What is cerebral malaria?

Cerebral malaria is the most severe neurological complication of infection with Plasmodium falciparum. With over 575,000 cases annually, children in sub-Saharan Africa are the most affected. Surviving patients have an increased risk of neurological and cognitive deficits, behavioral difficulties and epilepsy making cerebral malaria a leading cause of childhood neuro-disability in the region. The pathogenesis of neuro-cognitive sequelae is poorly understood: coma develops through multiple mechanisms and there may be several mechanisms of brain injury.

Studies have shown that about 10% of all patients of malaria are infected with falciparum malaria and over 80% of deaths occur due to the brain infection. The mortality rate is between 25 to 50% and if not treated promptly, it can cause death within 24 to 72 hours of infection. The most prominent histopathological characteristic of cerebral malaria is the segregation of the cerebral capillaries and venules with parasitized red blood cells (PRBC) and non-parasitized red blood cells (non-PRBC). One will see ring like lesions in the brain.

On rare occations, the parasite causes cerebellar ataxia, but no loss of consciousness. The ataxia can occur up to 4 weeks after a malaria attack occurs, but will disappear after 1-2 weeks.
Physical manifestations of the disease may be an abnormal EEG resulting from the lack of oxygen, loss of sulci, and a MRI may show hemorrhagic lesions and infarction.

If left untreated, cerebral malaria will lead to death of patient. There are two types of cerebral malaria treatment that help in saving the patient’s life. These include antimalarial chemotherapy as adjunctive measure. In case of chemotherapy, the patients with severe cerebral malaria are administered with quinine. The use of this drug that has remained the most effective treatment for cerebral malaria for many years. Quinine affects the digestive ability of the parasite’s enzymatic digestion causing its death.

Without treatment, cerebral malaria is invariably fatal. In children, parenteral antimalarials (cinchonoids or artemisinin derivatives) are indicated, but even with this treatment, 15-20% die.

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