Dengue Virus Co-infection Research Articles

Newest “co-members” of the 1000s club: A case of severe transaminitis secondary to Epstein-Barr and dengue virus co-infection in a returning traveler

Background: Timely identification of the etiology of transaminitis is critical in informing subsequent management as strategies can vary from supportive care to urgent transplant assessment. This is especially important in returning travelers as there may be multiple causes of injury that need to be addressed. Case report: We present a case of severe transaminitis secondary to non-hepatitis viral co-infections. A 28-year-old south Asian male returning traveler presented with an acute liver injury (aspartate aminotransferase/alanine aminotransaminase levels of >4000 IU/l) and marked jaundice. A thorough and expanded work-up of acute hepatitis was negative aside from positive mononucleosis spot testing and positive dengue fever serologies. This atypical presentation of mononucleosis and dengue fever was managed conservatively, and the patient was discharged with outpatient follow-up after an eight-day admission. Conclusions: Usually, non-hepatitis viruses typically do not present with severe transaminitis or hyperbilirubinemia. These viruses, such as infectious mononucleosis and dengue fever, may work synergistically to cause an elevated inflammatory response, resulting in severe transaminitis in returning travelers. In the absence of a classic clinical presentation, clinicians should be aware of co-infections in returning travelers and test for them based on a thorough history and physical examination.

Malaria and dengue fever in febrile children entering healthcare facilities in Mwanza, Tanzania.

Plasmodium spp. infections and cases of malaria are a long-standing public health problem for children living in middle- and low-income countries. Dengue virus causes an emerging under-recognized disease burden. A cross sectional study was conducted between March 2020 and December 2021 to determine the status of malaria and dengue fever, and the associated factors in children living in Mwanza, Tanzania. Clinical features were recorded; blood samples were analyzed using dengue NS1 rapid diagnostics test (NS1-RDT), malaria rapid diagnostic test (MRDT) and PCR and microscopy for malaria parasites. Descriptive analysis was based on infection status; odds ratio and confidence interval were used to determine the factors associated with dengue fever and malaria. The prevalence of malaria in the 436 children included in the final analysis was 15.6%, 8.5%, and 12.1% as determined by MRDT, blood smear examination and PCR, respectively. The prevalence of dengue fever determined by the NS1-RDT was 7.8%. Body rash, muscle and joint/bone pain were associated with a positive rapid dengue test result. Retro-orbital pain characterized Plasmodium spp. and dengue virus co-infections. Clinical signs and symptoms could not readily differentiate between malaria and dengue fever patients or patients co-infected with both causative agents underscoring the urgent need for the accurate laboratory diagnostics. Additional large-scale studies are required to assess the epidemiological burden of acute febrile illness in developing countries and to produce data that will guide empirical treatment.

Temperature affects viral kinetics and vectorial capacity of Aedes aegypti mosquitoes co-infected with Mayaro and Dengue viruses

BackgroundIncreasing global temperatures and unpredictable climatic extremes have contributed to the spread of vector-borne diseases. The mosquito Aedes aegypti is the main vector of multiple arboviruses that negatively impact human health, mostly in low socioeconomic areas of the world. Co-circulation and co-infection of these viruses in humans have been increasingly reported; however, how vectors contribute to this alarming trend remains unclear.MethodsHere, we examine single and co-infection of Mayaro virus (D strain, Alphavirus) and dengue virus (serotype 2, Flavivirus) in Ae. aegypti adults and cell lines at two constant temperatures, moderate (27 °C) and hot (32 °C), to quantify vector competence and the effect of temperature on infection, dissemination and transmission, including on the degree of interaction between the two viruses.ResultsBoth viruses were primarily affected by temperature but there was a partial interaction with co-infection. Dengue virus quickly replicates in adult mosquitoes with a tendency for higher titers in co-infected mosquitoes at both temperatures, and mosquito mortality was more severe at higher temperatures in all conditions. For dengue, and to a lesser extent Mayaro, vector competence and vectorial capacity were higher at hotter temperature in co- vs. single infections and was more evident at earlier time points (7 vs. 14 days post infection) for Mayaro. The temperature-dependent phenotype was confirmed in vitro by faster cellular infection and initial replication at higher temperatures for dengue but not for Mayaro virus.ConclusionsOur study suggests that contrasting kinetics of the two viruses could be related to their intrinsic thermal requirements, where alphaviruses thrive better at lower temperatures compared to flaviviruses. However, more studies are necessary to clarify the role of co-infection at different temperature regimes, including under more natural temperature settings.Graphical

Analysis of Dengue and SARS‐CoV‐2 Coinfection in a Tertiary Care Hospital: A Retrospective Study

Introduction. Coinfection of dengue virus and SARS‐CoV‐2 infections in dengue‐endemic areas is a significant public health concern. Coinfections can result in severe illness. Hence, this study determines the incidence of dengue and COVID‐19 coinfection for a better understanding of the clinical presentation, laboratory parameters, and outcomes including mortality. Methods. The patients admitted to two tertiary hospitals with RT PCR‐proven COVID‐19 infection and dengue positive by NS1 rapid antigen or IgM dengue ELISA for two years between January 2020 and December 2022 were considered. Clinical data were retrieved from medical records including the laboratory findings and outcomes of these patients. The categorical data were analyzed in the form of frequency and proportion. The quantitative data were analyzed in the form of mean, median, and proportion. Results. Out of 2301 confirmed dengue samples and 3718 confirmed COVID‐19 samples, there were 14 cases of coinfection with the presence of COVID‐19 and dengue infection at the same time. ICU admission of 14.2% and mean hospital stay of 7 days were noted. Mainly the symptoms reported were fever at 92.9%, myalgia at 35.7%, and headache, vomiting, and cough at 28.6%. The laboratory findings were elevated lactate dehydrogenase and C‐reactive protein in 100% of patients, elevated ferritin in 92.9%, thrombocytopenia in 71.4%, elevated AST and ALT in 71.4%, and elevated D‐dimer in 57.1% of patients. There was no effect on morbidity and mortality seen among coinfection. Conclusion. COVID‐19 and dengue share similar clinical features and laboratory findings. Diagnosis of one disease cannot rule out the presence of other infections. There might be chances of misdiagnosis or missed diagnosis. Hence, it is important to stress about early detection using specific methods and confirmation of disease with timely management, as it is a potentially new dimension for public health concern and management.

Increasing prevalence of malaria and acute dengue virus coinfection in Africa: a meta-analysis and meta-regression of cross-sectional studies

BackgroundMalaria and dengue fever are the leading causes of acute, undifferentiated febrile illness. In Africa, misdiagnosis of dengue fever as malaria is a common scenario. Through a systematic review of the published literature, this study seeks to estimate the prevalence of dengue and malaria coinfection among acute undifferentiated febrile diseases in Africa.MethodsRelevant publications were systematically searched in the PubMed, Cochrane Library, and Google Scholar until May 19, 2023. A random-effects meta-analysis and meta-regression were used to summarize and examine the prevalence estimates.ResultsTwenty-two studies with 22,803 acute undifferentiated febrile patients from 10 countries in Africa were included. The meta-analysis findings revealed a pooled prevalence of malaria and dengue coinfection of 4.2%, with Central Africa having the highest rate (4.7%), followed by East Africa (2.7%) and West Africa (1.6%). Continent-wide, Plasmodium falciparum and acute dengue virus coinfection prevalence increased significantly from 0.9% during 2008–2013 to 3.8% during 2014–2017 and to 5.5% during 2018–2021 (p = 0.0414).ConclusionThere was a high and increasing prevalence of malaria and acute dengue virus coinfection in Africa. Healthcare workers should bear in mind the possibility of dengue infection as a differential diagnosis for acute febrile illness, as well as the possibility of coexisting malaria and dengue in endemic areas. In addition, high-quality multicentre studies are required to verify the above conclusions.Protocol registration number: CRD42022311301.

Typhoid Dengue Co-infection: 2 Case Reports

Dengue and typhoid fever are different entities with overlapping signs and symptoms. The resemblance of symptoms makes clinical diagnosis and treatment difficult. Both are major health problems mainly during monsoon. If they are not diagnosed timely and treated, outcome can be fatal. We report 2 cases of dengue virus co-infection with typhoid fever during this outbreak of dengue. The aim of this report was to create awareness about this co-infection Bangladesh J Medicine 2023; 34(3): 239-240

Coinfection and circulation of chikungunya virus and dengue virus in pediatric patients in Myanmar, 2019

Myanmar is an endemic country for arboviruses, and outbreaks occur frequently. A cross-sectional analytical study was conducted during the peak season of the chikungunya virus (CHIKV) outbreak in 2019. A total of 201 patients with acute febrile illness who were admitted to the 550-bedded Mandalay Children Hospital in Myanmar were enrolled in the study, and virus isolation, serological tests, and molecular tests for the dengue virus (DENV) and CHIKV were performed for all samples. Out of 201 patients, 71 (35.3%) were only DENV-infected, 30 (14.9%) were only CHIKV-infected and 59 (29.4%) were coinfected with DENV and CHIKV. The viremia levels of the DENV- and CHIKV- mono-infected groups were significantly higher than those of the group coinfected with DENV and CHIKV. Genotype I of DENV-1, genotypes I and III of DENV-3, genotype I of DENV-4 and the East/Central/South African genotype of CHIKV were co-circulating during the study period. Two novel epistatic mutations of CHIKV (E1:K211E and E2:V264A) were noted. This study highlighted that there were many coinfection cases during the outbreak and that the co-circulation of both viruses in DENV-endemic regions warrants effective monitoring of these emerging pathogens via comprehensive surveillance to facilitate the implementation of effective control measures.

Emerging peril of post–dengue mucormycosis

Rationale: Dengue fever is a leading cause of death in tropical and subtropical countries. Although most patients have a self-limited febrile illness, the viral infection can induce virus-mediated host changes, making immunocompetent persons susceptible to deadly fungal infections. However, there are only a few reports of such an association. Here we present a case of this deadly co-infection. Patient’s Concern: A 17-year-old male patient was diagnosed with dengue fever. He presented to us with facial swelling, periorbital edema, and black discoloration over the palate during the second week of his illness. Diagnosis: Diagnostic tests confirmed the presence of fungal hyphae. A diagnosis of post-dengue mucormycosis was made. No other comorbidity or underlying immune deficit was detected. Interventions: The patient underwent surgical debridement and antifungal treatment. Outcomes: The patient recovered and showed signs of palatal healing with an advancing mucosal edge. Lessons: Dengue virus and mucor co-infection has brought to light a new pathogenic paradigm. Clinicians need to be aware of this emerging medical condition and maintain a high index of suspicion for mucor co-infections while treating dengue patients.

CO-INFECTION OF DENGUE AND CHIKUNGUNYA VIRUSES: A SEROLOGICAL STUDY IN A TERTIARY CARE HOSPITAL IN WARANGAL, TELANGANA, INDIA

Background: All around India, Dengue and Сhikungunya (CHIK) diseases seem to be rising. Aedes aegypti mosquitoes frequently transmit the CHIK virus and Dengue virus (DENV). Both viruses can spread together in regions where they cocirculate. Objectives: The objective of the current investigation is to determine the seroprevalence of coinfection with Dengue and Сhikungunya. Methods: The present study was conducted at the Virus Research and Diagnostic Laboratory, Kakatiya Medical College, Warangal, Telangana, India, from January to December 2022. The district health authority and the admitted cases provided the samples. The patients had symptoms typical of CHIK and DEN infections, including high fever (>39°C), chills, rashes, joint pain, joint swelling, nausea, and headache, myalgia, and pain behind the eyes. Results: Between January 2022 and December 2022, a total of 4892, 3344, and 2103 hospitalised patients underwent serological testing for the Dengue virus (DENV), the Сhikungunya virus (CHIKV), and both Dengue and Сhikungunya virus for co-infection, respectively. IgM Capture ELISA was used for all tests. 153 (7.8%) of the cases had both Dengue virus (DENV) and Сhikungunya virus IgM positivity. (CHIKV). Dengue virus (DENV) monoinfection, or 703 (14.3%), denotes the presence of Dengue virus. 313 (9.3%) individuals tested positive for the Сhikungunya virus, or mono-infected with the virus (CHIKV). Chikungunya IgM, Dengue IgM, and Co-infection Conclusion: Dengue and Chikungunya virus co-infections are clinically more serious than a single infection. However, in endemic regions, particularly during the monsoon season, clinically suspected cases should be tested for both viruses. To determine the severity and clinical result of co-infection, more thorough investigations are needed to analyse the pathophysiology and complications of co-infection.

Prevalence of Dengue and Chikungunya Virus Co-infection in Tertiary Care Hospital in Patiala, Punjab

Prevalence of Dengue and Chikungunya Virus Co-infection in Tertiary Care Hospital in Patiala, Punjab

SARS-CoV-2 and Dengue Virus Coinfection in a Mexican Pediatric Patient: A Case Report from Early Molecular Diagnosis

Mexico is an endemic region for dengue virus (DENV). The increase in this disease coincides with outbreaks of COVID-19, both of which are single-stranded positive RNA viruses. These characteristics make it difficult to distinguish each disease because they share clinical and laboratory features, which can consequently result in misdiagnoses. This is why the use of precision confirmatory tests (qRT-PCR) are crucial for early diagnosis. We herein report a pediatric patient who presented a coinfection for DENV and COVID-19, "SARS-CoV-2/Dengue". This patient initially presented a fever, cough, and headache and, three days later, developed generalized pain and epistaxis. Blood studies revealed thrombocytopenia and leukopenia, and the patient was admitted to the hospital for a probable DENV infection. Within 48 h, qRT-PCR tests specific for SARS-CoV-2 and DENV were performed and resulted as positive. The patient immediately received pharmacological treatment with azithromycin, oseltamivir, and metamizole. During hospitalization (9 days), the patient had no signs of respiratory distress and maintained normal body temperature and normal blood oxygen saturation. This case warns of the need for early diagnosis and adequate clinical and pharmacological management in the face of a "SARS-CoV-2/Dengue" coinfection. Early molecular detection of both viruses and timely treatment helped the patient to achieve a favorable recovery.

Short communication: Virological and B cell profiles of chikungunya and Dengue virus co-infections in Delhi during 2017–2019

With explosive epidemics of chikungunya in India since 2004, chikungunya virus (CHIKV) now co-circulates in geographical areas where Dengue virus (DENV) is already endemic and thus provides opportunity for the same mosquito to be infected with both viruses. Although there are excellent studies that have addressed the clinical of mono and co-infection, we have little to no knowledge on the current viral sequences that pre-dominate co-infections, and the B cell response elicited. In this study, we analyzed febrile patients that were confirmed to have DENV-CHIKV co-infections and asked the following questions: 1) what is the frequency of co-infections found in a single cycle of transmission; 2) what are the viral sequences associated with them; 3) what does the antibody secreting cell / plasmablast response look like in patients that are co-infected with both viruses. We report those co-infections occur at a frequency of 6.7% in the transmission cycle, and while DENV-3 is now frequently detected, we do not see a serotype bias in the patients that are co-infected with ESCA strain of CHIKV. Moreover, the effector B cell response (plasmablasts) observed are specific to both infecting viruses indicating no overt bias. Further studies to associate whether any of these properties have a bearing on clinical disease manifestation will be both timely and important.

Dengue and SARS-COV-2 co-infection in pregnancy: decision making dilemma

Background: Dengue virus (DENV) and coronavirus disease 2019 (COVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)) are two viral illnesses that require very distinct management protocols. Missed diagnosis and under reporting of DENV is predicted due to COVID-19 pandemic. Pregnancy is associated with increased fetal and maternal morbidity and mortality due to both illnesses. Co-infection need to be reported and studied to optimize the outcomes. Methods: This is a retrospective study on pregnant patients with COVID-19 and DENV co-infection conducted from the medical records from 1st of April 2021 to 1st of September 2021. Results: In this series four patients are described. Patient 1 is a diagnosed patient with immune thrombocytopenic purpura who was in remission. She developed DENV infection during recovery of SARS-CoV-2. She received intensive care unit (ICU) care during the leaking phase. Patient 2 had an uncomplicated miscarriage during the co-infection. Patient 3 was a patient with advanced maternal age with multiple co-morbidities. She did not progress into the leaking phase. Diagnosis of DENV was missed in patient 4 and she had a fetal death. Conclusions: SARS-CoV-2 and DENV co-infection in pregnancy can be life threatening to the mother and can lead to adverse fatal outcomes. Timely diagnosis and multidisciplinary management are essential for better outcomes. Continuous data collection and reporting is advisable till the guidance is formed.

Chikungunya virus: An emerging public health challenge for Pakistan

Chikungunya virus: An emerging public health challenge for Pakistan

SARS-CoV-2 and dengue virus co-infection: Epidemiology, pathogenesis, diagnosis, treatment, and management.

SARS‐CoV‐2 and dengue virus co‐infection cases have been on the rise in dengue‐endemic regions as coronavirus disease 2019 (COVID‐19) spreads over the world, posing a threat of a co‐epidemic. The risk of comorbidity in co‐infection cases is greater than that of a single viral infection, which is a cause of concern. Although the pathophysiologies of the two infections are different, the viruses have comparable effects within the body, resulting in identical clinical symptoms in the case of co‐infection, which adds to the complexity. Overlapping symptoms and laboratory features make proper differentiation of the infections important. However, specific biomarkers provide precise results that can be utilised to diagnose and treat a co‐infection, whether it is simply COVID‐19, dengue, or a co‐infection. Though their treatment is distinguished, it becomes more complicated in circumstances of co‐infection. As a result, regardless of whatever infection the first symptom points to, confirmation diagnosis of both COVID‐19 and dengue should be mandatory, particularly in dengue‐endemic regions, to prevent health deterioration in individuals treated for a single infection. There is still a scarcity of concise literature on the epidemiology, pathophysiology, diagnosis, therapy, and management of SARS‐CoV‐2 and dengue virus co‐infection. The epidemiology of SARS‐CoV‐2 and dengue virus co‐infection, the mechanism of pathogenesis, and the potential impact on patients are summarised in this review. The possible diagnosis with biomarkers, treatment, and management of the SARS‐CoV‐2 and dengue viruses are also discussed. This review will shed light on the appropriate diagnosis, treatment, and management of the patients suffering from SARS‐CoV‐2 and dengue virus co‐infection.

Natural vertical cotransmission of Dengue virus and Chikungunya virus from Aedes aegypti in Brumado, Bahia, Brazil.

ABSTRACTBackground: Arthropod-borne viruses have recently emerged and are pathogens of various human diseases, including dengue, zika, and chikungunya viruses. Methods: We collectedAedes aegyptilarvae (N = 20) from Brumado, Bahia, Brazil, and treated and individually preserved the specimens. We analyzed the samples for dengue, zika, and chikungunya viruses using molecular biology methods. Results: We found that 25% (N = 5) and 15% (N = 3) were positive exclusively for dengue and chikungunya viruses, respectively; 15% (N = 3) were coinfected with both. Conclusions: This is the first report of dengue and chikungunya virus coinfection in A. aegypti larvae.

The Prevalence of Dengue Virus and Malaria Co-Infection among HIV-Infected Patients within South Eastern Nigeria

Background: Dengue and malaria are infections of great public health concern, especially in tropical countries like Nigeria where the burden of HIV infection is high. This study was conducted to determine the seroprevalence of dengue virus and dengue/malaria coinfection among febrile HIV-infected patients attending the University of Nigeria Teaching Hospital and Nnamdi Azikiwe University teaching university both in the southeastern region of Nigeria. Methods: In this cross-sectional study, blood samples from 338 consenting HIV-infected patients were collected and tested for plasmodiasis and DENV using malaria microscopy and ELISA, respectively. Interviewer-based questionnaires were used to assess subjects’ sociodemographic variables and dengue risk factors. This study was conducted within the peak period of the dry season (January-February 2016). Results: Of the 338 screened participants, 13.02% were seropositive for DENV, whereas 55.8% were positive for Plasmodium spp. About 2.7% were positive for both dengue virus and Plasmodium spp. The overall seroprevalence of dengue virus by NS1 antigenemia, IgM and IgG antibodies was 9.5%, 5.6% and 8%. Conclusion: The high prevalence of malaria and DENV indicates the need to strengthen vector control and dengue surveillance programs.

Co-infection of Dengue and Chikungunya viruses: A Serological study from Ananthapuramu District, Andhra Pradesh

Introduction: It is observed that the infections of Dengue and Chikungunya were rising in many parts of India. Aedes aegypti mosquitoes are common vectors for dengue virus (DENV) and CHIK virus (CHIKV). In areas where both viruses co circulate, they can be transmitted together. The present study was undertaken to study the clinical features of dengue–CHIK coinfection and compare it with mono infection.
 Materials and Methods: This study was conducted at Government General hospital, Ananthapuramu on 100 hospitalized suspected patients from July 2021 and November 2021. They were serologically screened for DENV, CHIKV and both by performing RTPCR for dengue and ELISA CHIK IgM for Chikungunya.
 Results: Out of the total 100 samples collected from suspected patients, 28 (28%) samples were positive for DENV while 5 (5%) samples were positive for CHIKV. In addition to this, 4 sera were positive (4%) for coinfection of DENV and CHIKV. Co infected patients had fever in all cases while rash was seen in only 50% cases. Fever, Myaliga, Arthralgia and thrombocytopenia were seen in many number of co infected cases which signifies the overlapping nature of dengue–CHIK coinfection.
 Conclusion: It is concluded that strict control measures should be implemented to stop the spread of these viruses as there in Increase in the number of Dengue and Chikungunya infections and their co circulation.

Dengue and Chikungunya virus co-infection in major metropolitan cities of provinces of Punjab and Khyber Pakhtunkhwa: A multi-center study.

Dengue has become endemic in Pakistan with annual recurrence. A sudden increase in the dengue cases was reported from Rawalpindi in 2016, while an outbreak occurred for the first time in Peshawar in 2017. Therefore, a multi-center study was carried out to determine the circulating dengue virus (DENV) serotypes and Chikungunya virus (CHIKV) co-infection in Lahore, Rawalpindi, and Peshawar cities in 2016–18. A hospital-based cross-sectional study was carried out in Lahore and Rawalpindi in 2016–18, while a community-based study was carried out in Peshawar in 2017. The study participants were tested for dengue NS1 antigen using an immunochromatographic device while anti-dengue IgM/IgG antibodies were detected by indirect ELISA. All NS1 positive samples were used for DENV serotyping using multiplex real-time PCR assay. Additionally, dengue samples were tested for CHIKV co-infection using IgM/IgG ELISA. A total of 6291 samples were collected among which 8.11% were NS1 positive while 2.5% were PCR positive. DENV-2 was the most common serotype (75.5%) detected, followed by DENV-1 in 16.1%, DENV-3 in 3.9% and DENV-4 in 0.7% while DENV-1 and DENV-4 concurrent infections were detected in 3.9% samples. DENV-1 was the predominant serotype (62.5%) detected from Lahore and Rawalpindi, while DENV-2 was the only serotype detected from Peshawar. Comorbidities resulted in a significant increase (p-value<0.001) in the duration of hospital stay of the patients. Type 2 diabetes mellitus substantially (p-value = 0.004) contributed to the severity of the disease. Among a total of 590 dengue positive samples, 11.8% were also positive for CHIKV co-infection. Co-circulation of multiple DENV serotypes and CHIKV infection in Pakistan is a worrisome situation demanding the urgent attention of the public health experts to strengthen vector surveillance.

Clinical features and outcomes of COVID-19 and dengue co-infection: a systematic review

BackgroundDengue is the most common arboviral disease in the tropical and sub-tropical regions of the world. Like other regions, dengue-endemic areas have faced the additional public health and socio-economic impact of the ongoing coronavirus disease 2019 (COVID-19) pandemic. COVID-19 and dengue co-infections have been reported, with complicated patient management and care requirements. This review aimed to collate and synthesise current knowledge on the clinical features and outcomes of COVID-19 and dengue virus co-infection, a potentially important new dimension to be considered in public health management of the COVID-19 pandemic.MethodsA systematic literature review was conducted using PubMed, Web of Science and Scopus databases from 1st January to 21st November 2020. The key search terms used were “dengue” and “coronavirus”. Descriptive analysis with graphical illustrations were used to present the clinical and laboratory parameters of the co-infection.ResultsThirteen published papers and four news articles were included in the review. Most studies were case reports with a detailed description of the clinical and laboratory characteristics of the co-infection. All cases were in adults with the exception of a six-year old child. The common symptoms of co-infection were fever, dyspnea, headache, and cough. Common laboratory results included thrombocytopenia, lymphocytopenia, elevated transaminases, and leukopenia. Serious outcomes of co-infection included septic shock, acute respiratory disease syndrome and multi-organ failure, leading to death in some patients.ConclusionsCOVID-19 and dengue co-infection was associated with severe disease and fatal outcomes. The correct diagnosis and treatment of co-infection poses a substantial challenge due to the overlapping clinical and laboratory parameters. Therefore, confirmative diagnostic tests are necessary for accurate and timely diagnosis and patient management.