We retrospectively reviewed clinical records, laboratory findings,Morphological characteristics of the pathogen under microscope and chest CT scans for patent with laboratory-confirmed Plasmodium falciparum infection with COVID − 19 pneumonia. Evidence of Plasmodium falciparum infection with COVID − 19 was assessed by testing for the presence of SARS-CoV-2 in blood,,throat swab sampales, plasmodium parasite and its nucleic acid in microscopic examination and blood sampales.The blood samples of the patients were confirmed as plasmodium falciparum by RDT or a mixture of three plasmodium parasites,Under the microscope, plasmodium trophozoite and PCR typing result were plasmodium falciparum.
The patient is a 65-year-old man from Liuwan Village, Qianyi Town, Tianmen City, Hubei Province. On the afternoon of December 27, 2019, he was diagnosed with fever due to unknown causes. The outpatient was admitted to the hospital with "upper respiratory infection and fever, fever to be checked". The highest temperature was 39℃ on admission., with headache, fatigue and other symptoms, physical examination: temperature (T): 38.1 ℃, respiration (R): 20 beats / min, heart rate (P): 88 beats / min, blood pressure (B): 130/80 mmHg. The patient was pale, with a lack of energy, with a clearer mind, with a regular heart rhythm, clear breathing in both lungs, no wet and dry rales, no symptoms of nausea, vomiting, abdominal pain and diarrhea. Physical examination revealed an old surgical scar about 8 cm long on the abdomen, soft abdomen, no tenderness and rebound pain,the underside of the liver could not be touch, normal bowel sounds, no edema in both lower limbs. Past medical history: The patient suffered from splenic rupture due to a fall and had a history of splenectomy in 2005.He has infected malaria while working in Africa in November 2019,. treated with antimalarial drugs, specific drugs and insect species unknown,,with no history of hypertension, diabetes, heart disease༌hepatitis, tuberculosis or food and drug allergy history .
The first blood cell analysis was performed on December 27, 2019: white blood cell count (WBC) 4.36 × 109 cells / L[normal, 3.5–9.5 × 109 cells/L], red blood cell count (RBC) 3.81 × 1012 / L[normal, 4.3–5.8 × 1012 cells/L], hemoglobin (HGB) 124 g / L[normal, 130–175 g / L], thrombocytopenia (PLT) 77 × 109 cells / L[normal, 125–350 × 109 cells/L],
absolute neutrophil (NEU #) 3.68 × 109 / L[normal, 1.8–6.3 × 109 cells/L], neutrophil ratio (NEU%) 84.4%[normal,40–75%], and the C-reactive protein was 53.0 mg / L[normal, ≤ 6.0 mg / L]. Electrolyte: potassium ion 3.43 mmol / L[normal, 3.5–5.3 mmol / L], sodium ion 132.7 mmol / L[normal, 137–147 mmol / L], total calcium 2.02 mmol / L[normal, 2.11–2.52 mmol / L], total carbon dioxide 21.8 mmol / L[normal, 24–32 mmol / L], serum iron 2.4umol / L[normal, 10.6–36.7 mmol / L], magnesium ion 0.6 mmol / L[normal, 0.75–1.02 mmol / L], Inorganic phosphorus 0.83 mmol / L[normal, 0.85–1.51 mmol / L],liver function:total protein 51.15 g / L[normal, 65–85 g / L], albumin28.5 g / L[normal, 40–55 g / L], and the rest were not significantly abnormal. Influenza virus antigen test: negative. Hemorrhagic fever virus antibody (IgG + IgM) test: negative. Gold labeling rapid malaria diagnostic reagent (RDT) test: It indicates that Plasmodium falciparum is positive, but it does not rule out simultaneous infection with the other three malaria parasites (Plasmodium malaria, oval malaria, and vivax malaria). Plasmodium microscopy: find a large number of Plasmodium ring bodies, thick blood plate counts, the density is about 6,872 /ul, the plasmodium parasite is small,the ring is slender, accounting for about 1/5 of the entire red blood cell diameter, and the nucleus is tight, fuchsia, one or two nuclei ,usually two can be seen on the ring of a Plasmodium(Fig. 1A); the cytoplasm is blue, the amount is small, trophozoite is often close to the edge of the cell, and the parasitic red blood cells do not swell,some even shrink, two or more trophozoite can be parasitic in a red blood cell (Fig. 1B); the trophozoite on the thick blood film are comma-shaped, exclamation marks, nucleus and cytoplasm are smaller, there are more trophozoite, the phenomenon of "Starry sky" was often presented(see Fig. 2C,D).The plasmodium parasite was immediately reported to the public health department of the hospital and the tianmen center for disease control and prevention according to the procedures for reporting infectious diseases. the CDC immediately dispatched medical staff from the department of infectious diseases to send the antimalarial drugs (artemether and piperaquine phosphate) to the hospital. The patient received dihydroartemisinin piperaquine tablets orally. 2 hours after taking the drug, the patient's fever was relieved
The patient reviewed the blood test December 28,2019: RBC 3.91 × 1012 / L, HGB 130 g / L, PLT 81 × 109 / L,CRP 31.73 mg / L, patients with mild anemia, platelet reduction, but CRP decreased. Continue to observe the medication, and check the blood test again on December 30: RBC 3.46 × 1012 / L, HGB 113 g / L, PLT 79 × 109 / L, NEU # 1.80 × 109 / L, NEU% 36.8%, Absolute value of monocytes (MON #) 0.80 × 109 / L[normal, 0.1–0.6 × 109 cells/L], monocyte ratio (MON%) 16.1%[normal, 3–8%], EOS # 0.80 × 109 / L[normal, 0.02–0.52 × 109 cells/L], EOS% 8.70%[normal, 0.4–8%], CRP 8.63 mg / L, patient eosinophilic Both the absolute value and proportion of granulocytes increased, anemia further worsened, but platelets rebounded, CRP gradually returned to normal, indicating that the condition improved. Patients were treated with dihydroartemisinin and piperazine tablets, with a total dose of 8 tablets (each containing 40 mg of dihydroartemisinin and 0.32 g of piperazine phosphate), 2 tablets / time, 4 tablets / day, 2 days as a course of treatment. After the end of a course of treatment, the fever symptoms have completely disappeared. Upon re-examination of the Plasmodium, a large number of Plasmodium rings are still visible on the microscope, but the cytoplasm has disappeared, leaving only purple naked nuclei, as shown in Fig. 3E、F. Dual-nuclear naked nuclei can be seen in some red blood cells., Or multiple naked cores, see Fig. 3B, C. Continue to consolidate the treatment and re-examine again after a course of treatment. The patient was negative for Plasmodium. The patient was asked to leave the hospital. The patient was instructed to review the Plasmodium 3 days later. No Plasmodium was found in the peripheral blood.
COVID − 19 after the outbreak of disease, the patient was identified as close contacts, was the emergency isolation under medical observation on January 23,2020, during the patient had symptoms of fever, but negative for pharyngeal swab virus nucleic acid detection, 2019 - nCoV IgM antibody detection:weakly positive, IgG positive, lung CT imaging examination showed high density shadow grinding of glass samples, as shown in Fig. 4, microscopic examination of the malaria parasite negative, after the designated hospital for treatment,after 1 week of treatment, lung shadow gradually disappear, instruct patient to remain in isolation for 14 days, not again appear the symptom such as fever, and continue to follow-up to track the patients condition.