylaxis with are becoming available but still not years.
antimalarials is widespread, not for all species of
recommended before leptospira, and not effective for
traveling to an endemic long periods.
area.
Patient
Education
Hospitaliz Patients with elevated Admission for intravenous Patients with poor immune Rare after correct diagnosis of Usually recommended if there
ation parasitemia (>5% of RBCs fluid administration is systems (elderly, young, leptospirosis, and only if severe or are severe symptoms such as
infected), CNS infection, indicated for patients who immunosuppressed, etc) may if there are complications. persistent vomiting, severe
or otherwise severe develop signs of dehydration. require hospitalization. 20-30% However, many patients (especially diarrhea, or abdominal
symptoms and those are hospitalized for around a in dengue-endemic areas) are distention. As a precaution,
with P falciparum couple of days. misdiagnosed as having dengue young children are admitted.
infection should be and admitted. Severe cases of
considered for inpatient leptospirosis can affect any organ
treatment to ensure that system and can lead to multiorgan
medicines are tolerated. failure so these patients must be
admitted and continuously
monitored for cardiac and renal
dysfunction.
Medicatio  P Falciparum: Quinine- Oral rehydration therapy. Treatment consists of Severe leptospirosis: IV penicillin G Antiviral drugs, commonly: Azithromycin,
n based therapy is with There is no antiviral supportive care including anti- and 3rd-gen cephalosporins. Mild entecavir and tenofovir. fluoroquinolones, or third
quinine (or quinidine) medication available. inflammatory agents that leptospirosis: Doxycycline, generation cephalosporins.
sulfate plus Patients with DHF or DSS relieve symptoms in many Ampicillin, or amoxicillin. Pregnant Consider the rapidly growing
doxycycline or may require IV volume patients, and analgesic agents patients or allergic to penicillin: antibiotic resistance when
clindamycin or replacement. Plasma volume for pain relief. Erythromycin. Glucose and salt prescribing.
pyrimethamine- expanders can be used in solution infusions. Dialysis is used Sensitivity: cefotaxime
sulfadoxine; patients who do not respond in serious cases. Calcium carbonate (100.0%), ceftriaxone (98.9%),
alternative therapies to isotonic fluids. if hyperphosphatemia occurs. ofloxacin (93.5%),
are artemether- Acetaminophen cotrimoxazole (93.5%),
lumefantrine, (paracetamol) for pain and chloramphenicol (93.2%).
atovaquone-proguanil, fever.
or mefloquine
 P vivax, P ovale:
Chloroquine plus
primaquine. But
recently there's some
evidence for
combination of
dihydroartemisinin-
piperaquine with
primaquine.