Cerebral Malaria

29 March, 2005

Case Study (Click here)

Exclusive to Plasmodium falciparum

2% cases

Especially pregnant women, nonimmune individuals, children

Characterised by headache, seizures, coma & rarely hemiplegia, aphasia, hemianopia, cerebellar ataxia, other focal neuro signs.

Pathophysiology:

1.      Mechanical obstruction

2.      Disseminated vasculomyelinopathy from a neuroallergic reaction (Poser)

-vasculopathy affecting myelin system leading to perivascular demyelination.

Ie myelinoclasia

Vasculopathy: changes in permeability leading to perivascular & parenchymatous

edema

endothelial thickening, vein wall necrosis, microthrombosis,

perivascular hemorrhages

            Myelinoclasia & reactive gliosis: perivascular demyelination, reactive gliosis,

                                                            Malarial granuloma.

Investigations:

CSF:    normal pressure

            Few lymph

            Slight increase protein

            Glucose may be reduced

CT/MRI:          infarction

                        Periventricular hyperintensity; sometimes gadolinium hyperintensity.

EEG: posterior parieto-temporal discharges most common finding

Prognosis

20% mortality

75% complete recovery

5% neurologic sequelae

Postmalaria Neurologic Syndrome

Acute onset of confusion or epileptic seizures, occurring in a patient without parasitemia, with a latency of several days to weeks, after recovery from successfully treated malaria.

1.      localized form with isolated tremor or cerebellar ataxia

2.      mild encephalopathy with acute confusion or seizures

3.      severe, steroid responsive encephalopathy with motor aphasia, generalized myoclonus, tremor & ataxia.

Adverse prognostic markers:

Delay in diagnosis / nondiagnosis

Deep coma with extensor posturing

Absent brainstem reflexes

< 3 yo

parasitemia >100,000/microlitre

high CSF lactate

Low serum glucose

High WCC

Severe metabolic acidosis

Multiorgan failure

Treatment

Iv quinine

Steroids not beneficial & may be harmful

Anti TNF antibodies – useless

Pentoxifylline – useless

Desferroxamine - useless