Dengue Fever, Crimean-Congo Hemorrhagic Fever, and COVID-19 Triple Co-infection: Out of the Frying Pan Into the Fire

Abstract

In developing countries, infectious diseases are thriving due to poor hygiene, inadequate public health infrastructure, and socio-cultural factors. Generally, infections are due to a single pathogen, but due to the shared risk factors for transmission, co-infections are not uncommon. The severity and outcome of infections are adversely affected by co-infection. Co-infections present as diagnostic and therapeutic enigmas because of the complex interaction between different pathogens involved and distorted host responses. The southeast Asian region, particularly Pakistan, is known for unique combinations of different infections. We present a distinctive case of triple co-infection of dengue virus, Crimean-Congo hemorrhagic fever virus, and severe acute respiratory syndrome coronavirus-2. The index case was a 60-year-old gentleman who presented with fever, cough, shortness of breath, bruises, and hemoptysis. He had thrombocytopenia, deranged liver and renal function, coagulopathy, and infiltrates in both lung fields. Subsequent investigations revealed a positive polymerase chain reaction for ribonucleic acid of dengue virus, Crimean-Congo Hemorrhagic fever virus, and severe acute respiratory syndrome coronavirus-2. He received supportive treatment including antibiotics, blood products, ribavirin, and supplemental oxygen. He developed multi-organ failure and succumbed to the triple co-infection. This case will act as a wake-up call for clinicians, public health authorities, and infectious disease specialists to plan before the volcano of co-infections erupts.

Keywords: coinfection; covid-19; crimean-congo hemorrhagic fever virus; dengue fever; dengue virus; public health; sars-cov-2.

Figure 1. Picture of the right flank of the patient showing bruising.

Figure 2. Picture of the left forearm of the patient showing ecchymosis.

Figure 3. X-ray chest (Posterior anterior view) showing multifocal infiltrates (arrows) involving both lung fields.

Figure 4. Computed tomography of the chest; lung (A and B) and mediastinal windows (C and D).

Multifocal cavitating consolidations (yellow arrows: A, B, C) involving both lung fields with surrounding ground glass halos (blue arrows: A). Consolidation with air bronchograms is seen in the left lung (red arrow: B, D). Multiple ground glass nodules scattered randomly in both lung fields (white arrows: A, D).