Fatal Dengue, Chikungunya and Leptospirosis: The Importance of Assessing Co-infections in Febrile Patients in Tropical Areas

Abstract

The febrile patient from tropical areas, in which emerging arboviruses are endemic, represents a diagnostic challenge, and potential co-infections with other pathogens (i.e., bacteria or parasites) are usually overlooked. We present a case of an elderly woman diagnosed with dengue, chikungunya and Leptospira interrogans co-infection. Study Design: Case report. An 87-year old woman from Colombia complained of upper abdominal pain, arthralgia, myalgia, hyporexia, malaise and intermittent fever accompanied with progressive jaundice. She had a medical history of chronic heart failure (Stage C, New York Heart Association, NYHA III), without documented cardiac murmurs, right bundle branch block, non-valvular atrial fibrillation, hypertension, and chronic venous disease. Her cardiac and pulmonary status quickly deteriorated after 24 h of her admission without electrocardiographic changes and she required ventilatory and vasopressor support. In the next hours the patient evolved to pulseless electrical activity and then she died. Dengue immunoglobulin M (IgM), non-structural protein 1 (NS1) enzyme-linked immunosorbent assay (ELISA), microagglutination test (MAT) for Leptospira interrogans and reverse transcription polymerase chain reaction (RT-PCR) for chikungunya, were positive. This case illustrates a multiple co-infection in a febrile patient from a tropical area of Latin America that evolved to death.

Cardiomyopathy and Death Following Chikungunya Infection: An Increasingly Common Outcome

“…Many sources reported arrythmia in general, as well as palpitations [ 15 , 46 , 53 , 76 , 77 ] ( Table 2 and Table 3 ). Additional cardiac alterations included myocardial infarct, heart failure, cardiac arrest, and myocarditis [ 14 , 26 , 29 , 30 , 41 , 43 , 44 , 53 , 61 , 67 , 74 ] ( Table 2 and Table 3 ). In children (ages 1 year to 18 years), the symptoms were similar to that in adults with tachycardia, bradycardia, hypertensive shock, myocarditis, cardiorespiratory failure, and death being reported [ 2 , 34 , 38 , 50 , 52 , 66 , 72 ] ( Table 2 and Table 3 ).…”

“…There are a number of cases in which the CHIKV infection may have aggravated a pre-existing heart condition, including hypertension, ischemic heart disease, cardiac compromise, and heart failure [ 37 , 41 , 44 , 55 , 61 , 70 , 71 , 74 , 79 , 80 ] ( Table 2 and Table 3 ). Additionally, those who are elderly, especially if they have cardiac alterations, were found to be at higher risk of death [ 81 ] ( Table 2 and Table 3 ).…”

“…Some of these patients had to be taken off their medications for hypertension in order to prevent hypotensive crisis [ 47 ]. Death can be caused by any of these conditions, risk factors for which is older age and cardiac comorbidities such as hypertension and congestive heart failure [ 29 , 31 , 43 , 47 , 70 , 74 , 86 , 96 , 97 ]. Children usually do not have comorbidities; however, in one case there was an individual with a mutation of the SCN5A gene, which is linked to cardiac sinus node dysfunction [ 84 ].…”

The diagnosis of leptospirosis complicated by pulmonary tuberculosis complemented by metagenomic next-generation sequencing: A case report

“…Cases of leptospirosis with other infectious comorbidities, such as dengue ( Wijesinghe et al., 2015 ; Paul, 2022 ), malaria ( Wilairatana et al., 2021 ), chikungunya ( Nhan et al., 2016 ; Cardona-Ospina et al., 2018 ), and scrub typhus ( Watt et al., 2003 ; Borkakoty et al., 2016 ; Vikram et al., 2020 ), have been increasingly described in tropical and subtropical regions, especially in the overlapping endemic regions. Co-occurrences of leptospirosis and tuberculosis in humans, however, are less frequently reported ( Viswanathan and Iqbal, 2015 ).…”

Spatial Distribution of Dengue in Honduras during 2016-2019 Using Geographic Information Systems (GIS) – Implications During Epidemic for Public Health and Travel Medicine

“…However, indeed, in Honduras, as in other areas of the tropical Americas, ZIKV and CHIKV also circulate with DENV, and there is overlap in their clinical features, maybe also with other arboviruses not yet detected, such as MAYV [37]. All three viruses have similar clinical presentations, and coinfections may be more common than previously known [10,11,37,[50][51][52][53], even with other endemic pathogens such as Leptospira [54]. Also, there is probably under-reporting of cases in certain areas as compared with more accurate reporting in individual municipalities.…”