Malaria as a tropical disease is of significant public health problem worldwide with an estimated 3.2 billion people at risk and with ongoing malaria transmission in 91 countries. In Nepal, southern plains which has border with India are endemic for malaria with majority of the cases due to Plasmodium vivax [3]. Although, there has been a significant improvement towards achieving malaria elimination in Nepal, still significant number of cases is annually recognized. A major problem which is noted is the significant co-infection of malaria with other diseases that has not been addressed and programmes not tailored to curtail such cases [4].
Another tropical disease of much concern in South Asia with significant morbidity and mortality is Leishmaniasis. The southern belt (Terai region) of Nepal is also endemic for visceral Leishmaniasis. Major control programmes are concentrated in these regions. However, there has been a geographical variation in cases of Leishmaniasis recently. Few cases are even noted in Hilly regions of Nepal [1]. Moreover, studies have demonstrated that cutaneous Leishmaniasis is an under recognized presentation of Leishmaniasis with significant cases noted in individuals inhabiting in the Terai belt as well as hilly region [5, 6].
Malaria and visceral Leishmaniasis co-infection are noted in certain African studies constituting almost 4.1% in endemic regions. There is dearth of literature of cases of co-infection in Nepal [2]. Certain studies have demonstrated co-infection prevalence rate ranging from 3.8 to 60.8% [7]. Our case was a child who was treated locally for on and off fever and demonstrated co-infection for P. vivax and Leishmaniasis. In our case, splenomegaly was present with no evidence of infarction on ultrasound. Few cases of co-infection have been reported with splenic infarction [8]. Our case is unique with presence of pancytopenia which although sometimes noted with P. falciparum infection is a rare presentation of P. vivax infection. Moreover, treatment with chloroquine is often not effective requiring other drugs including Artesunate [9]. Since, our patient hailed from choloroquine sensitive areas, oral chloroquine was used a first line antimalarial drug along with injectable liposomal amphotericin B.
Our case has highlighted potential areas of concern in endemic regions for malaria and Leishmaniasis. Firstly, in a resource limited settings as ours, vector control programs should be in an integrated and coordinated manner addressing endemic diseases as a whole and not indivualised; high risk areas and population groups should be identified beforehand. Routine screening for possible co-infection should be performed as delay in diagnosis and treatment results in significant morbidity and mortality. Besides, potential treatment failure and adverse reactions while managing such cases should be understood and planned accordingly. A high index of suspicion for a possibility of a co-infection is to be made when individuals hailing from endemic regions present with fever.
