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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 7  |  Issue : 2  |  Page : 63-66

Concomitant infection of typhoid and rickettsia with dengue fever in acute febrile patient


Department of Pediatrics, Kurmitola General Hospital, Dhaka Cantonment, Dhaka, Bangladesh

Date of Submission09-Feb-2022
Date of Acceptance31-Mar-2022
Date of Web Publication22-Nov-2022

Correspondence Address:
Dr. Ferdousi Hasnat
Department of Pediatrics, Kurmitola General Hospital, Dhaka Cantonment, Dhaka
Bangladesh
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/pnjb.pnjb_5_22

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  Abstract 

Rationale of the study and objectives: Dengue fever is one of the major causes of acute febrile illness. Other causes of febrile illness may be associated with dengue. This cross-sectional observational study was done to find out other coinfections such as typhoid, malaria, and rickettsia with dengue in an acute febrile patient and aimed to reduce the morbidity and mortality of patients. Materials and Methods: This study was conducted at Kurmitola General Hospital from June 2019 to November 2019. A total of 244 patients were included in this study. All patients were admitted to the hospital with fever. All investigations that aimed to diagnose the acute febrile illness were done. Results: Among 244 patients, 62.29% patients were tested positive for dengue, 26.22% for rickettsia, and 11.47% for typhoid. Dengue monoinfection was 44.26%, and coinfection was 18.03%. Malarial case was not found. The mean age of children was 6.4 years. Majority (75%) came from rural areas, and 64.75% of studied children were male. Fever, myalgia, arthralgia, and gastrointestinal symptoms such as abdominal pain, vomiting, loose motion were the main symptoms, and jaundice, hepatomegaly, and splenomegaly were the main signs both in monoinfection and coinfection. Leukopenia, thrombocytopenia, raised serum alanine transaminase, and elevated hematocrit were found in monoinfection as well as in coinfection. Conclusion: Symptoms of monoinfection and coinfection were overlapping, but treatment was rather different and difficult. So for proper treatment, early detection was necessary for reducing death rate and complication in acute febrile illness.

Keywords: Acute febrile illness, coinfection, monoinfection


How to cite this article:
Hasnat F, Shoma F, Mehnaj S, Farzana S, Nurullah M, Anne RT. Concomitant infection of typhoid and rickettsia with dengue fever in acute febrile patient. Paediatr Nephrol J Bangladesh 2022;7:63-6

How to cite this URL:
Hasnat F, Shoma F, Mehnaj S, Farzana S, Nurullah M, Anne RT. Concomitant infection of typhoid and rickettsia with dengue fever in acute febrile patient. Paediatr Nephrol J Bangladesh [serial online] 2022 [cited 2022 Dec 3];7:63-6. Available from: http://www.pnjb-online.org/text.asp?2022/7/2/63/361620




  Introduction Top


Acute febrile illness is a ubiquitous problem among hospital-admitted patients. Infections may be the main cause of acute febrile illness in tropical countries.[1] Dengue fever, rickettsial fever, typhoid fever, malaria, urinary tract infection, and respiratory tract infections are the main causes of acute febrile illness. Children with coinfection may cause difficulty in the diagnosis of acute febrile illness. Coinfection is the simultaneous infection of a host by multiple pathogen.[2] Children with coinfection present with atypical or serious manifestations may cause a delay in diagnosis and a bad prognosis.[2] Because of common causes of acute febrile illness during outbreak, it causes a significant delay in making diagnosis, where the suspicion of other diseases is very low.[3] There is no study describing overall coinfections associated with dengue during an outbreak.[3] Coinfection of dengue fever with chikungunya, malaria, and other arboviruses has been frequently reported from endemic areas.[4],[5] Coinfection of typhoid fever has been documented with various enteric viruses.[6]

In tropical countries, because of seasonal variation, there is a chance of coinfection of host by dengue with other infectious disease such as rickettsia, malaria, and typhoid.[1]

Virus transmitted by Aedes aegypti and H1N1 virus is responsible for dengue fever and has four serotypes. Dengue fever shows mild clinical symptoms to life-threatening dengue hemorrhagic fever or dengue shock syndrome.[1]

Rickettsial infections are caused by bacteria of rickettsia family. These are a heterogeneous group of small obligately, intracellular, gram-negative coccobacilli and short bacilli.[1] They are transmitted to humans by arthropods such as fleas, mites, and lice.[7] Rickettsial diseases include different types of typhus; those are scrub typhus, murine typhus, and epidemic typhus.[8]

Enteric fever is a systemic disease that includes typhoid and paratyphoid, which is due to Salmonella typhi or Paratyphi A, B.[9] They are transmitted to human through feco-oral route. These organisms are gram-negative bacilli. They are endemic in nature. Poor disposal of human excreta, poor sanitation, poor hand washing, and taking impure drinking water are the main causes of transmission of typhoid fever in developing countries.[10],[11]

Malaria is another cause of febrile illness and also a fatal disease in the world. It is a protozoan parasitic infection caused by plasmodium. It is transmitted by Anopheles mosquito.[1] Plasmodium falciparum, plasmodium vivax, plasmodium ovale, and plasmodium malariae are the species of plasmodium who are responsible for malaria.[12]

During dengue season, dengue, typhoid fever, malaria, and rickettsial fever may have a diagnostic problem in acute febrile illness, because all diseases have similar clinical pattern.[1] Besides coinfection of dengue with typhoid or dengue with rickettsia can observe in a same patient and physician faced a new challenge. The treatment of single infection and coinfection are not the same. This study was aimed to see the association of typhoid, malaria, and rickettsia with dengue in acute febrile patient.


  Materials and Methods Top


This study is a cross-sectional observational study, which was conducted at Kurmitola General Hospital from June 2019 to November 2019. A total of 244 patients were enrolled in the study. Inclusion criteria were (1) patients of age group D1–15 years with documented fever of 38°C or more, (2) duration of fever for 2–7 days reported in the hospital, and (3) all seropositive cases of dengue fever and with coinfection. Detailed history was taken from patient’s guardians. After through physical examination, laboratory tests were done. Dengue was diagnosed by serology with nonstructural protein 1 antigen and immunoglobulin (Ig) M antibody capture enzyme-linked immunosorbent assay test. Rickettsial fever was diagnosed by Weil–Felix test (a four-fold rise in the agglutinin titers or a single-titer dilution more than 1:320 was considered significant). Serodiagnosis of typhoid was by Widal test (single acute-phase sample with O > 1:160). Malaria was diagnosed with thick and thin film and immuno chromatographic test. All seropositive cases of dengue and with coinfection were considered for the study. Blood for complete blood count, blood culture sensitivity, urine routine examination and c/s, and chest x-ray were also done. All investigations were done at Armed Forces Institute of Pathology (AFIP) and pathology of Kurmitola General Hospital. We took written consent from the local authority before data collection. Statistical analysis was done by Statistical Package for the Social Science (SPSS) software program version 26.0.


  Results Top


A total of 244 patients were included in the study. The distribution of patients according to pattern of investigations was showed in [Table 1]. Among all, a total of 62.29% patients tested positive for dengue, rickettsial fever positive for 26.22% patients, and typhoid fever was positive for 11.47% patients [Table 2]. Dengue monoinfection was 44.26%, and dengue with coinfection was present in 18.03% (dengue with typhoid was 7.37% and dengue with rickettsia was 10.66%, which is showed in [Figure 1]). About 64.75% of the study population was male, and 35.25% was female. The mean age of the children was 6.4 years; out of them, 37.70% were 0–5 years, 45.08% were 5–10 years, and 17.21% were 10–15 years. A majority (75%) of children were from rural area.
Table 1: Distribution of patient according to the pattern of investigations

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Table 2: Percentage of monoinfection and coinfection

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Figure 1: Percentage of monoinfection and coinfection

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[Table 3] shows all patients with dengue monoinfection came with fever; other symptoms include myalgia (73.14%), arthralgia (61.12%), abdominal pain (29.62%), vomiting (58.33%), loose motion (52.77%), headache (44.45%), cough (8.34%), chest pain (7.4%), and bleeding manifestation (7.4%). Hypotension (52.77%), shock (34.25%), and thrombocytopenia (68.52%) were prominent in monoinfection [Table 4].
Table 3: Symptoms of all patients with dengue monoinfection and dengue coinfection with rickettsia and typhoid

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Table 4: Sign of dengue monoinfection and dengue coinfection with rickettsia and typhoid

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[Table 3] shows coinfection with rickettsia compared with monoinfection had the same-type illness such as myalgia (69.23%), arthralgia (61.53%), rash (50%), abdominal pain (26.92%), vomiting (34.61%), loose motion (23.07%), headache (19.23%), chest pain (11.53%), cough (11.53%), and bleeding manifestation (7.69%). Hepatomegaly (61.53%), splenomegaly (50%), and jaundice (57.69%) were seen more in this group [Table 4].

Concurrent infection of dengue with typhoid mainly presented with gastrointestinal symptoms such as pain in abdomen (62.5%), vomiting (75%), and loose motion (68.75%). Bradycardia (75%) was the prominent feature in this group [Table 3] and [Table 4].

[Table 5] shows laboratory findings: thrombocytopenia (53.84%) was seen in dengue with rickettsial infection, 68.52% in dengue monoinfection and 27.78% in typhoid coinfection. Serum glutamic pyruvic transaminase level was seen (76.9%) in rickettsial coinfection, 66.67% in typhoid coinfection and 40.74% in monoinfection. Electrolyte imbalance (33.34%) was seen in coinfection with typhoid and 9.25% in monoinfection. Hypoalbuminemia and increased hematocrit were seen (15.38% and 12.96%) in coinfection and (26.92% and 57.40%) were also seen in dengue monoinfection [Table 5].
Table 5: Laboratory finding of dengue monoinfection and dengue coinfection with rickettsia and typhoid

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  Discussion Top


In South-East Asia, dengue fever is endemic in many areas. Coinfection with different organisms in the same patient is not so common in developing countries.[1] Malaria was not found in this study, so it was excluded from results and discussion.

In our study, a total of 44 patients showed coinfection; out of this, 26 patients were diagnosed with dengue with rickettsia and 18 patients were diagnosed with dengue with typhoid; similar results were seen in Kamath et al.[13] and Basheer et al.[14] In this study, a male preponderance was observed, which was similar with Kamath et al.[13] Most of the patients of this study came from rural area (75%), which is similar with a study by Kamath et al.[1]

In this study, all patients with dengue mono and coinfections had fever, which was seen in Kamath et al. and Saleem et al.[13],[15] Fever, myalgia, arthralgia, abdominal pain, vomiting, and loose motion were seen in our study, which were also seen in other studies.[13],[14] Though rash is the characteristic feature of rickettsial infection, in this study, rash was seen only in 50%, which was similar with a study by Kamath et al.[1] Hepatomegaly (61.53%), jaundice (57.69%), splenomegaly (50%), and elevated transaminase (76.9%) were seen in rickettsial coinfection of this study; similarly, hepatomegaly and elevated transaminase were narrated by Kamath et al. and Saleem et al.[13],[15] Thrombocytopenia was also prominent both in dengue monoinfection (68.52%) and in rickettsial coinfection (53.84%) in this study, and thrombocytopenia was seen in different studies.[15],[16] Increased hematocrit (26.92%) and hypoalbuminemia (15.38%) in rickettsial coinfection were seen in this study, and different studies of coinfections showed hypoproteinemia.[13],[14],[17]

In monsoon season, stagnant water is breeding place for Aedes mosquito and improper sanitation is one of the causes of typhoid fever and may cause enhanced coinfection. In dengue infection, some inflammatory and hemodynamic changes occur and that lead to invasive[18] salmonella infection. Abdominal pain (62.5%), loose stool (68.75%), vomiting (75%), and bradycardia (75%) were the main symptoms of dengue with typhoid coinfection in this study, which is consistent with other study by Kamath et al.[1] Jaundice (18.75%), hepatomegaly (43.75%), electrolyte imbalance(33.34%), and increased serum alanine transaminase (66.67%) were seen in dengue with typhoid coinfection of this study, but different studies Sharma et al.[18] and Ramya and Sunitha[19] showed 60% patient had jaundice and 68% patient had elevated serum alanine transaminase in dengue with typhoid coinfection.

Limitations of the study

Serotyping of dengue was not performed. Speciation of rickettsial infection was not done. All children those were diagnosed as typhoid fever are not confirmed by culture sensitivity, but by Widal test.


  Conclusion Top


In tropical countries, sometimes coinfection may observe. Sometimes many clinical features of acute febrile illness superimposed, and it is tough for a clinician to find out exact diagnosis. So in acute febrile illness, it is necessary to monitor investigations of coinfections for relevant treatment and decrease complication and death due to coinfection.

Financial support and sponsorship

Nil.

Conflicts of interest

There were no conflicts of interest.



 
  References Top

1.
Kamath V, Ganguly S, Avinash BL A comparative study of concurrent infections of rickettsial infection, malaria, typhoid, and chikungunya with dengue. APIK J Int Med 2019;7:120-6.  Back to cited text no. 1
    
2.
Uzzal KG, Azmeri S, Nobo KG, Kazi I, Morsheda K, Madhabi B Pattern of co-infection with dengue fever: An observational study. Bangladesh J Child Health 2020;44:157-60.  Back to cited text no. 2
    
3.
Prasan KP, Srikant M, Naveet W, Manish S Dengue co-infections—An emerging entity during the outbreak. J Clin Diagn Res 2018;12:OR01-4.  Back to cited text no. 3
    
4.
Vaddadi S, Vamsi K, Raju CHN, Teja PS, Usha V A rare case of triple infection with dengue, malaria, and typhoid: A case report. Int J Res Dev Health 2013;1:200-3.  Back to cited text no. 4
    
5.
Bhalla A, Sharma N, Sharma A, Suri V Concurrent infection with dengue and malaria. Indian J Med Sci 2006;60:330-1.  Back to cited text no. 5
    
6.
Basuki PS Concurrent dengue infection and enteric fever. A case series. Semanticscholar.org 2003;39:54-60.  Back to cited text no. 6
    
7.
Vishal D, Prabhdeep K, Manoj VM Rickettsial disease outbreaks in India: A review. Ann Trop Med Public Health 2014;7:249-54.  Back to cited text no. 7
    
8.
Robin GM Typh fevers: A combination of typhoid and typhus. Asian J Med Sci 2017;8:40-1.  Back to cited text no. 8
    
9.
Stephen JD, Megan ER Spotted fever group rickettsioses. In: St Geme K, Blum S, Tasker W, editors. Nelson Textbook of Paediatrics. 21st ed. Philadelphia, PA: Elsevierhealth.com; 2020. p. 1619-30.  Back to cited text no. 9
    
10.
Malisa HN Prevalence and constraints of typhoid fever and its control in an endemic area of Singida region in Tanzania: Lessons for effective control of the disease. J Public Health Epidemiol 2010;5:93-9.  Back to cited text no. 10
    
11.
Buckle GC, Fischer W CL, Robert EB Typhoid fever and paratyphoid fever: Systematic review to estimate global morbidity and mortality for 2010. J. Glob Health 2012;2:1-9.  Back to cited text no. 11
    
12.
Meseret B, Belay T, Getachew F, Mengistu E, Bamlaku EM Typhoid fever, and their coinfection among febrile patients at a rural health center in Northwest Ethiopia: A cross-sectional study. Adv Med 2014;2014:1-8.  Back to cited text no. 12
    
13.
Kamath V, Ganguly S, Bhatia JK Rickettsial infections: Spreading beyond boundaries. In: Narsimalu G, editor. Progress in Medicine. Mumbai: Jaypee; 2019. p. 195-9.  Back to cited text no. 13
    
14.
Basheer A, Iqbal N, Mookkappan S, Anitha P, Nair S, Kanungo R, et al. Clinical and laboratory characteristics of dengue-orientia tsutsugamushi co-infection from a tertiary care center in South India. Mediterr J Hematol Infect Dis 2016;8:e2016028.  Back to cited text no. 14
    
15.
Saleem M, Gopal R, Shivekar SS, Mangaiyarkarasi T Scrub typhus & dengue co-infection among patients attending a tertiary care hospital at Puducherry. Indian J Microbiol Res 2016; 3:149.  Back to cited text no. 15
    
16.
Sapkota S, Bhandari S, Sapkota S, Hamal R Dengue and scrub typhus coinfection in a patient presenting with febrile illness. Case Rep Infect Dis 2017;2017:6214083.  Back to cited text no. 16
    
17.
Garg A, Jain A, Kashyap R Travel-acquired scrub typhus infection masked by dengue fever in a patient from nonendemic area. J Glob Infect Dis 2018;10:114-5.  Back to cited text no. 17
    
18.
Sharma Y, Arya V, Jain S, Kumar M, Deka L, Mathur A Dengue and typhoid co-infection study from a government hospital in North Delhi. J Clin Diagn Res 2014;8:DC09-11.  Back to cited text no. 18
    
19.
Ramya TG, Sunitha BR Enteric fever cases showing concurrent seropositivity with dengue and malaria: A sero-diagnostic challenge. Microbiol Res 2018;8:69-72.  Back to cited text no. 19
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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