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 Table of Contents  
Year : 2021  |  Volume : 23  |  Issue : 1  |  Page : 43-44

Mixed infection of Plasmodium vivax and Plasmodium falciparum diagnosed by polymerase chain reaction

Department of Medical Parasitology, PGIMER, Chandigarh, India

Date of Submission09-Feb-2021
Date of Decision13-Apr-2021
Date of Acceptance22-Jun-2021
Date of Web Publication16-Sep-2021

Correspondence Address:
Prof. Rakesh Sehgal
Head, Department of Medical Parasitology, PGIMER, Chandigarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jacm.jacm_36_21

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We have reported two cases of mixed infection of Plasmodium species, namely Plasmodium vivax and Plasmodium falciparum, whose DNA was tested by nested polymerase chain reaction (PCR). One case was a 29-year-old male, who presented fever and diurnal variation. He belonged to Jharkhand but was admitted in the emergency ward of PGIMER, Chandigarh, while the other was a 21-year-old female from Aligarh, Uttar Pradesh, who was admitted to PGIMER, Chandigarh, with complaints of fever and vomiting. Smear test of peripheral blood of both the patients found the presence of P. falciparum while nested PCR diagnosis detected the DNAs of both P. vivax and P. falciparum.

Keywords: Malaria, mixed infection, polymerase chain reaction

How to cite this article:
Kaur D, Kaura T, Kaur U, Sehgal R. Mixed infection of Plasmodium vivax and Plasmodium falciparum diagnosed by polymerase chain reaction. J Acad Clin Microbiol 2021;23:43-4

How to cite this URL:
Kaur D, Kaura T, Kaur U, Sehgal R. Mixed infection of Plasmodium vivax and Plasmodium falciparum diagnosed by polymerase chain reaction. J Acad Clin Microbiol [serial online] 2021 [cited 2023 Jun 3];23:43-4. Available from: https://www.jacmjournal.org/text.asp?2021/23/1/43/326043

  Introduction Top

Malaria remains a significant health problem in many countries and it has been cited that amongst Plasmodium species, the Plasmodium vivax and Plasmodium falciparum remain the most predominant.[1],[2] India has by far the greatest estimated P. vivax burden of any country[3] and it has been reported that ten states account for around 89% of P. vivax malaria out of which 64% of cases are contributed by five states which include Jharkhand, Madhya Pradesh, Odisha, Uttar Pradesh and Gujarat. Moreover, P. vivax also shows polymorphism in the patterns of relapse. Routinely, malaria is diagnosed by rapid diagnostic tests and microscopy, but mixed malaria species infections often remain undiagnosed and undetected by microscopy.[4] In the present report, we have described two cases of P. vivax and P. falciparum mixed infection as diagnosed by polymerase chain reaction (PCR).

  Case Reports Top

Case 1

A 29-year-old male who belonged to Pashchimi Singhbhum, a district in Jharkhand, was admitted to PGIMER, Chandigarh. He developed initially low-to-high-grade fever from the last 15 days with diurnal variation. Along with these symptoms, he had abdominal pain also from 12 days. The patient had blood pressure (BP) – 118/70 mmHg, pulse – 84/min, respiration rate (RR) – 18/min, temperature – 104°F and saturation – 97%. On laboratory examination, the haemoglobin was 12.6 g/dL, white blood cell count – 5000/mm3 and platelet count – 20,000/mm3. His urea was 61 mg/dL, serum creatinine – 0.9 mg/dL, total bilirubin – 0.95 mg/dL, serum glutamic-oxaloacetic transaminase – 51 IU and serum glutamic-pyruvic transaminase – 30 IU.

Peripheral blood smear examination revealed the presence of P. falciparum. He was also positive for scrub typhus by card test. Late molecular examination by nested PCR showed mixed infection for P. vivax and P. falciparum species. He was treated with Artesunate orally of 200 mg for three days, Sulphadoxine–Pyrimethamine of 250/37.5 mg and intravenously received Ceftriaxone as well as Doxycycline.

Case 2

A 21-year-old female from Aligarh, a state in Uttar Pradesh, was admitted to PGIMER, Chandigarh, with complaints of fever and vomiting from the last five days. At the time of admission, BP recorded was 100/70 mmHg with pulse rate – 100/min and RR – 18/min, temperature – 101°F and saturation – 98%. Laboratory examination showed haemoglobin – 4.9 g/dL, white blood cell count – 10,400/mm3 and platelet count – 107 × 103/mm3. Urea level was 120 mg/dL, serum creatinine was 1.1 mg/dL, serum glutamic-oxaloacetic transaminase – 26 IU and serum glutamic-pyruvic transaminase – 24 IU. Peripheral blood smear showed the presence of P. falciparum. Molecular analysis through PCR showed mixed infection for both Plasmodium species. She was treated orally with Artesunate and Sulphadoxine–Pyrimethamine for three days.

The amplified products of both the cases were sequenced for P. vivax and P. falciparum. The sequences obtained were submitted to GenBank, and the following accession numbers were obtained: Case 1: P. vivax – MW549873, P. falciparum – MW550039 and Case 2: P. vivax – MW466536, P. falciparum – MW550040.

  Discussion Top

India has a vision of a malaria- free country by 2027 and elimination by 2030. Mixed Plasmodium species infection usually remains undetected by RDT and microscopy. Recently, a study showed the incidence of mixed infections by PCR in different states and it was found to be the highest in Karnataka (30%) followed by Jharkhand (27%) while the incidence was low in Delhi and Goa with 2.9% and 2.6% respectively. This study also highlighted that the states like Karnataka and Jharkhand where less number of monoinfection by either P. falciparum or P. vivax were reported the percentage of mixed infections by P. falciparum and P. vivax by PCR was found to be maximum.[5],[6] There have been a number of studies in recent years which are highlighting the importance of severe P. vivax cases in Asia while some suggest P. vivax as virulent as P. falciparum.[7],[8] As mixed species infection of malaria not only complicates the diagnosis but also alters the severity and morbidity of the disease. Therefore, these two cases highlight the usefulness of PCR testing for diagnosis of mixed infections which often present with a low parasitaemia level in relapse of P. vivax.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Gething PW, Elyazar IR, Moyes CL, Smith DL, Battle KE, Guerra CA, et al. A long neglected world malaria map: Plasmodium vivax endemicity in 2010. PLoS Negl Trop Dis 2012;6:e1814.  Back to cited text no. 1
Hay SI, Okiro EA, Gething PW, Patil AP, Tatem AJ, Guerra CA, et al. Estimating the global clinical burden of Plasmodium falciparum malaria in 2007. PLoS Med 2010;7:e1000290.  Back to cited text no. 2
Anvikar AR, Shah N, Dhariwal AC, Sonal GS, Pradhan MM, Ghosh SK, et al. Epidemiology of Plasmodium vivax malaria in India. Am J Trop Med Hyg 2016;95:108-20.  Back to cited text no. 3
Mbakilwa H, Manga C, Kibona S, Mtei F, Meta J, Shoo A, et al. Quality of malaria microscopy in 12 district hospital laboratories in Tanzania. Pathog Glob Health 2012;106:330-4.  Back to cited text no. 4
Singh US, Siwal N, Pande V, Das A. Can mixed parasite infections thwart targeted malaria elimination program in India? Biomed Res Int 2017;16;1-11.  Back to cited text no. 5
Krishna S, Bharti PK, Chandel HS, Ahmad A, Kumar R, Singh PP, et al. Detection of Mixed Infections with Plasmodium spp. by PCR, India, 2014. Emerg Infect Dis 2015;21:1853-7.  Back to cited text no. 6
Baird JK. Evidence and implications of mortality associated with acute Plasmodium vivax malaria. Clin Microbiol Rev 2013;26:36-57.  Back to cited text no. 7
Shaikh S, Memon H, Iohano B, Shaikh A, Ahmed I, Baird JK. Severe disease in children hospitalized with a diagnosis of Plasmodium vivax in southeastern Pakistan. Malar J 2012;11:144.  Back to cited text no. 8


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