A Mixed Malaria and Mycoplasma Co-Infection in a Sri Lankan Patient: A Case Report

Case Report

J Bacteriol Mycol. 2018; 5(1): 1062.

A Mixed Malaria and Mycoplasma Co-Infection in a Sri Lankan Patient: A Case Report

Palangasinghe DR*1, Kodithuwakku G2, Dahanayaka N3, Dissanayake A3 and Yahathugoda C4

¹Senior Registrar in Medicine, University Medical Unit, Teaching Hospital Karapitiya, Sri Lanka

²Registrar in medicine, University Medical Unit, Teaching Hospital Karapitiya, Galle, Sri Lanka

³Department of Medicine, Senior Lecturer in Medicine, Faculty of Medicine, University of Ruhuna, Sri Lanka

4Department of Parasitology, Professor in Parasitology, University of Ruhuna, Sri Lanka

*Corresponding author: Palangasinghe DR, Senior Registrar in Medicine, University Medical Unit, Teaching Hospital Karapitiya, Sri Lanka

Received: February 06, 2018; Accepted: February 21, 2018; Published: February 28, 2018


Background: Although last indigenous case of malaria in 2012 and achievement of malaria free status since 2016; there were few imported cases throughout last five years. Therefore it is important to suspect malaria in a patient with a febrile illness with recent history of travel to malarial areas. Delay in diagnosing can end up in severe malaria which has a high morbidity and mortality. Complex inter-relationship between mycoplasma and plasmodium species were reported in vitro. We report the first case of malaria mixed species infection with mycoplasma pneumoniae co-infection.

Case Presentation: A 45 year old gem businessman from Southern Sri Lanka came with 16 days of high fever with chills and rigors, dry cough and dyspnea after returning recently from India. Patient did not receive malaria chemoprophylaxis before or during a one month stay in India. On examination he was ill and had hepatomegaly. With dry cough and dyspnea he had alveolar nodular shadows in the right middle zone of chest radiograph with a significantly high mycoplasma pneumonia antibody titre for which he was commenced on oral clarithromycin treatment. With persistent fever with chills and rigors while on clarithromycin treatment for 2 days, carefully examined blood films revealed Plasmodium falciparum, vivax and ovale parasites. Antigen tests and Polymerase Chain Reaction (PCR) tests confirmed the mixed Plasmodium species infection. Hewas continued on oral Clarythromycin, together with Artemether-Lumefantrine combination therapy followed by primaquine. He became fever free from day 2 of treatment with artemether and lumafantrine combination while plasmodium parasitaemia and antigenemia disappeared from blood after 2 days of antimalarial treatment. He was apparently well at 2 weeks review without fever, cough or dyspnea and repeat chest radiograph showed resolution of alveolar nodular shadows on right middle zone.

Conclusions: Even in a malaria eradicated country it is important suspect malaria in a traveller returning from an endemic area for prompt diagnosis and treatment. Mycoplasma pneumonia could be a co infection which might alter the clinical presentation in a patient with malaria.

Keywords: Malaria Mixed Infection; Mycoplasma; Co Infection; Sri Lanka


Malaria was once a common infection in Sri Lanka where the country had to suffer several out brakes that had claimed many lives in the 19th century [1,2]. In last decade malaria was in a steady decline and last indigenous case was reported in 2012 [1]. World health organization has declared the country as malaria eradicated since 2016 [1]. But still several imported cases of malaria were reported in Sri Lanka from travellers returning from countries like India, Pakistan, Haiti and Africa. Out of them several patients developed severe malaria due to delayed diagnosis [1]. Early identification of imported cases of malaria is of paramount importance to avoid re introduction of the infection to Sri Lankan community. Severe malaria has a high morbidity and mortality which could be minimized by early identification and treatment.

Presence of other infections with malaria may alter the clinical presentation and poses a challenge to diagnosis as well as treatment [7,8,9]. Mycoplasma is a common respiratory pathogen that can cause a wide spectrum of disease manifestations; the most common being upper respiratory tract infections [12]. Mycoplasma is well known to contaminate cell cultures of plasmodium species, posing a great challenge to researchers and microbiologists [3,4]. Co-existence and clinical implications of malaria and mycoplasma infections are yet to be evaluated. We encountered one previous reported case of falciparum malaria and mycoplasma co-infection in the literature [5].

We report the first case a case of malaria infection caused by 3 Plasmodium species (P. falciparum, P. ovale and P. vivax) with a Mycoplasma pneumoniae co-infection. Even though there were case reports of imported malaria cases to Sri Lanka since 2012, this is the 1st triple infection identified.

Case Presentation

A 45 year old gem businessman from Galle district (Southern Province, Sri Lanka) presented on 01.09.2017 with fever and dry cough for 16 days. The fever was associated with chills and rigors.

He had type 2 diabetes mellitus with a satisfactory glycaemic control while on Gliclazide 80mg twice daily. He developed fever, 2 days after returning from India where he went on a business tour for one month. He stayed in Kolkata during that month (from 14.07.2017 to 15.08.2017) and he came back to Sri Lanka through Madras where he stayed one night. During the stay in India he had numerous mosquito bites and he had not taken chemoprophylaxis for malaria. The last time he visited India was 10 years back where he did not have any febrile illnesses. During the current febrile illness, he was seen by several doctors on 3 outpatient visits where he was treated with oral antibiotics (with amoxicillin on one occasion and with amoxicillin and clavulinic acid combination on another occasion), antipyeretics and bronchodilators without improvement of his symptoms. From the 10th day of illness he was developed shortness of breath but he did not have orthropnea or paroxysmal nocturnal dyspnea.

He had fever daily during this period with fever spikes appearing around 7pm associating with chills and rigors. The temperature was recorded in the range of 103-104 F. On examination he was pale and was not icteric. He was looking ill during height of fever with tachypnea and tachycardia. The throat was inflamed with no pustules and there were no palpably enlarged lymph nodes or rashes. He was alert with no signs of meningeal irritation. There was hepatomegaly, with a non tender diffusely enlarged liver which was palpable 6cm below the right costal margin and there was no surface nodularity or bruits over it. There was no splenomegaly. No free fluid or ballotable masses were noted. His cardiovascular, respiratory and nervous system examinations were unremarkable.

Investigations on admission (day 17 of illness) revealed Hemoglobin of 10g/dL with a hematocrit of 30, Mean Corpuscular Volume (MCV) was 72fL, White Cell Count (WBC) of 11110/uL with neutrophils and lymphocytes being59% and 28% respectively. He was thrombocytopenic with a platelet count of 67000/uL. He had a high C-reactive protein (CRP) value of 75mg/dL and Erythrocyte Sedimentation Rate (ESR) was 60mm in 1st hour. Urine analysis was normal and there was no bacterial growth in urine culture. Liver functions revealed an Aspartate Transaminase (AST) 28IU/L, Alanine Transaminase (ALT) 48IU/L, Alkaline Phosphatase (ALP) 337IU/L and Gammaglutamyltransferase (GGT) 314IU/L. His total Bilirubin level was17umol/L and direct bilirubin level was 10umol/L. He had a serum total protein concentration of 53g/dL and serum albumin level of 35g/dL. His renal functions were normal throughout with a Serum creatinine of 75umol/L and blood urea of 25mg/ dL on admission. Ultrasound scan (USS) of the abdomen revealed hepatomegaly, but no splenomegaly or bile duct dilatation. Chest radiograph revealed right middle zone alveolar nodular shadows. He was commenced on oral clarithromycin 500mg twice daily on day 1 of admission (day 17 of illness) after taking blood for culture and mycoplasma antibodies which became positive at a titre of 1: 320. A blood film was analyzed on 2nd day of admission was reported as neutrophil leukocytosis with features of coexisting iron deficiency anemia (hypochromic microcytic cells and pencil shaped cells). Although cough has improved he continued to have high fever with chills and rigors despite 3 days of treatment with clarithromycin with persistent shortness of breath. Arterial blood gas analysis performed on day 3 of admission showed following. PH 7.44, PaO2 69mmHg, PCO2 24mmHg and HCO3- 17mmol/L, Lactate level was 2.4mmol/L. Electrocardiogram was normal apart from sinus tachycardia with a heart rate of 108/min. Due to high suspicion of malaria a repeat blood film with Giemsa stain was sent on day 3 of admission (day 19 of illness) to be seen by a professor of parasitology who detected falciparum ring forms, gametocytes and trophozoites of Plasmodium vivax and Plasmodium ovale (Figure 1). A rapid diagnostic test (RDT) to detect the falciparum antigen and polymerase chain reaction (PCR) to detect Plasmodium falciparum and Plasmodium vivax were positive. He was commenced on oral artimisnin based combination therapy (artemether 80mg and lumafantrine 480mg twice daily) followed by primaquine 15mg daily. He responded to treatment with resolution of fever from day 4 of admission (day 2 of artimisnin based combination therapy). We continued artemether 80mg with lumafantrine 480mg twice daily for 2 consecutive days followed by artemether 40mg and lumafantrine 240mg twice daily for one day. After 3 days of artimisnin based combination therapy (ACT) he was discharged from hospital where primaquine 15mg daily was given for 14 days. Oral clarithromycin 500mg twice daily was continued for 10 days. He had blood glucose ranging from 130mg/dL to 160mg/ dL during the hospital stay. Blood films were monitored from day two of treatment which showed clearance of parasitaemia and repeat RDT for falciparum antigen became negative from day 2 of ACT. At two week’s review after discharge he was well with no fever or constitutional symptoms. Repeat mycoplasma antibody titre 2 weeks later was 1: 1280. Repeat chest radiograph at two weeks showed resolution of previous alveolar nodular shadows on right middle zone. There was gradual resolution of ALP and GGT levels with levels becoming normal after one month. Size of the liver found to be normal in the ultrasound scan performed one month later.

Citation: Palangasinghe DR, Kodithuwakku G, Dahanayaka N, Dissanayake A and Yahathugoda C. A Mixed Malaria and Mycoplasma Co-Infection in a Sri Lankan Patient: A Case Report. J Bacteriol Mycol. 2018; 5(1): 1062.