Pancytopenia unveils hidden coinfections of scrub typhus and leptospirosis in a malaria case

Background : Tropical infections are the leading cause of acute undifferentiated febrile illnesses (AUFI).While they are commonly suspected and tested through protocolized workup, sometimes the infections occur concurrently.Patients with concurrent infections present with atypical findings that delay diagnosis and treatment.Case Report : This case report describes a rare case of triple coinfection with an atypical clinical presentation.This patient presented with a fever in May and tested positive for Malaria.The patient was started on anti-malarial therapy.However, further workup revealed pancytopenia along with an abnormal renal and liver profile.Repeat testing for AUFI revealed concurrent scrub typhus as well as Leptospirosis.The treatment was accordingly adjusted, which led to recovery. Conclusion: Patients presenting with AUFI and having a residence or history of travel to endemic areas should be investigated for tropical infections.Moreover, a high index of suspicion should be borne in mind in cases of AUFI patients presenting with atypical signs and symptoms before ruling them out.AUFI patients usually present with nonspecific manifestations such as fever, thrombocytopenia, hepatic involvement, or leucopenia.Concurrent infections can cause atypical clinical findings, resulting in a substandard treatment response.[3]Due to overlapping clinical features and laboratory findings among tropical infections, diagnoses of concurrent infections pose a challenge, hence emphasizing a high suspicion in endemic regions, especially in a patient with unusual presentation. CASE REPORTA 24-year-old patient from the Indian state of Punjab presented with chief complaints of on-and-off fever.The fever was associated with chills, rigors, and headaches.There were no other complaints.On physical examination, the patient was conscious, oriented, and pale.Cardiovascular, abdominal, respiratory, and central nervous systems were normal on physical examination.Blood investigations were sent, and on complete blood count, pancytopenia was found with elevated reticulocyte count.With suspicion of hemolysis, Direct and Indirect Coombs tests were done and found to be positive. Moreover, malaria parasites were seen on peripheral bloodCase Report 1 www.directivepublications.org