{"paper_id":"4dd88f89-c09a-415a-a95f-1712243db4bf","body_text":"Triple coinfections of Brucella abortus, scrub typhus, and S. typhi in the subtropical region of Nepal: A rare case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Triple coinfections of Brucella abortus, scrub typhus, and S. typhi in the subtropical region of Nepal: A rare case report Santosh Basyal, Dipendra prasad yadav, Neeraj Acharya, Roshika Budhathoki, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5790693/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Brucella is a zoonotic bacterial infection that requires antibiotic treatment. Four of the six traditional diseases cause human zoonoses: B. melitensis , B. abortus , B. suis , and B. canis . B. melitensis causes the majority of cases worldwide, but B. abortus is often misdiagnosed. The lack of clear symptoms often leads to the underdiagnosis of scrub typhus, another endemic disease in Nepal. In Nepal, typhoid, dengue fever, and scrub typhus spread during the monsoon and post monsoon seasons, often coinfecting each other. Case presentation: A 35-year-old female patient with fever, fatigue, and myalgia presented to Damak Hospital in Jhapa, Nepal, with no history of close contact with animals. We admitted her due to her fever, fatigue, and myalgia, and initial reports revealed a decrease in her hemoglobin and platelets. Routine urinalysis and stools were normal, but the patient tested positive for the S. typhi O antigen. Enzyme-linked immunosorbent assay (ELISA) tests revealed positive results for scrub typhus and Brucella abortus antigens. Conclusion: This study identified triple coinfection via enzyme-linked immunosorbent assay (ELISA) and Widal testing in rural areas, with the aim of early detection in endemic regions such as Nepal and South Asia. Triple infection brucellosis subtropical region Background Brucellosis is a persistent granulomatous infection caused by intracellular bacteria that require appropriate antibiotic treatment. Four of the six traditional diseases are known to cause human zoonoses: B. melitensis, B. abortus , B. suis , and B. canis . Among them, B. melitensis , which is isolated from sheep, goats, and camels, is responsible for the majority of human cases worldwide. 1 In humans, brucellosis caused by B. melitensis is by far the most severe clinical condition. 2 Another disease to be cautious about is scrub typhus, which is endemic in Nepal and is caused by the bacteria Orientia tsutsugamushi. Because scrub typhus lacks clear clinical symptoms and reliable diagnostic tools, it is often underdiagnosed. 3 Typhoid, dengue fever, and scrub typhus are most likely to spread during the monsoon and post monsoon seasons in endemic countries such as Nepal. 4 . The majority of cases are associated with B. melitensis , but we report a 35-year-old female who presented with fever and had a rare coinfection involving B. abortus , scrub typhus , and typhoid in the southern subtropical region of Nepal following the monsoon season. Case presentation In October 2024, a 35-year-old female patient presented to the Damak Hospital in Jhapa, Nepal, with a five-day history of fever, fatigue, and myalgia. Patient taking paracetamol where symptoms do not subside. She had no history of any close contact with cattle or domestic animals. The patient's family history as well as his medical and surgical history were unremarkable. On admission, the patient was in an ill condition. Her body temperature was 102.7 degrees Fahrenheit, her respiratory rate was 24 breaths/min, her heart rate was 110 beats/min, and her blood pressure was 130/80 mm of hg. Chest auscultation revealed crackles over the lower zone of the right hemithorax. During the admission, the patient’s blood picture revelaed decreased hemoglobin and decreased platelets with elevated liver enzymes and vitamin B12 levels. Tests Results Normal range Hemoglobin ( gm%) 8.9 11.5–16.5 Total leucocyte count (/cumm) 3300 4000–11000 Platelets 1,93,000 1,50,000–4,50,000 Liver function test Total bilirubin (mg/dl) 0.9 0.4–1.2 Direct bilirubin (mg/dl) 0.3 0.0–0.4 Indirect bilirubin (mg/dl) 0.6 0.0–0.8 Alkaline phosphatase (U/L) 391.0 30–120 S.G.P.T (IU/L) 117.0 5–35 S.G.O.T (IU/L) 94.0 8–40 Total protein (gm%) 5.6 6–8 Albumin (gm%) 3.0 3.5–5.5 Globulin (g/dl) 2.6 2.0–3.8 A/G ratio 1.2 1.2 to 2.0:1 Renal function test Serum urea (mg/dl) 17.0 10–45 Serum creatinine (mg/dl) 0.63 0.6–1.4 Sodium (mEq/l) 137 135–155 Potassium (mEq/l) 3.9 3.5–5.5 immunology CRP Positive Endocrine Vit. B 12 (pga/ml) 1024.0 211 − 11 Stool tests and routine urinalysis were normal. The Widal test was positive for the S. typhi O antigen. As part of the routine fever panel tests, blood culture, urine culture, and ELISA for typhoid IgG, IgM, dengue IgM, IgG, and NS1, Leptospira IgG, IgM, and scrub typhus IgG, IgM, and malaria MP (RDT) (Pv/Pf) Ag, MP (slide), and Brucella abortus antigen were performed, of which the results for scrub typhus IgM, typhoid IgG, IgM, and Brucella abortus antigen were positive. Blood culture and urine culture were negative. Serology was nonreactive, and thyroid function tests and serum iron profiles were within the normal range. An ultrasound of the abdomen revealed hepatosplenomegaly with a sludge gallbladder. An echocardiography revealed mild tricuspid regurgitation. During the first few days of hospitalization, the patient was treated with ceftriaxone and doxycycline for a fever of unknown origin until brucellosis was diagnosed. five days after the initial course of medications, she complained of a fever that had not subsided despite her full compliance with the medication. Following confirmation of brucellosis, definitive therapy was initiated, with the patient starting on Tab. Rifampicin 600 mg once a day for 5 days After three days of rifampicin therapy, the patient became afebrile. The patient's symptoms improved, and she was discharged after receiving maintenance therapy consisting of the oral cap doxycycline 100 mg once daily for 35 days and Tab rifampicin 600 mg once daily for 40 days. The patient had been in contact three months later, and she had recovered from her issues. Discussion Human Brucella is transmitted through the consumption of infected, unpasteurized animal products or infected animal fluids (such as blood, urine, or milk) or the inhalation of infected aerosolized particles. Brucella organisms eventually become trapped inside monocytes and macrophages of the reticuloendothelial system (RES), which includes the lymph nodes, the liver, the spleen, and the bone marrow. 5 Scrub typhus, caused by Orientia tsutsugamushi , is an important but neglected vector-borne zoonotic disease with an increasing known distribution, with the majority of the disease occurring in South and East Asia and Pacific regions. 6 . The identification of scrub typhus and brucellosis is crucial in areas where coinfection may be suspected because they share clinical characteristics with the more prevalent typhoid fever. The prognosis of the patients is significantly improved by early detection, which also helps to shorten hospital stays and prevent complications. These viruses cause vague symptoms such as fever, malaise, and gastrointestinal difficulties, which could lead to systemic sickness, making it difficult to identify the infection source without a thorough diagnostic investigation. Owing to the overlapping clinical presentation of these viruses and bacteria, it is always difficult to diagnose a patients with such coinfections in rural areas of Nepal because of the limited diagnostic resources available, which makes such co-infections in rural areas of Nepal because of the limited diagnostic resources available, making it challenging to detect and treat such infections. In a 3 study mixed seropositivity for scrub typhus alongside dengue, brucellosis, and typhoid was detected in 12 (0.6%), 9 (0.4%), and 5 (0.2%) cases, respectively. However, the simultaneous occurrence of all three infections has never been documented before, making our case report unique. In our cases, we made the diagnosis of brucellosis via ELISA. A standard agglutination test (SAT) level of ≥ 1:320 and a 2-mercaptoethanol (2-ME) titer of ≥ 1:80 in patients with compatible clinical symptoms are the primary diagnostic tests for brucellosis in underdeveloped nations. 7 The sensitivity of ELISA IgM and IgG was inferior to that of SAT (45% and 79% versus 95%, respectively); however, when ELISA IgM and IgG were utilized in conjunctions, their sensitivity and specificity were equal to SAT (94% and 97%, respectively). However, because of the increased time consumption and the potential for cross-reactivity with other bacteria in the SAT, we opted for the ELISA in our setup. Elisa has tested positive for Brucella abortus . We also attempt to identify Brucella from blood cultures. Regrettably, the blood culture yielded a negative result, despite the sensitivity for diagnosing brucellosis ranging from 15 to 70. 8 In Nepal, the IgM immunofluorescence assay (IFA) and IgM ELISA are frequently utilized for the diagnosis of scrub typhus. We confirm the presence of scrub typhus via IgM ELISA, which demonstrated an overall sensitivity of 84.0% (95% CI: 79.73–87.68%) and a specificity of 94.82% (95% CI: 93.43–95.99%). 9 In addition to the lower specificity of the Widal test, in our setting we used it to detect anti-Salmonella typhi antibodies via the Widal test. Despite the lower specificity of the Widal test, we utilized it to identify anti-Salmonella typhi antibodies in our context. In conclusion, we established a diagnosis of triple coinfection via ELISA and Widal testing. In rural settings with limited resources, we employ nongold standard techniques to identify infections. The primary objective of the diagnosis is to achieve early detection in endemic regions such as Nepal and South Asia, followed by appropriate treatment to avert future complications. Abbreviations ELISA Enzyme-linked immunosorbent assay IFA Immunofluorescence assay SAT Standard agglutination test IgG Immunoglobulin G IgM Immunoglobulin M IFA immunofluorescence assay SAT Standard agglutination test MP malaria parasite RDT Rapid diagnostic Test Pv/pf Plasmodium vivax/plasmodium falciparum Declarations Patient Consent Written informed consent was obtained from the patient for publication of this case report. Ethical approval Not applicable. Consent for publication The written consent form for publication has been obtained from the patients and the hospital administrations. Availability of data and materials Data sharing is not relevant to this article, as no datasets were generated or analyzed in the current study. Funding No funding or grant support Authors contributions: All the authors have prepared, read, and approved the final manuscript. Disclosure : none Conflict of interest: The authors have no conflicts of interest. Acknowledgment: Not applicable. References Pappas G, Akritidis N, Bosilkovski M, Tsianos E, Brucellosis. N Engl J Med. 2005;352(22). 10.1056/NEJMra050570 . https://www.nejm.org/doi/full/ . Corbel MJ. Brucellosis: an Overview - 3, Number 2—June 1997 - Emerging Infectious Diseases journal - CDC. Emerg Infect Dis. 1997;3(2):213–21. https://wwwnc.cdc.gov/eid/article/3/2/97-0219_article . Pokhrel A, Rayamajhee B, Khadka S, Thapa S, Kapali S, Pun SB et al. Seroprevalence and clinical features of scrub typhus among febrile patients attending a referral hospital in Kathmandu, Nepal. Trop Med Infect Dis.;6(2):78. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8163188/ Babarmahal K. Monsoon Preparedness & Response Plan-2077 Part 1 Monsoon Preparedness and Response Plan. :2077. Corbel MJ. Brucellosis in Humans and Animals. World Health Organization; 2006. p. 102. Elliott I, Pearson I, Dahal P, Thomas NV, Roberts T, Newton PN. Scrub typhus ecology: a systematic review of Orientia in vectors and hosts. Parasit Vectors. 2019;12(1):513. https://pmc.ncbi.nlm.nih.gov/articles/PMC6829833/ . Roushan MRH, Amiri MJS, Laly A, Mostafazadeh A, Bijani A. Follow-up standard agglutination and 2-mercaptoethanol tests in 175 clinically cured cases of human brucellosis. Int J Infect Dis. 2010;14(3):e250–3. Memish Z, Mah MW, Mahmoud S, Al, Shaalan M, Al, Khan MY. Brucella bacteraemia: Clinical and laboratory observations in 160 patients. J Infect. 2000;40(1):59–63. https://pubmed.ncbi.nlm.nih.gov/10762113/ . Gautam R, Parajuli K, Tshokey T, Stenos J, Sherchand JB. Diagnostic evaluation of IgM ELISA and IgM Immunofluorescence assay for the diagnosis of Acute Scrub Typhus in central Nepal. BMC Infect Dis. 2020;20(1):1–6. 10.1186/s12879-020-4861-y . https://bmcinfectdis.biomedcentral.com/articles/ . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-5790693\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Case Report\",\"associatedPublications\":[],\"authors\":[{\"id\":400476452,\"identity\":\"e45a4432-c10f-4535-9103-c0552ed91e15\",\"order_by\":0,\"name\":\"Santosh Basyal\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABE0lEQVRIiWNgGAWjYPCCAwlg6gGPjRyY+wC/csYGuJYEmTRjJBOI0mJzOLEBzMCjXr797PEHH/7cyePvP2P4ISHncPr8sMMPgSbYyek2YNdicCYvsXFm27NiiRs5xhIJZ9JzN95OMwBqSTY2O4BDC0OOYTNvA9A9N3gMJBJ7rHM3zk4AaTmQuA2HFvn+N4bNPH8OJ84/f8b4R+I/5nTD2ekf8GphuAG0hYftcOKGAzlmEgk8zgny0jn4bTG48cZw5sy2w8WGN9LKLBJ40gw3SOcUHEgwwO0X+f4cgw8f/hzOkzt/ePONDzw28vKz0zd/+FBhJ4dLCxLgMIDYewASLMQA9gcQexuIUj0KRsEoGAUjCAAAwqpuMOmPIBQAAAAASUVORK5CYII=\",\"orcid\":\"\",\"institution\":\"\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Santosh\",\"middleName\":\"\",\"lastName\":\"Basyal\",\"suffix\":\"\"},{\"id\":400476453,\"identity\":\"279af896-f2b4-48f2-8b6e-820640489492\",\"order_by\":1,\"name\":\"Dipendra prasad yadav\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Dipendra\",\"middleName\":\"prasad\",\"lastName\":\"yadav\",\"suffix\":\"\"},{\"id\":400476454,\"identity\":\"0eb2679c-cc5a-4a5d-9cd2-f2d1e07c50b6\",\"order_by\":2,\"name\":\"Neeraj Acharya\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Neeraj\",\"middleName\":\"\",\"lastName\":\"Acharya\",\"suffix\":\"\"},{\"id\":400476455,\"identity\":\"09f176ff-8d20-4109-a4b9-2be44d5f47a3\",\"order_by\":3,\"name\":\"Roshika Budhathoki\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Roshika\",\"middleName\":\"\",\"lastName\":\"Budhathoki\",\"suffix\":\"\"},{\"id\":400476456,\"identity\":\"62ffe02d-3b1a-4816-a4e6-17add4d6a7a1\",\"order_by\":4,\"name\":\"Rahul parajuli\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Rahul\",\"middleName\":\"\",\"lastName\":\"parajuli\",\"suffix\":\"\"},{\"id\":400476457,\"identity\":\"4d21f2d2-250b-48a3-8cac-069aba37acd8\",\"order_by\":5,\"name\":\"Shardul Bhattarai\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Shardul\",\"middleName\":\"\",\"lastName\":\"Bhattarai\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-01-08 16:23:14\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-5790693/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-5790693/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":74328230,\"identity\":\"0c65be02-9108-46ce-a934-12125c336b74\",\"added_by\":\"auto\",\"created_at\":\"2025-01-21 06:08:54\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":471902,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5790693/v1/df3e847d-982f-408e-ad03-3a32a6485e7c.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Triple coinfections of Brucella abortus, scrub typhus, and S. typhi in the subtropical region of Nepal: A rare case report\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eBrucellosis is a persistent granulomatous infection caused by intracellular bacteria that require appropriate antibiotic treatment. Four of the six traditional diseases are known to cause human zoonoses: \\u003cem\\u003eB. melitensis, B. abortus\\u003c/em\\u003e, \\u003cem\\u003eB. suis\\u003c/em\\u003e, and \\u003cem\\u003eB. canis\\u003c/em\\u003e. Among them, \\u003cem\\u003eB. melitensis\\u003c/em\\u003e, which is isolated from sheep, goats, and camels, is responsible for the majority of human cases worldwide.\\u003csup\\u003e\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u003c/sup\\u003e In humans, brucellosis caused by \\u003cem\\u003eB. melitensis\\u003c/em\\u003e is by far the most severe clinical condition.\\u003csup\\u003e\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003eAnother disease to be cautious about is scrub typhus, which is endemic in Nepal and is caused by the bacteria \\u003cem\\u003eOrientia tsutsugamushi.\\u003c/em\\u003e Because scrub typhus lacks clear clinical symptoms and reliable diagnostic tools, it is often underdiagnosed.\\u003csup\\u003e\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e\\u003c/sup\\u003e Typhoid, dengue fever, and scrub typhus are most likely to spread during the monsoon and post monsoon seasons in endemic countries such as Nepal. \\u003csup\\u003e\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e\\u003c/sup\\u003e. The majority of cases are associated with \\u003cem\\u003eB. melitensis\\u003c/em\\u003e, but we report a 35-year-old female who presented with fever and had a rare coinfection involving \\u003cem\\u003eB. abortus\\u003c/em\\u003e, \\u003cem\\u003escrub typhus\\u003c/em\\u003e, and typhoid in the southern subtropical region of Nepal following the monsoon season.\\u003c/p\\u003e\"},{\"header\":\"Case presentation\",\"content\":\"\\u003cp\\u003eIn October 2024, a 35-year-old female patient presented to the Damak Hospital in Jhapa, Nepal, with a five-day history of fever, fatigue, and myalgia. Patient taking paracetamol where symptoms do not subside. She had no history of any close contact with cattle or domestic animals. The patient's family history as well as his medical and surgical history were unremarkable.\\u003c/p\\u003e \\u003cp\\u003eOn admission, the patient was in an ill condition. Her body temperature was 102.7 degrees Fahrenheit, her respiratory rate was 24 breaths/min, her heart rate was 110 beats/min, and her blood pressure was 130/80 mm of hg. Chest auscultation revealed crackles over the lower zone of the right hemithorax. During the admission, the patient\\u0026rsquo;s blood picture revelaed decreased hemoglobin and decreased platelets with elevated liver enzymes and vitamin B12 levels.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"No\\\" id=\\\"Taba\\\" border=\\\"1\\\"\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTests\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eResults\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003eNormal range\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHemoglobin ( gm%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003e11.5\\u0026ndash;16.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTotal leucocyte count (/cumm)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3300\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003e4000\\u0026ndash;11000\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePlatelets\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1,93,000\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003e1,50,000\\u0026ndash;4,50,000\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eLiver function test\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTotal bilirubin (mg/dl)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003e0.4\\u0026ndash;1.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDirect bilirubin (mg/dl)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003e0.0\\u0026ndash;0.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eIndirect bilirubin (mg/dl)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003e0.0\\u0026ndash;0.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAlkaline phosphatase (U/L)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e391.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003e30\\u0026ndash;120\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eS.G.P.T (IU/L)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e117.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003e5\\u0026ndash;35\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eS.G.O.T (IU/L)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e94.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003e8\\u0026ndash;40\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTotal protein (gm%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e5.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003e6\\u0026ndash;8\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAlbumin (gm%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003e3.5\\u0026ndash;5.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGlobulin (g/dl)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003e2.0\\u0026ndash;3.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eA/G ratio\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003e1.2 to 2.0:1\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eRenal function test\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSerum urea (mg/dl)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e17.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003e10\\u0026ndash;45\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSerum creatinine (mg/dl)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.63\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003e0.6\\u0026ndash;1.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSodium (mEq/l)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e137\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003e135\\u0026ndash;155\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePotassium (mEq/l)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e3.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e \\u003cp\\u003e3.5\\u0026ndash;5.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eimmunology\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCRP\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c4\\\" namest=\\\"c2\\\"\\u003e \\u003cp\\u003ePositive\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eEndocrine\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"3\\\" nameend=\\\"c4\\\" namest=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVit. B 12 (pga/ml)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c3\\\" namest=\\\"c2\\\"\\u003e \\u003cp\\u003e1024.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e211\\u0026thinsp;\\u0026minus;\\u0026thinsp;11\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eStool tests and routine urinalysis were normal. The Widal test was positive for the S. typhi O antigen. As part of the routine fever panel tests, blood culture, urine culture, and ELISA for typhoid IgG, IgM, dengue IgM, IgG, and NS1, Leptospira IgG, IgM, and scrub typhus IgG, IgM, and malaria MP (RDT) (Pv/Pf) Ag, MP (slide), and \\u003cem\\u003eBrucella abortus\\u003c/em\\u003e antigen were performed, of which the results for scrub typhus IgM, typhoid IgG, IgM, and \\u003cem\\u003eBrucella abortus\\u003c/em\\u003e antigen were positive. Blood culture and urine culture were negative. Serology was nonreactive, and thyroid function tests and serum iron profiles were within the normal range. An ultrasound of the abdomen revealed hepatosplenomegaly with a sludge gallbladder. An echocardiography revealed mild tricuspid regurgitation.\\u003c/p\\u003e \\u003cp\\u003eDuring the first few days of hospitalization, the patient was treated with ceftriaxone and doxycycline for a fever of unknown origin until brucellosis was diagnosed. five days after the initial course of medications, she complained of a fever that had not subsided despite her full compliance with the medication. Following confirmation of brucellosis, definitive therapy was initiated, with the patient starting on Tab. Rifampicin 600 mg once a day for 5 days After three days of rifampicin therapy, the patient became afebrile. The patient's symptoms improved, and she was discharged after receiving maintenance therapy consisting of the oral cap doxycycline 100 mg once daily for 35 days and Tab rifampicin 600 mg once daily for 40 days. The patient had been in contact three months later, and she had recovered from her issues.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eHuman Brucella is transmitted through the consumption of infected, unpasteurized animal products or infected animal fluids (such as blood, urine, or milk) or the inhalation of infected aerosolized particles. Brucella organisms eventually become trapped inside monocytes and macrophages of the reticuloendothelial system (RES), which includes the lymph nodes, the liver, the spleen, and the bone marrow. \\u003csup\\u003e\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u003c/sup\\u003e Scrub typhus, caused by \\u003cem\\u003eOrientia tsutsugamushi\\u003c/em\\u003e, is an important but neglected vector-borne zoonotic disease with an increasing known distribution, with the majority of the disease occurring in South and East Asia and Pacific regions. \\u003csup\\u003e\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eThe identification of scrub typhus and brucellosis is crucial in areas where coinfection may be suspected because they share clinical characteristics with the more prevalent typhoid fever. The prognosis of the patients is significantly improved by early detection, which also helps to shorten hospital stays and prevent complications. These viruses cause vague symptoms such as fever, malaise, and gastrointestinal difficulties, which could lead to systemic sickness, making it difficult to identify the infection source without a thorough diagnostic investigation. Owing to the overlapping clinical presentation of these viruses and bacteria, it is always difficult to diagnose a patients with such coinfections in rural areas of Nepal because of the limited diagnostic resources available, which makes such co-infections in rural areas of Nepal because of the limited diagnostic resources available, making it challenging to detect and treat such infections.\\u003c/p\\u003e \\u003cp\\u003eIn a \\u003csup\\u003e\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e\\u003c/sup\\u003e study mixed seropositivity for scrub typhus alongside dengue, brucellosis, and typhoid was detected in 12 (0.6%), 9 (0.4%), and 5 (0.2%) cases, respectively. However, the simultaneous occurrence of all three infections has never been documented before, making our case report unique.\\u003c/p\\u003e \\u003cp\\u003eIn our cases, we made the diagnosis of brucellosis via ELISA. A standard agglutination test (SAT) level of \\u0026ge;\\u0026thinsp;1:320 and a 2-mercaptoethanol (2-ME) titer of \\u0026ge;\\u0026thinsp;1:80 in patients with compatible clinical symptoms are the primary diagnostic tests for brucellosis in underdeveloped nations. \\u003csup\\u003e\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u003c/sup\\u003e The sensitivity of ELISA IgM and IgG was inferior to that of SAT (45% and 79% versus 95%, respectively); however, when ELISA IgM and IgG were utilized in conjunctions, their sensitivity and specificity were equal to SAT (94% and 97%, respectively). However, because of the increased time consumption and the potential for cross-reactivity with other bacteria in the SAT, we opted for the ELISA in our setup. Elisa has tested positive for \\u003cem\\u003eBrucella abortus\\u003c/em\\u003e. We also attempt to identify Brucella from blood cultures. Regrettably, the blood culture yielded a negative result, despite the sensitivity for diagnosing brucellosis ranging from 15 to 70. \\u003csup\\u003e\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003eIn Nepal, the IgM immunofluorescence assay (IFA) and IgM ELISA are frequently utilized for the diagnosis of scrub typhus. We confirm the presence of scrub typhus via IgM ELISA, which demonstrated an overall sensitivity of 84.0% (95% CI: 79.73\\u0026ndash;87.68%) and a specificity of 94.82% (95% CI: 93.43\\u0026ndash;95.99%).\\u003csup\\u003e9\\u003c/sup\\u003e\\u003c/p\\u003e \\u003cp\\u003eIn addition to the lower specificity of the Widal test, in our setting we used it to detect anti-Salmonella typhi antibodies via the Widal test. Despite the lower specificity of the Widal test, we utilized it to identify anti-Salmonella typhi antibodies in our context.\\u003c/p\\u003e \\u003cp\\u003eIn conclusion, we established a diagnosis of triple coinfection via ELISA and Widal testing. In rural settings with limited resources, we employ nongold standard techniques to identify infections. The primary objective of the diagnosis is to achieve early detection in endemic regions such as Nepal and South Asia, followed by appropriate treatment to avert future complications.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 20.2216%;\\\"\\u003e\\n \\u003cp\\u003eELISA\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 79.7784%;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;Enzyme-linked immunosorbent assay\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 20.2216%;\\\"\\u003e\\n \\u003cp\\u003eIFA\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 79.7784%;\\\"\\u003e\\n \\u003cp\\u003eImmunofluorescence assay\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 20.2216%;\\\"\\u003e\\n \\u003cp\\u003eSAT\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 79.7784%;\\\"\\u003e\\n \\u003cp\\u003eStandard agglutination test\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 20.2216%;\\\"\\u003e\\n \\u003cp\\u003eIgG\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 79.7784%;\\\"\\u003e\\n \\u003cp\\u003eImmunoglobulin G\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 20.2216%;\\\"\\u003e\\n \\u003cp\\u003eIgM\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 79.7784%;\\\"\\u003e\\n \\u003cp\\u003eImmunoglobulin M\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 20.2216%;\\\"\\u003e\\n \\u003cp\\u003eIFA\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 79.7784%;\\\"\\u003e\\n \\u003cp\\u003eimmunofluorescence assay\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 20.2216%;\\\"\\u003e\\n \\u003cp\\u003eSAT\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 79.7784%;\\\"\\u003e\\n \\u003cp\\u003eStandard agglutination test\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 20.2216%;\\\"\\u003e\\n \\u003cp\\u003eMP\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 79.7784%;\\\"\\u003e\\n \\u003cp\\u003emalaria parasite\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 20.2216%;\\\"\\u003e\\n \\u003cp\\u003eRDT\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 79.7784%;\\\"\\u003e\\n \\u003cp\\u003eRapid diagnostic Test\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 20.2216%;\\\"\\u003e\\n \\u003cp\\u003ePv/pf\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 79.7784%;\\\"\\u003e\\n \\u003cp\\u003ePlasmodium vivax/plasmodium falciparum\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003ePatient Consent\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWritten informed consent was obtained from the patient for publication of this case report.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthical approval\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe written consent form for publication has been obtained from the patients and the hospital administrations.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eData sharing is not relevant to this article, as no datasets were generated or analyzed in the current study.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNo funding or grant support\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors contributions:\\u0026nbsp;\\u003c/strong\\u003eAll the authors have prepared, read, and approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eDisclosure\\u003c/strong\\u003e:\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003enone\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConflict of interest:\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors have no conflicts of interest.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgment:\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003ePappas G, Akritidis N, Bosilkovski M, Tsianos E, Brucellosis. N Engl J Med. 2005;352(22). \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1056/NEJMra050570\\u003c/span\\u003e\\u003cspan address=\\\"10.1056/NEJMra050570\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.nejm.org/doi/full/\\u003c/span\\u003e\\u003cspan address=\\\"https://www.nejm.org/doi/full/\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCorbel MJ. Brucellosis: an Overview - 3, Number 2\\u0026mdash;June 1997 - Emerging Infectious Diseases journal - CDC. Emerg Infect Dis. 1997;3(2):213\\u0026ndash;21. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://wwwnc.cdc.gov/eid/article/3/2/97-0219_article\\u003c/span\\u003e\\u003cspan address=\\\"https://wwwnc.cdc.gov/eid/article/3/2/97-0219_article\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003ePokhrel A, Rayamajhee B, Khadka S, Thapa S, Kapali S, Pun SB et al. Seroprevalence and clinical features of scrub typhus among febrile patients attending a referral hospital in Kathmandu, Nepal. Trop Med Infect Dis.;6(2):78. Available from: \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://pmc.ncbi.nlm.nih.gov/articles/PMC8163188/\\u003c/span\\u003e\\u003cspan address=\\\"https://pmc.ncbi.nlm.nih.gov/articles/PMC8163188/\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBabarmahal K. Monsoon Preparedness \\u0026amp; Response Plan-2077 Part 1 Monsoon Preparedness and Response Plan. :2077.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCorbel MJ. Brucellosis in Humans and Animals. World Health Organization; 2006. p. 102.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eElliott I, Pearson I, Dahal P, Thomas NV, Roberts T, Newton PN. Scrub typhus ecology: a systematic review of Orientia in vectors and hosts. Parasit Vectors. 2019;12(1):513. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://pmc.ncbi.nlm.nih.gov/articles/PMC6829833/\\u003c/span\\u003e\\u003cspan address=\\\"https://pmc.ncbi.nlm.nih.gov/articles/PMC6829833/\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRoushan MRH, Amiri MJS, Laly A, Mostafazadeh A, Bijani A. Follow-up standard agglutination and 2-mercaptoethanol tests in 175 clinically cured cases of human brucellosis. Int J Infect Dis. 2010;14(3):e250\\u0026ndash;3.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMemish Z, Mah MW, Mahmoud S, Al, Shaalan M, Al, Khan MY. Brucella bacteraemia: Clinical and laboratory observations in 160 patients. J Infect. 2000;40(1):59\\u0026ndash;63. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://pubmed.ncbi.nlm.nih.gov/10762113/\\u003c/span\\u003e\\u003cspan address=\\\"https://pubmed.ncbi.nlm.nih.gov/10762113/\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGautam R, Parajuli K, Tshokey T, Stenos J, Sherchand JB. Diagnostic evaluation of IgM ELISA and IgM Immunofluorescence assay for the diagnosis of Acute Scrub Typhus in central Nepal. BMC Infect Dis. 2020;20(1):1\\u0026ndash;6. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1186/s12879-020-4861-y\\u003c/span\\u003e\\u003cspan address=\\\"10.1186/s12879-020-4861-y\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://bmcinfectdis.biomedcentral.com/articles/\\u003c/span\\u003e\\u003cspan address=\\\"https://bmcinfectdis.biomedcentral.com/articles/\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Triple infection, brucellosis, subtropical region\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-5790693/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-5790693/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e \\u003cp\\u003eBrucella is a zoonotic bacterial infection that requires antibiotic treatment. Four of the six traditional diseases cause human zoonoses: \\u003cem\\u003eB. melitensis\\u003c/em\\u003e, \\u003cem\\u003eB. abortus\\u003c/em\\u003e, \\u003cem\\u003eB. suis\\u003c/em\\u003e, and \\u003cem\\u003eB. canis\\u003c/em\\u003e. \\u003cem\\u003eB. melitensis\\u003c/em\\u003e causes the majority of cases worldwide, but B. abortus is often misdiagnosed. The lack of clear symptoms often leads to the underdiagnosis of scrub typhus, another endemic disease in Nepal. In Nepal, typhoid, dengue fever, and scrub typhus spread during the monsoon and post monsoon seasons, often coinfecting each other.\\u003c/p\\u003e\\u003ch2\\u003eCase presentation:\\u003c/h2\\u003e \\u003cp\\u003eA 35-year-old female patient with fever, fatigue, and myalgia presented to Damak Hospital in Jhapa, Nepal, with no history of close contact with animals. We admitted her due to her fever, fatigue, and myalgia, and initial reports revealed a decrease in her hemoglobin and platelets. Routine urinalysis and stools were normal, but the patient tested positive for the S. typhi O antigen. Enzyme-linked immunosorbent assay (ELISA) tests revealed positive results for scrub typhus and \\u003cem\\u003eBrucella abortus\\u003c/em\\u003e antigens.\\u003c/p\\u003e\\u003ch2\\u003eConclusion:\\u003c/h2\\u003e \\u003cp\\u003eThis study identified triple coinfection via enzyme-linked immunosorbent assay (ELISA) and Widal testing in rural areas, with the aim of early detection in endemic regions such as Nepal and South Asia.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Triple coinfections of Brucella abortus, scrub typhus, and S. typhi in the subtropical region of Nepal: A rare case report\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-01-13 07:57:01\",\"doi\":\"10.21203/rs.3.rs-5790693/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"4a1952c2-c008-4e5d-9b57-93fe50f39bc1\",\"owner\":[],\"postedDate\":\"January 13th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-01-31T05:38:05+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-01-13 07:57:01\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-5790693\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-5790693\",\"identity\":\"rs-5790693\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}