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Malaysian Journal of Medical Sciences
School of Medical Sciences, Universiti Sains Malaysia
ISSN: 1394-195X
Vol. 13, Num. 1, 2006, pp. 74-75
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Malaysian Journal of Medical Sciences, Vol. 13, No. 1, January 2006,
pp.74-75
CASE REPORT
TYPHOID AND MALARIA CO-INFECTION -AN INTERESTING FINDING IN
THE INVESTIGATION OF A TROPICAL FEVER
Brian Cheong Mun Keong & Wahinuddin Sulaiman
Department of Medicine, Hospital Taiping, Jalan Taming Sari, 34000 Taiping,
Perak, Malaysia
Correspondence: Dr. Wahinuddin Sulaiman M.B.B.S (Malaya),
M.Med (Int. Med.)(USM)
Department of Medicine,
Hospital Taiping, Jalan Taming Sari,
34000 Taiping, Perak, Malaysia
Tel : 609+05-808 3333 Direct : 609+05-840 8025
Fax : 609+05-808 0930
E-mail : wahin@hotmail.com
Code Number: mj06012
In the investigation of fever in the tropics, two important diagnoses to be
ruled out are typhoid and malaria. Both cause significant morbidity, mortality
and economic loss. An estimated 17 million cases of typhoid are reported worldwide
each year, resulting in 0.6 million deaths. Seventy five to eighty percent
of these cases occur in Asia alone. Malaria affects 1 billion people each year;
out of which 1-3 million die. Although caused by very different organisms -one
a Gram negative bacilli, the other a protozoa, and transmitted via different
mechanisms -ingestion of contaminated food and water and via the bite
of an insect vector respectively, both typhoid and malaria share rather similar
symptomatology and epidemiology. Malaysia is endemic for both these diseases
and one should not be too surprised when faced with a diagnosis of co-infection
of typhoid and malaria, as have been described in India and Canada. Here we
describe one such case of Salmonella typhi and Plasmodium vivax infection.
Keywords : typhoid,
malaria, co-infection.
Introduction
Case Report
A 41-year-old Malay man, working as a
logger, presented with two weeks of fever, myalgia
and abdominal pain. He had been diagnosed and
treated for malaria 20 years ago. He remained
asymptomatic until now. He had no other history of
traveling to other malaria endemic country and not
taking any malarial chemoprophylaxis. On
examination, he was febrile with temperatures
swinging between 37°C and 39.3°C and relative
bradycardia. He was not jaundiced and neither were
any rashes noted. There was no hepatosplenomegaly.
His full blood count showed normal Hb (14.2
g/dl) and platelet count (201 x 109/l). The
white cell count, however was within normal range
(5.2 x 109/l) with neutrophil predominance. Serum
albumin was 34.9 g/l, alkaline phosphatase 178 IU/
l, aspartate transaminase 63 IU/l, alanine
transaminase 63.9 IU/l and total bilirubin 9.4 umol/
l.
Ultrasonography of the abdomen showed
hepatomegaly with a mildly echogenic parenchyma.
The spleen was at the upper limit of normal (13.8 cm). Blood cultures isolated
Salmonella typhi. The
first Widal test was not significant (T(O) 1:50 and
T(H) 1:50). The second Widal test taken nine days
later showed T(O) 1:100 and T(H) 1:200. Serial
blood smears for malaria parasites was positive for
Plasmodium vivax (160/ul blood) on the fifth smear.
He was treated with chloramphenicol 500mg
qid for 14 days and a course of chloroquine and
primaquine with uneventful recovery.
Discussion
Typhomalaria was first described by an army
doctor, J J Woodward (1833-1884) in 1862 among
young soldiers during the American Civil War who
were suffering from febrile illness that seemed to
be typhoid (including intestinal lesions found at
postmortem) but with fever patterns also suggestive
of intermittent fever. He believed that it might be a
hybrid rather than a new species of disease (1 - 3).
However, by the end of 19th century, laboratory tests
had eliminated this theory as they found that it was
either one thing or the other, or in rare instances,
co-infection with both S. typhi and the plasmodium
of malaria.
Both typhoid and malaria share social circumstances which are imperative to
their transmission. Therefore, a person living in such an environment is at
risk of contracting both these diseases, either concurrently or an acute infection
superimposed on a chronic one. A high index of suspicion is necessary to diagnose
a co-infection as most clinicians are used to linking every symptom and sign
to a single pathology.
In co-infections, the diagnosis of typhoid should be made from a culture specimen
as false positives and overestimation occur with the use of the Widal test.
Ammah et al reported that in 200 patients with fever, 17% had concurrent
malaria and typhoid fever based on bacteriological proven diagnosis as compared
to 47.9% based on the Widal test (4). This is to be expected as the Widal test
being a serological test, only proves exposure to a certain antigen. It does
not tell if an infection is recent or not. Samal et al, described 52
patients with malaria positive in the peripheral blood smear (cases consisted
of vivax, falciparum or mixed vivax and falciparum), out of whom eight cases
had a positive Widal test but blood cultures were negative for S. typhi in
all. All of the cases were cured with antimalarial therapy (5). There were
no complications attributed to these infections documented in the previous
reported cases. Nevertheless, complications may occur even if the patients
received adequate treatment. Hence, monitoring for the complications is essential
especially for travelers traveling to endemic areas.
The actual and precise underlying mechanisms to explain the association between
malaria and Salmonella species infection is still uncertain. However,
there are few postulations which may explain why malaria may predispose to
salmonella bacteremia and sepsis. It has been shown that antibody response
to O antigen of S. typhi was markedly reduced in acute episode of malaria compared
with that in controls where humoral immunity is transiently impaired (6). It
has been demonstrated in a murine model of infection with Salmonella murium that
hemolysis which occur in malaria may predispose to gram-negative organism as
what has been seen in hemolytic disease caused by sickle cell disease and bartonellosis
(7).
In the case illustrated above, the diagnosis was from a blood smear and a blood
culture, both providing objective evidence of the on-going dual infection.
Fortunately, he did not developed any complications such as hemolysis.
Although cases which had been reported were common among travelers, certain
areas in our country is still considered endemic for both malaria and typhoid
infections and our patient demonstrated that although he is not a traveler,
these co-infection may still occur. Thus, in malarial patient with persistent
fever in spite of therapy, one should consider drug resistant as well as concomitant
gramnegative infection such as typhoid fever.
References
- Bynum B. Typhomalaria. Lancet 2002; 360: 1339.
- Smith DC: The rise and fall of typhomalarial fever : I. Origins. J Hist Med
Allied Sci 1982; 37: 182-220.
- Smith DC: The rise and fall of typhomalarial fever: II. Decline and fall. J
Hist Med Allied Sci 1982; 37: 287-321.
- Ammah A, Nkujo-Akenji
T, Ndip R, Deas JE. An update on concurrent malaria and typhoid
fever in Cameroon. Trans R Soc Trop Med Hyg. 1999; 2: 127
-129.
- Samal KK, Sahu CS. Malaria and Widal reaction. J Assoc Physicians India. 1991; 10: 745-747.
- Greenwood BM, Bradley-Moore AM, Palit A, Bryceson ADM. Immunosuppression in
children with malaria. Lancet 1972; 1: 169-172.
- Kaye D, Hook EW. The influence of hemolysis or blood loss on susceptibility
to infection. J Immunol 1963; 91: 65-75.
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