Malaria or COVID-19? A case report highlighting a diagnostic challenge in Africa

A 40 years old woman previously healthy was diagnosed and treated for malaria without any signicant improvement. At the concern of an increase in shortness of breath, she consulted the nearby hospital where an additional diagnosis of COVID-19 infection was made. She died shortly after due to severe COVID-19 Pneumonia. In countries like Rwanda where 70% of malaria cases are treated at community level by community health workers, typical malaria signs and symptoms (fever, shivering, headache, fatigue, muscle aches, diarrhea, vomiting) are well known by lay providers and even by patients themselves. These overlap with common COVID-19 symptoms. It is very likely that unrecognized COVID-19 disease transmitters will lead to a much wider virus spread, especially by those patients for whom a concurrent malarial disease is easily conrmed using the widely available malaria rapid tests. There is a growing need to reinforce the ability of fragile health systems to discriminate between multiple common causes for common symptoms, especially for malaria and COVID-19 infection.

A 40 years old woman previously healthy, living in a suburban neighborhood in Rwanda presented with general malaise and fever. She reported to the nearby clinic in her community where a diagnosis of malaria was made. She was provided with a 3-days course of oral antimalarial drugs (artemetherlumefantrine), which she completed without any signi cant improvement. At the concern of an increasing shortness of breath, she decided to go for further medical consultation at the hospital whereby a rapid test for COVID-19 was done and it was reported positive. Within a short time, her respiratory function deteriorated with a rate of 57 breaths per minute and her oxygen saturation was uctuating around 60% on oxygen supplementation of 15 liters per minute. Her chest X-ray was signi cant for bilateral diffuse lungs opaci cations. Additional blood work-up was done, including the complete blood count, malaria smear and metabolic panel [see table 1 below]. She was started on drugs therapy including dexamethasone, heparin and broad spectrum antibiotherapy without any signi cant improvement. As per the COVID-19 management guidelines, she met the criteria for endotracheal intubation and a referral to the designated COVID-19 Treatment Center where she died one day after arrival. This case report highlights the need to review the diagnostic approach for COVID-19 in this wetter season known with an increase in incidence of malarial disease.  Fever, chills, headache, muscles pain and fatigue. NB: 1. Complicated forms of Plasmodium falciparum infection can result in severe di culty in breathing (due to ARDS, or severe anemia causing heart failure).

Abdominal pain and diarrhea can be seen in COVID-19 infection (although rare).
Cough, sore throat, running nose, nasal congestion, new loss of smell and taste, chest pain and di culty in breathing (due to ARDS). Sudden death from silent hypoxia and cardiac injury has also been cited.
Although respiratory signs and symptoms are most pronounced in COVID-19 infection, a typical malarial disease complicated with Acute Respiratory Distress Syndrome (ARDS) is nearly undifferentiable from severe COVID-19 infection.
In most African countries, community health workers (CHWs) are the frontline workers dealing with malaria, diagnosing cases with rapid diagnostic tests and treating simple cases. The current lack of widely validated antigen tests for COVID-19 with comparable sensitivity and speci city to RT-PCR tests hinder the ability of CHWs to accurately differentiate malaria from COVID-19 infection.
It is very likely that unrecognized COVID-19 disease transmitters will lead to a much wider virus spread, especially by those patients for whom a concurrent malarial disease is easily con rmed using the widely available rapid tests.
The picture of COVID-19 in Africa is confused by other endemic diseases with similar presentation, causing major challenges in the management of multiple public health threats. There is a growing need to reinforce the ability of fragile health systems to discriminate between multiple common causes.
Without improved access to simple diagnostic tests there is possibility of patients being diagnosed and treated for one infection, only to die of another.

Declarations
Consent: The consent to share this case report for both educational and COVID-19 strategic response purposes was obtained from the patient's next of kin.