4. Cerebral malaria
• It is a serious complication of Plasmodium
falciparum infection.
• Manifests as diffuse symmetric
encephalopathy.
• Common in children and non immune adults.
• Despite treatment fatality rate is ~20%.
• Long term sequelae is rare with appropriate
treatment.
5. Pathogenisis
• Usually develops after several days after
patient has become ill, but may develop
suddenly.
• Occurs with parasitaemia >5%.
6. Late schizonts secretes protein on the on surface
of RBCs
Proteins cause aggregation of non infected RBCs
and capillary endothelium in brain
Capillary plugging
Anoxia, ischemia and haemorrhage
7. Clinical features
• Decreased level of consciousness
- Severity ranges from drowsiness and severe
head ache to delirium, hallucinations, or
deep coma.
• Fever of 106-108oF
• Seizures
• Contracted or unequal pupils, retinal
haemorrhages, papilloedema, discrete spots of
retinal calcification may be seen.
8. • Muscle tone may be either increased or
decreased.
• Abdominal and cremasteric reflexes absent.
• Plantar reflex may be flexor or extensor.
• Hemiplegia
• Cortical blindness
• Cerebral palsy
• Deafness
9. Investigations
• Lumbar puncture
- Increased pressure and proteins
- Minimal or no pleocytosis
- Normal glucose.
• EEG findings are non specific.
10. Treatment
• Intravenous artesunate is the treatment of
choice for sever P. falciparum malaria.
• Artesunate 2.4mg/kg bw i.v or i.m. given.
11. Renal failure
• Is a common complication of severe
P. falciparum malaria.
• Results from deposition of haemoglobin in
renal tubules decreased renal blood flow
acute tubular necrosis ARF
• Blackwater fever is a clinical syndrome which
consists of severe haemolysis,
haemoglobinuria and renal failure.
• Renal failure requires either peritoneal dialysis
or hemodialysis.
12. Non cardiogenic pulmonary oedema
• It is a complication of severe
P. falciparum malaria may occur with P. vivax
also.
• Mortality is >80%.
• Pathogenesis of respiratory distress is unclear.
• It is aggravated by over hydration with IV
fluids.
13. Hypoglycemia
• An important and common complication of
severe malaria.
• Associated with poor prognosis.
• Hypoglycemia occurs due to failure of hepatic
gluconeogenesis.
• Quinine and quinidine also aggravates
hypoglycemia.
14. Acidosis
• Important cause of death from severe malaria.
• Occurs due to anaerobic glycolysis in tissues
sequesterated by parasites interfere with
microcirculation, hypovolemia, lactate
production by parasites and failure of hepatic
and renal lactate clearance.
15. Haematologic abnormalities
• Anemia
- accelerated destruction of RBCs by spleen
- ineffective erythropoiesis
• Thrombocytopenia.
• <5% patients may have significant bleeding
due to DIC.
• Jaundice
16. Relative incidence of severe
complications of Falciparum malaria
Complication Nonpregnant
adults
Pregnant Women Children
Anemia + ++ +++
Convulsions + + +++
Hypoglycemia + +++ +++
Jaundice +++ +++ +
Renal failure +++ +++ -
Pulmonary oedema ++ +++ +
17. Chronic complications of malaria
• Tropical splenomegaly (Hyperreactive
Malarial Splenomegaly) :
• Chronic or repeated malarial infections
produce hypergammaglobulinemia;
normochromic, normocytic anemia; and in
certain situations, splenomegaly
18. Quartan Malarial Nephropathy
• Rarely seen in chronic or repeated infections
with P. malariae.
• Histology shows focal or segmental
glomerulonephritis with splitting of capillary
membrane.
• It usually responds poorly to treatment with
either antimalarial agents or glucocorticoids
and cytotoxic drugs.
19. References
• Nelson’s Textbook of Paediatrics, 18th Edition.
• Harrison’s Principles of Internal Medicine, 17th
Edition.
• Guidelines for the treatment of Malaria,
Second edition, WHO 2010.
