Cerebral malaria
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
- 5% of the world’s population is parasitized by malaria at any given time
- 0.5-2.5 million deaths per year
- Nearly all deaths (and neurologic complications) caused by Plasmodium falciparum
- Cerebral Malaria – Case Definition
- Deep level of unconsciousness with inability to localize a painful stimulus
- P. falciparum asexual parasitemia
- Hypoglycemia and other encephalopathies have been excluded
- Coma should persist >6 hours in adults and >1 hour in children after a seizure
- Deep level of unconsciousness with inability to localize a painful stimulus
Pathophysiology & Etiology
- Based on Age and Prior Exposure
- < 2 years old – severe anemia
- 2-18 years old – seizures/cerebral malaria
- >18 years old – acute renal failure, pulmonary edema, liver dysfunction, cerebral malaria
- All – metabolic acidosis (lactate)
- Vector
- Female Anopheles Mosquito
- What’s in the Smear?
- Ring forms mostly (occ banana gametocytes) – because trophozoites and schizonts are sequestered in vascular beds, causing pathology
- Pathology
- Sequestration of parasitized red blood cells (RBCs) in relatively hypoxic venous beds allows optimal parasite growth and prevents splenic destruction
- Peripheral parasite count relatively poor predictor of sequestered biomass
- Parasitized RBCs have electron dense “knobs” on surface, thought to be mediators of cytoadherence
- Antigenic variation of “knobs” allow immune evasion
- Decreased deformability of RBCs
- Increased tumor necrosis factor (TNF) production
History and Symptoms
- Diffuse encephalopathy
- Febrile, unconscious, variable tone, usually lacking focal neurologic signs
- No rash, no lymphadenopathy
- Hypoglycemia common (8% adults, 20% children)
- Seizures (10-50%)
- Mortality 20% (8% ->50% if concomitant with renal failure and metabolic acidosis)
- Most deaths occur within 48 hours of admission
- Full recovery of consciousness takes a median of 2 days, but can take >1 week
Treatment
- Supportive
- IV Quinine (in US, Quinidine 10-20 mg/kg load followed by 0.02 mg/kg/min drip over 72 hours
- Blood transfusion for hematocrit < 20
- Correct hypoglycemia (but does not improve neurologic recovery)
Contraindicated Medications
Future or Investigational Therapies
- Artemisin derivatives may replace quinine in the future
- Exchange transfusion?