A Case Series on Early Virological Clearance in Malaria-COVID-19 Co-infection
Ketaki Utpat
Published Date: Apr 26, 2021
A Case Series on Early Virological Clearance in Malaria-COVID-19 Co-infection
Parikshit Thakare1, Sandeep Sharma1, Abhishek Gupta1, Neha Lilare1, Ketaki Utpat1, Unnati Desai1, Joshi JM1, Bharmal RN2
1Department of Pulmonary Medicine, Topiwala National Medical College & B. Y. L. Nair Charitable Hospital, Mumbai, India
2Dean, Topiwala National Medical College & B. Y. L. Nair Charitable Hospital, Mumbai, India
Corresponding author: Ketaki Utpat, Department of Pulmonary Medicine, Topiwala National Medical College & B. Y. L. Nair Charitable Hospital, Mumbai, India.
Abstract
Malaria is a very rampant monsoon-related illness in an endemic country for such diseases as India. COVID-19 pandemic has started to spread rapidly across the country over the last 3-4 months. On this background, COVID-19 and malaria coinfection becomes a challenging predicament to handle for clinicians. We, therefore, analysed series of cases on the same to study the properties of this coinfection. The COVID-19 patients with a history of fever were subjected to malaria fever testing along with dengue and leptospirosis. Those cases positive for Malaria are treated as per standard malaria treatment protocol, and the results were speculated. We observed that these cases showed dramatic early response for the COVID-19 virological clearance within 7-8 days pertaining to likely anti-viral activity of anti-malarial drugs like Artesunate.
Keywords: malaria, Artesunate, COVID-19
Introduction
A novel coronavirus, designated as 2019-nCoV, emerged in Wuhan, China, at the end of 2019. Soon after that, it rapidly spread across the whole world and affected more than 150 countries in a short time. The virus that causes COVID -19 was initially called 2019-nCoV and was then termed as syndrome coronavirus 2 (SARS-CoV-2) by the International Committee on Taxonomy of Viruses (ICTV) [1]. The coronavirus disease was declared a pandemic on March 11, 2020, by the World Health Organisation (W.H.O.) [2]. The COVID-19 spread rapidly across India since mid-March 2020. Simultaneously the monsoon-related illnesses like malaria, dengue, and leptospirosis began to creep up with the advent of monsoons. These monsoon-related illnesses and COVID-19 share significant overlap with respect to symptoms like fever, myalgia, and frequent respiratory symptoms. We report a case series of five COVID-19 patients presenting with high-grade fever found to be Plasmodium Vivax Malaria coinfection and managed with standard P.vivax malaria treatment with rapid and early virological clearance for the COVID-19.
Case series
Our study population for the case series included five cases presenting to our institute, a dedicated tertiary care COVID hospital. All five cases were reported during the monsoon-related illness season between the end of May to mid-July month. All the five COVID cases were diagnosed based on Nasopharyngeal swab testing using the RT-PCR method and hospitalized for the isolation facility at our dedicated tertiary care hospital in Mumbai. Out of the 5 cases, 4 were males, and one was female, predominantly of the younger age group of the third decade. Out of 5 cases, case no.4 & case no.5 had co-morbidity of diabetes mellitus [Table 1]. All the cases were having high-grade fever. Case numbers 2 and 5 had fever with chills. Some of the cases had mild symptoms like headaches, sore throat, cough, myalgia, and fever.
Table 1. Demographic, clinicoradiological and microbiological traits of all five cases Case No. Case 1 Case 2 Case 3 Case 4 Case 5 Age 26 22 42 53 29 Sex M M F M M Predominant symptom Fever Fever with chills Fever Fever Fever with chills Chest Xray Normal Normal Normal Normal Normal HRCT thorax WNL WNL - - - Co-morbidities None None None Diabetes Mellitus Diabetes Mellitus Haemoglobin (gm/dl) 14 14.7 11.6 14 12.8 TLC (per mm3) 3,100 4,900 6,100 5,000 5,800 Platelet counts (per mm3) 1,14,000 89,000 1,38,000 2,34,000 1,94,000 Swab Positive Date 06.07.20 17.06.20 03.07.20 04.07.20 23.05.20 Swab Negative date 13.07.20 24.06.20 09.07.20 09.07.20 28.05.20 No. of days for swab conversion 7 7 6 5 5
After hospitalization, all the cases were evaluated with blood investigations like complete hemogram, liver function, and renal function test and radiology like Chest roentgenogram (CXR). Case no.1 was already pre-evaluated with computed tomography (CT) of thorax before hospitalization showing normal findings. Case no.2 was later subjected to CT thorax given complaints of shortness of breath. It showed normal lung findings. The primary blood parameters were normal for all cases except case no.2 showed thrombocytopenia of 89,000/mm3. None of the cases had any radiological findings.
All cases with a fever profile were evaluated because of fever symptoms, including rapid malaria antigen diagnostic test, leptospira IgM test, dengue NS1 antigen, and dengue IgM/IgG testing by immunochromatography method at a serology laboratory of the hospital. All the cases were positive for Plasmodium vivax malaria. All the cases were started on a standard COVID-19 treatment protocol with tablet Doxycycline 100 mg orally twice a day along with tablet ivermectin 12 mg stat dose along with Vitamin C 500 mg thrice a day and zinc supplement of 50 mg twice a day. All the cases were managed on parenteral artesunate 120 mg BD on day 1, followed by 120 mg OD for the next four days, along with injectable ceftriaxone 1 gm BD for five days. All the cases were subjected to G6PD levels testing and later on started on Primaquine treatment after artesunate therapy to prevent relapse of malaria at a dose of 0.25 mg/kg for 14 days
All the cases were subjected to nasopharyngeal swab RT-PCR testing after four days from 1st swab report and repeated thereafter every alternate day. All the 5 cases showed early virological clearance, with case no. 4 & 5 showed clearance in 5 days, and case no.3 showed clearance in 6 days, and case 1 & case 2 showed swab negativity on the 7th day.
Discussion
The COVID-19 pandemic has affected more than 180 nations over a brief period of time and has caused a global health crisis. The COVID-19 has a variable presentation from the asymptomatic presentation or upper respiratory tract infection to pneumonia and respiratory failure. According to the Centers for Disease Control and Prevention (CDC), the main symptoms of COVID-19 symptoms can be very mild to severe and include a fever, cough, and shortness of breath. Symptoms may appear two to 14 days after exposure. Current information suggests that the virus can cause mild, flu-like symptoms and more severe disease. Most patients seem to have mild disease, and about 20% appear to progress to more severe diseases, including pneumonia, respiratory failure, and, in some cases, death [1,2].
In our case series, fever was the predominant symptom reported by all 5 cases. In studies by Huang et al. [3] and Wang et al. [4], fever was reported as the most common symptom in COVID-19 infection. It is very necessary and important to note that many symptoms of COVID-19 such as fever, myalgia, and headache are similar to the co-infections which may occur simultaneously with COVID-19. It is essential to take certain measures in patients with overlapping symptoms to identify such cases and treat them simultaneously. A recent study concluded that the prevalence of secondary infections with COVID-19 amongst non-survivors might be as high as 50 % [5]. Co-infections in COVID-19 are relatively unexplored, with recently emerging data reporting concomitant infections with influenza [6–11], varicella-zoster [12,13], and respiratory syncytial virus (RSV) [14].
Co-infection with monsoon-related illnesses like malaria, dengue, leptospirosis is of paramount clinical importance during the rainy season in the endemic region like India as the pandemic continues to spread. The endemic diseases share common symptoms like fever, myalgia, headache with COVID-19 infections. Thus, it is important to remain vigilant about these presenting symptoms and rule out these diseases and COVID-19 during the rainy season. Owing to similar clinical presentations, dual infections of dengue and COVID-19 have surfaced [15]. Malaria and COVID-19 co-infection as reported in our study, could lead to excessive pro-inflammatory response leading to severe manifestations.
All the five reported cases have been treated with Artemisinin’s derivative like Artesunate, showing dramatic and early clinical improvement for malaria and rapid virological clearance for COVID-19. Artemisinin derivatives such as Artesunate have attracted attention in the treatment of COVID-19 due to their antiviral and anti-inflammatory properties, likely attributed to inhibition of Nuclear Factor kappa B (NF-kB) downregulation and consequent disruption of viral replication in the early phase [16]. Artesunate has already reported its broad spectrum of antiviral activity against hepatitis B viruses, human cytomegaloviruses, herpes simplex viruses, human immunodeficiency viruses, Epstein Barr Viruses. The treatment regimen for the COVID-19 pandemic yet remains undefined, with a myriad of clinical trials exploring the role of various pharmacological agents as a possible cure for the virus. Whether Artesunate agents offered protective effects from respiratory deterioration or multi-organ involvement despite SARS-CoV-2 infection is unclear and should be further explored as this agent was successful in early virological clearance for COVID-19 infection.
Conclusion
Our case series highlighted the importance of identifying co-infection of monsoon-related illnesses like malaria in concurrence with COVID-19 infection, which may be otherwise overlooked during the pandemic scenario. Our cases treated with Artesunate successfully recovered and showed early virological clearance within a week. Additional studies and trials are required to explore the possible antiviral activity of Artesunate.
References
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Article type: Case Series
Publication History
Received: March 21, 2021
Accepted: April 19, 2021
Published: April 26, 2021
Copyright ©2021 Thakare P. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation: Thakare P, Sharma S, Gupta A, Lilare N, Utpat K, et al. A Case Series on Early Virological Clearance in Malaria-COVID-19 Co-infection. Int Clin Case Rep 2021; 1(1): 1-3
Corresponding Author
Ketaki Utpat
Ketaki Utpat Department of Pulmonary Medicine, Topiwala National Medical College & B. Y. L. Nair Charitable Hospital, Mumbai, India.
Table 1. Demographic, clinicoradiological and microbiological traits of all five cases
Case No. |
Case 1 |
Case 2 |
Case 3 |
Case 4 |
Case 5 |
Age |
26 |
22 |
42 |
53 |
29 |
Sex |
M |
M |
F |
M |
M |
Predominant symptom |
Fever |
Fever with chills |
Fever |
Fever |
Fever with chills |
Chest Xray |
Normal |
Normal |
Normal |
Normal |
Normal |
HRCT thorax |
WNL |
WNL |
- |
- |
- |
Co-morbidities |
None |
None |
None |
Diabetes Mellitus |
Diabetes Mellitus |
Haemoglobin (gm/dl) |
14 |
14.7 |
11.6 |
14 |
12.8 |
TLC (per mm3) |
3,100 |
4,900 |
6,100 |
5,000 |
5,800 |
Platelet counts (per mm3) |
1,14,000 |
89,000 |
1,38,000 |
2,34,000 |
1,94,000 |
Swab Positive Date |
06.07.20 |
17.06.20 |
03.07.20 |
04.07.20 |
23.05.20 |
Swab Negative date |
13.07.20 |
24.06.20 |
09.07.20 |
09.07.20 |
28.05.20 |
No. of days for swab conversion |
7 |
7 |
6 |
5 |
5 |