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CASE REPORT Table of Contents   
Year : 2009  |  Volume : 52  |  Issue : 1  |  Page : 125
Infection potpourri: Are we watching?

Department of Microbiology, All India Institute of Medical Sciences, Delhi, India

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Population explosion, frequent travel and urbanization have led to certain changes in the environment, which are conducive for the survival of multiple pathogens and their transmission vehicle in the same niche. Therefore, there are more chances of acquiring multiple infections at the same time with overlapping clinical manifestations. We would like to share a case having concurrent infection with four different agents.

Keywords: Leptospirosis, mixed infection

How to cite this article:
Chaudhry R, Pandey A, Das A, Broor S. Infection potpourri: Are we watching?. Indian J Pathol Microbiol 2009;52:125

How to cite this URL:
Chaudhry R, Pandey A, Das A, Broor S. Infection potpourri: Are we watching?. Indian J Pathol Microbiol [serial online] 2009 [cited 2023 Nov 29];52:125. Available from:

A 28-year-old female resident of Delhi, India presented in an altered sensorium for 1 day with low-grade fever and pain in the abdomen for the past 8 days. She was anemic, icteric and had no rash or bleeding from any site. She had tender hepatomegaly and non tender splenomegaly with no evidence of ascites. Initial investigations revealed derranged liver functions (total bilrubin: 12.0 mg %, moderately elevated liver enzymes and prolonged Prothrombin time), severe anemia (Hb: 2.9 gm %) and low platelet counts (24,000/µl). A chest X-ray revealed cardiomegaly and prominent upper lobe vessels. She received intravenous fluids, a blood transfusion and oxygen using a mask. A differential diagnosis of malaria was considered; the patient was tested for Plasmodium Lactate Dehydrogenase (pLDH) by OptiMal® assay and found to be positive. The patient was transferred to the Intensive Care Unit and artesunate was added. A peripheral blood smear revealed the presence of Plasmodium vivax (total parasite count of 640/µl). She was negative for Human Immunodeficiency Virus (HIV), enteric fever, HbsAg and anti-HCV antibodies. On the 3 rd day of admission, she developed petechiae. An ultrasonography of the abdomen showed massive splenomegaly and moderate hepatomegaly. A repeat chest X-ray showed left-sided pleural effusion. A differential diagnosis of Congenital Dyserythropoetic Anemia (CDA) Type 2 was also considered due to severe anemia and jaundice. A bone marrow aspiration was done and it showed marked erythroid hyperplasia and megaloblastic maturation. However, the Hams test came out to be negative and CDA Type 2 was ruled out. Since platelet counts dropped further and her fever was continuous, malaria did not appear to be the sole cause. Therefore, further investigations were undertaken to look for any concurrent infections. Interestingly, the patient was found to be positive for leptospirosis (LeptoTek Dri- Dot: BioMerieux, The Netherlands and IgM capture ELISA Serion Verion, GmbH, Würzburg, Germany), dengue, (Dengue IgM capture ELISA, PanBio, Australia) and Hepatitis E virus infection (EIAgen HEV IgM kit, Adaltis). She was given ceftriaxone and her condition started improving. During her stay, she received 4, 5 and 2 units of blood, platelet rich plasma and fresh frozen plasma, respectively. On the 14 th day, she was discharged afebrile, hemodynamically stable wth normal laboratory parameters. She was unfortunately lost to follow-up.

The above-mentioned case having concurrent infections with so many agents having overlapping clinical manifestations is a challenge to the medical fraternity. Till date, only four cases of mixed infection with dengue and leptospirosis have been reported. [1],[2],[3] There are also reports of co-infection of P.falciparum with HEV [4] and leptospira with plasmodium . [5] This is the first case report of a mixed infection due to leptospirosis, dengue, malaria and Hepatitis E virus. Morbidity and mortality is quiet high in such cases. Therefore, awareness and optimal use of microbiology laboratory services can overcome such diagnostic dilemmas.

   References Top

1.Levett PN, Branch SL, Edwards CN. Detection of dengue infection in-patients investigated for leptospirosis in Barbados. Am J Trop Med Hyg 2000;62:112-4.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Rele MC, Rasal A, Despande SD, Koppikar GV, Lahiri KR. Mixed Infection due to dengue and leptospira in a patient with pyrexia. Indian J Med Microbiol 2001;19:206-7.  Back to cited text no. 2  [PUBMED]  Medknow Journal
3.Kaur H, John M. Mixed infection due to leptospira and dengue. Indian J Gastroenterol 2002;21:206.  Back to cited text no. 3  [PUBMED]  Medknow Journal
4.Ghoshal UC, Somani S, Chetri K, Akhtar P, Aggarwal R, Naik SR. Plasmodium falciparum and hepatitis E virus co-infection in fulminant hepatic failure. Indian J Gastroenterol 2001;20:111.  Back to cited text no. 4  [PUBMED]  
5.Wongsrichanalai C, Murray CK, Gray M, Miller RS, McDaniel P, Liao WJ, et al . Co-infection with malaria and leptospirosis. Am J Trop Med Hyg 2003;68:583-5.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]

Correspondence Address:
Rama Chaudhry
Department of Microbiology, All India Institute of Medical Sciences, Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0377-4929.44990

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