Cerebral malaria

Cerebral malaria is the main cause of death (80 %) in falciparum malaria. This complication occurs chiefly in non-immune persons (children, travellers). Cerebral signs include confused behaviour, psychosis, convulsions, stupor, coma, paralysis. Unlike meningitis, there is no real neck stiffness (pain) or photophobia (intolerance to light) but neck retraction and opisthotonos may occur. Sometimes the difference between neck stiffness and neck retraction is not clinically clear. It is typical of the coma that it develops swiftly in 75% of cases and also quickly disappears. If a child survives cerebral malaria it has approximately a 10% chance of significant sequelae. Children with cerebral malaria and with a normal eye fundus have a good prognosis, while papiloedema and retinal bleeding suggest a guarded prognosis. Repeated generalised convulsions should not be regarded as "normal" febrile convulsions. Severe convulsions with contraction of the abdominal muscles and compression of the stomach, may cause reflux of gastric acid and food into the pharynx. Aspiration of gastric contents into the lungs is a real danger as this may result in Mendelson’s syndrome or aspiration pneumonia. IM phenobarbital is sometimes given as a prophylactic measure (a dose of 3.5 mg/kg up to 10 mg/kg). If there are convulsions, these are stopped by administering diazepam (Valium®) IV or paraldehyde IM. Paraldehyde should be drawn up into a glass syringe (not plastic). A CT scan or MRI scan of the brain of patients with cerebral malaria shows few abnormalities except fpossibly an increased cerebral volume. Herniation of the brain stem is a rare event.


If confronted by a febrile coma or confusion with fever in the tropics, glucose must be administered (preferably IV), quinine therapy should be instituted and a lumbar puncture carried out without hesitation (to rule out meningitis). Of the persons who will die in hospital due to cerebral malaria, 50% of the fatalities occur within the first 12 hours after admission. At autopsy countless petechiae can be seen in the brain. Small ring-shaped haemorrhages also occur around cerebral blood vessels.

Category: Medicine Notes