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30]

Original Article

Evaluation of Concurrent Malaria and Dengue Infections among

Febrile Patients
Parul D. Shah, Tanmay K. Mehta
Department of Microbiology, Smt. N.H.L. Municipal Medical College, Ahmedabad, Gujarat, India

Abstract
Context: Despite a wide overlap between endemic areas for two important vector‑borne infections, malaria and dengue, published reports
of co‑infections are scarce till date. Aims: To find the incidence of dengue and malaria co‑infection as well as to ascertain the severity of
such dengue and malaria co‑infection based on clinical and haematological parameters. Setting and Design: Observational, retrospective
cross‑sectional study was designed including patients who consulted the tertiary care hospital of Ahmedabad seeking treatment for fever
compatible with malaria and/or dengue. Subjects and Methods: A total of 8364 serum samples from clinically suspected cases of fever
compatible with malaria and/or dengue were collected. All samples were tested for dengue NS‑1 antigen before 5 days of onset of illness and
for dengue IgM after 5 days of onset of illness. In all samples, malaria diagnosis was based on the identification of Plasmodium parasites
on a thin and thick blood films microscopy. Results: Only 10.27% (859) patients with fever were tested positive for dengue and 5.1% (434)
were tested positive for malaria. 3.14% (27) dengue cases show concurrent infection with malarial parasites. Hepatomegaly and jaundice
37.03% (10), haemorrhagic manifestations 18.51% (5) and kidney failure 3.7% (1), haemoglobin <12 g/dl 100% (27) and thrombocytopenia
(platelet count <150,000/cmm) 96.29% (26) were common in malaria and dengue co‑infections and were much more common in Plasmodium
falciparum infections. Conclusion: All febrile patients must be tested for malaria and dengue, both otherwise one of them will be missed in
case of concurrent infections which could lead to severe diseases with complications.

Keywords: Concurrent infection, dengue, malaria

Introduction
Vector‑borne infections such as malaria and dengue
are of major public health concern worldwide. The
former is a parasitic disease transmitted by Anopheles
mosquito, and the latter is a viral disease transmitted by Aedes
mosquito.
In a geographical area where both the vectors coexist,
simultaneous occurrence of malaria and dengue in an
individual cannot be ruled out. The two diseases share many
clinical features and may be clinically indistinguishable.
It is important; however, to differentiate between the two
conditions, otherwise, it may result in a poor outcome.
Objective
The aim of our study was to find out the incidence of dengue
and malaria co‑infection as well as to ascertain the severity
of such dengue and malaria co‑infection based on clinical and
haematological parameters.
Subjects and Methods
We carried out an observational retrospective cross‑sectional
study on patients who consulted the tertiary care hospital
of Ahmedabad for fever compatible with malaria
and/or dengue during 1.5 years period, from June 2013 to
November 2014.

Despite a wide overlap between endemic areas for these Address for correspondence: Dr. Tanmay K. Mehta,
vector‑borne infections, published reports of co‑infections M‑4‑67‑521, Shastrinagar Shopping Centre, Naranpura,
are very scarce till date. Very few publications described Ahmedabad ‑ 380 013, Gujarat, India.
proven or suspected associations, but always as isolated E‑mail: tanmay.smit@gmail.com
cases.[1‑6]
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DOI: How to cite this article: Shah PD, Mehta TK. Evaluation of concurrent
10.4103/ijmm.IJMM_15_455 malaria and dengue infections among febrile patients. Indian J Med
Microbiol 2017:35;402-5.

402 © 2017 Indian Journal of Medical Microbiology | Published by Wolters Kluwer - Medknow
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Shah and Mehta: Concurrent malaria and dengue infections

A total of 8364 blood samples were collected from clinically
suspected cases of fever compatible with malaria and/or
dengue. All samples were tested for dengue NS‑1 antigen
ELISA on or before 5 days of onset of illness and for dengue
IgM ELISA after 5 days of onset of illness. Malaria diagnosis
was based on the identification of Plasmodium parasites on a
thin and thick blood films microscopy in all samples.
All demographic, clinical, haematological and other laboratory
parameter data were collected and analysed.
Results
Only 10.27% (859) patients with fever were tested positive for
dengue, and 5.1% (434) were tested positive for Plasmodium
parasite. Only 3.14% (27) cases show concurrent infection with
dengue virus and Plasmodium parasites. Of these, 62.96% (17)
were positive for Plasmodium vivax, 33.33% (9) were
Plasmodium falciparum and 3.7% (1) case of mixed infection
with P. vivax and P. falciparum. As per recent (2009) WHO
classification for dengue cases, out of 859 dengue‑positive
cases, 50.6% (435) were dengue without warning signs (D),
37.6% (323) were dengue with warning signs (DW) and
11.8% (101) cases were severe dengue (SD). Out of total
malaria and dengue concurrent infections, 11.11% (3) were
dengue without warning signs, 55.55% (15) were DW signs
and 33.33% (9) cases were SD cases [Table 1].[7,8] All the
co‑infection cases presented after 5 days of febrile illness and
were positive for dengue IgM ELISA.
Complications such as hepatomegaly and jaundice 37.03% (10);
haemorrhagic manifestations 18.51% (5) and kidney failure
3.7% (1) are common in malaria and dengue co‑infections. These
complications are more common if P. falciparum infection is
present [Table 2]. Important haematological parameters
in dengue and malaria co‑infection cases are summarised
in Table 3 showing haemoglobin <12 g/dl in 100% (27)
and thrombocytopenia (platelet count <150,000/cmm) in
96.29% (26) cases. No mortality was detected in dengue and
malaria co‑infection cases.
Discussion
Dengue and malaria, both are preventable vector‑borne
diseases. Coexistence of both is very important to understand
as both have almost similar signs and symptoms but entirely
different treatment protocols. Simultaneous presence of
both the infections in one individual can easily be missed as
detection of any one of them in an acute febrile patient can
mask the diagnosis of other.
In the present study, the incidence of concurrent dengue and
malaria infection was 3.14%. The incidence of concurrent
infection in other studies has been quite variable and range
from 1% in French Guiana[2] to 6% in India and 27% in
Pakistan.[3,4] Classical concept of malaria occurring in rural
areas and dengue in urban areas has been challenged in many
reports from different countries due to overlap of mosquito
biotypes.[9] As only hospitalised patients were included in the
study, this co‑infection incidence does not represent incidence
in community or local population. We could not determine the
vector load which would have been helpful in determining the
concurrent infection in a locality. Other published studies also
had similar limitation.[10,11]
In published case reports, the diagnosis of dengue infection
is usually made based on positive dengue IgM; however,
this cannot confirm recent dengue with certainty because

Table 1: Co‑infection with malarial parasite in dengue cases

Co‑infection with Dengue without warning Dengue with warning Severe Total
malarial parasite signs n(%) sign n(%) dengue n(%) n(%)
P. vivax 2 (7.4) 11 (40.74) 4 (14.81) 17 (62.96)
P. falciparum 1 (3.7) 3 (11.11) 5 (18.51) 9 (33.33)
P. vivax and P. falciparum 0 1 (3.7) 0 1 (3.7)
Total 3 (11.11) 15 (55.55) 9 (33.33) 27 (100)
P. vivax: Plasmodium vivax, P. falciparum: Plasmodium falciparum

Table 2: Clinical spectrum of dengue cases showing concurrent infection with malaria
Clinical feature P. vivax P. falciparum P. vivax and P. falciparum Total
n(%) n(%) n(%) n(%)
Fever 17 (62.96) 9 (33.33) 1 (3.7) 27 (100)
Hepatomegaly and jaundice 6 (22.22) 3 (11.11) 1 (3.7) 10 (37.03)
Haemorrhagic manifestations 2 (7.4) 2 (7.4) 1 (3.7) 5 (18.51)
Muscle pain 3 (11.11) 1 (3.7) 1 (3.7) 5 (18.51)
Headache 3 (11.11) 1 (3.7) 1 (3.7) 5 (18.51)
Joint pain 2 (7.4) 1 (3.7) 0 3 (11.11)
Vomiting 2 (7.4) 0 1 (3.7) 3 (11.11)
Skin rash 1 (3.7) 0 0 1 (3.7)
Kidney failure 0 1 (3.7) 0 1 (3.7)
P. vivax: Plasmodium vivax, P. falciparum: Plasmodium falciparum

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Shah and Mehta: Concurrent malaria and dengue infections
Table 3: Important haematological parameters of malaria‑dengue co‑infection
Clinical feature P. vivax
n(%)
Haemoglobin <12 g/dl 17 (62.96)
Platelet count <150,000/cmm 16 (3.7)
Serum bilirubin >1.2 mg/dl 6 (22.22)
SGPT >55 U/l 5 (18.51)
Blood urea >45 mg/dl 1 (3.7)
Serum creatinine >1.5 mg/dl 0 1 (3.7)
SGPT: Serum glutamic pyruvic transaminase, P. vivax: Plasmodium vivax, P. falciparum: Plasmodium falciparum
IgM can persist for months and cross‑react with other
arboviruses.[1‑6,12,13] In our study, the presence of both malaria
and dengue in a patient at one point of time was presented after
5 days of febrile illness, and all these cases were positive for
dengue IgM ELISA. This could be a concurrent infection of
patients with dengue virus and Plasmodium parasite. Another
possibility could be an infection of malarial parasites in a
previously infected dengue patient with persistent dengue
IgM in their serum. Dengue patients can have poor immunity
during convalescence which makes them susceptible to other
infections. Beyond 1 week of fever, if dengue infection shows
no signs of improvement to conservative treatment, consider
other possibilities of co‑infections most importantly malaria.
In the present study, P. vivax was present in the majority of
the cases (62.96%) similar to study done in French Guiana
and Pakistan showing P. vivax in 63.9% and 96.2% cases.[10,11]
This can be attributed to the species prevalent in a particular
geographical region.
The clinical features of dengue and malaria co‑infection
were more like dengue mono‑infection than malaria
mono‑infection. Therefore, clinically, it is difficult to diagnose
concurrent dengue and malaria. As 89% of total concurrent
malaria and dengue concurrent infection belong to DW
signs and SD implicating the role of malaria in increasing
severity of dengue cases, especially when P. falciparum is
implicated. Complications such as hepatomegaly and jaundice
37.03% (10), haemorrhagic manifestations 18.51% (5) and
kidney failure 3.7% (1) are common in malaria and dengue
co‑infections with maximum cases in P. falciparum infected
cases. Therefore, screening for malaria is essential after
clinical and haematological correlation in dengue‑positive
cases and vice versa. Anaemia, thrombocytopenia, altered
liver and renal function tests were observed in malaria and
dengue co‑infection cases with higher number of cases in
P. falciparum infection. Similar findings were found in study
done in Pakistan.[11] Deranged liver function was also found
in that study.[11] It is interesting to note that haemorrhagic
manifestations are uncommon in falciparum malaria whereas
in dengue, they are common. As both malaria and dengue can
cause thrombocytopenia, it is difficult to decide which one is
responsible for the haemorrhagic manifestation. Therefore,
malaria with bleeding manifestations are considered as severe
malaria and treated accordingly.[14] The biological influence
of dengue virus, which affects the endothelium, a major
404 Indian Journal of Medical Microbiology ¦ Volume 35 ¦ Issue 3 ¦ July-September 2017
P. falciparum P. vivax and P. falciparum Total
n(%) n(%) n(%)
9 (33.33) 1 (3.7) 27 (100)
9 (33.33) 1 (3.7) 26 (96.29)
3 (11.11) 1 (3.7) 10 (37.03)
3 (11.11) 1 (3.7) 9 (33.33)
2 (7.4) 0 3 (11.11)
0 1 (3.7)
protagonist of severe malaria pathophysiology, on the eventual
severity of falciparum malaria, needs to be studied.[15]
Although severity and complications are more in co‑infection
cases, especially with P. falciparum infection, no mortality was
detected in such cases. The increased severity could result from
longer evolution duration or increased virulence or both. Our
study was retrospective so the results should be interpreted
with caution. Prospective studies with homogeneous diagnosis
methods and patient groups should be tried to confirm the
higher severity of co‑infection, but the usefulness of such a
study is questionable because of the very low prevalence of
dual infection. The benign outcome has also been observed
in other two studies.[10,11] The good outcome was attributed
to early medical treatment of co‑infection cases.[5,6] The
distinction between SD and severe malaria must be made in
an emergency department or hospital setting because in both
situations, early diagnosis is essential for patient care.
The present study showed three notable findings. First, it
showed that malaria and dengue co‑infection is not uncommon
in a geographical area where both the mosquito vectors coexist.
Second, in concurrent infection, the clinical features of dengue
fever are predominant over malaria. Third, DW signs and SD
cases are found more in dengue and malaria co‑infection cases
especially when P. falciparum is implicated.
Malaria and dengue must be suspected in febrile patients
living in or returning from areas endemic for these infections.
If malaria is confirmed first, then dengue should not be ruled
out without testing for it. If first dengue is confirmed, then all
such cases also should be sought for malaria. All clinicians
treating febrile patients in or returning from endemic areas
should systematically order examinations for both malaria and
dengue diagnoses, even if one or the other is positive.
Conclusion
All febrile patients must be tested for both malaria and
dengue otherwise one of them can be missed in case of
concurrent infections which could lead to severe disease with
complications.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Shah and Mehta: Concurrent malaria and dengue infections

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