Background:
Rift Valley Fever (RVF) is a mosquito-borne zoonotic viral disease that
is associated with high morbidity and mortality rates among both human
and animals populations in endemic countries [1]. The disease is
caused by the Rift valley fever virus (RVFV) that belongs to
genus Phlebovirus and family Phenuiviridae [2]. The
disease was described for the first time in 1931 in the Rift Valley area
in Kenya; this how the disease obtained its name (Ref). The RVFV is
transmitted mainly through several species of Aedes andCulex mosquitoes, however, other modes of transmission including
vertical transmission from mother to child, sexual transmission, and
through the consumption of row milk and uncooked meat were documented
[3].
In addition to malaria [4,5], Sudan is endemic with several
arboviruses including RVF, Chikungunya, Crimean–Congo hemorrhagic fever
(CCHF), dengue, and West Nile virus [1, 6 - 11]. Infections with the
RVFV were detected in Sudan in early 1930s [3, 12]. Since then,
outbreaks of RVF occur frequently in the country [1,13]. The disease
is associated with high abortion among human and domestic animals,
therefore, in addition to its negative health affects it has devastating
socioeconomic impacts on animals-dependent communities in endemic
countries [1,13,14]. Recently, several outbreaks of emerging
infectious diseases including RVF occurred in Sudan [1,6-11, 13-17
]. Additionally, there is rapidly growing evidence about the emergence
and spread of invasive diseases vectors in the region including Sudan
[10, 18 - 21]. Studies have suggested that the major risk factors
that drive this upsurge in the burden and outbreaks of infectious
diseases and rapid spread of invasive diseases vectors include Climate
change, armed-conflicts and the growing size of population living in
humanitarian crisis, globalization, and unplanned urbanization [1,13,
22 - 25]. These risk factors increase the dynamic and the interactions
of different populations of human and animals substantially, this in
turn magnifies the occurrence of spill over and pathogens sharing events
across the different species of diseases-susceptible hosts [26].
Despite the frequent outbreaks of arboviral diseases in Sudan, still
there is a huge gap in the local knowledge about the epidemiology,
pathology, and the clinical presentation and outcome of patients,
particularly in cases of co-infection [3,6]. This gap mainly because
of the limited sharing of information about these diseases of local
public health and global health concerns [27]. In this
communication, we report a case of a differential diagnosis challenge in
areas endemic with several causes of febrile illness. Our case, a young
(19-year-old) female from central Sudan was confirmed to be co-infected
with RVFV malaria.
Case presentation :
A 19-year-old student female from Kampo five, Kenana, White Nile state
(Fig. 1), has arrived at the emergency unit of Kenana. She was presented
on 23th October 2019; with fever, headache, joint
pain, fatigue, and loss of consciousness. The patient is a student
resident in kenana district and she reported staying at home for the
week before the onset of the symptoms; she reported no contact with sick
or apparently ill people or animals. However, she reported being
recently exposed to heavy mosquitoes’ bites during that time. She
complained from fever, severe diffuse throbbing headache, and joint pain
specifically in the knee and elbow. These symptoms were also accompanied
by progressively fatigue and muscle pain.
On initial examination, she had a normal pulse rate (74/min),
respiratory rate (19/min), blood pressure (95/555), and temperature
(39°C). A blood samples were drown from the patient and sent to the
local laboratory.
A blood film was made and was positive for the presence of malaria
parasite; blood film showed asexual stage trophozoites ofPlasmodium falciparum and ICT was also positive. She was started
on malaria treatment, however, she did not show response to the
treatment. Therefore, another sample of blood was taken and sent to the
central National Public Health Laboratory (NPHL) in Khartoum to be
tested for the major viral infections endemic in the country including
dengue, RVF, CCHF, and Chikungunya [3]. Nonetheless, considering the
recent reports about RVF outbreaks in different states of the country,
namely River Nile and Gedaref (Fig. 1), and a sudden increase in
abortion rate among cattle and sheep was reported in the area, the
sample was prioritized for testing RVFV infection. The result of the
real time–polymerase chain reaction (RT-PCR) confirmed infection with
RVFV.
For the treatment, the patient received paracetamol infusion for the
pain. For the malaria infection, the patient received
artemether/lumefantrine four tablets (20 mg artemether; 120 mg
lumefantrine per tablet) orally (PO) as an initial dose, followed by
four tablets PO after 8 hours, then four tablets PO twice daily (morning
and evening) for two days for a total course of 24 tablets. She was
advised to stay all day under mosquito net to avoid infecting mosquitoes
with RVFV and maintain the virus transmission in the area and she was
followed up closely to monitor her case, she responded well and
recovered after three days. After two week follow up, she showed no
signs of sequela or any damage.