Saleem Iqbal, Abdul Hafiz Pirzada, Sadeequr Rahman, Noorul Iman.
Cerebral Malaria, an experience in NWFP, Pakistan.
J Med Sci Jan ;14(1):35-9.

Background: Cerebral malaria is defined as unrousable coma persisting for more than 6 hours following a generalized convulsion, after excluding other causes of encephalopathy, and confirmed by finding asexual forms of P. Falciparum in peripheral smear or bone marrow in life or in a brain smear after death1,2. It occurs in 0.01% to 16% patients suffering from falciparum malaria. Research Methodology: This observational study was conducted in Medical C Unit of Khyber Teaching Hospital Peshawar, from 1st July 2001 to 12th December 2002. Fifty patients above 14 years, who presented with clinical features suggestive of cerebral malaria, having positive plasmodium falciparum in blood smear, were included. Patients less than 13 years age, or who were found to be smear negative and patients who became unconscious after having generalized convulsion but regained consciousness within six hours, were excluded. Results: Out of 50 patients, 32 patients (64%) were male and 18 patients (36%) were female. Six ladies were pregnant. 66% patients were below 30 years of age. All the fifty patients (100%) presented with fever and altered consciousness. Gastrointestinal symptoms like nausea, vomiting, diarrhea and abdominal pain were present in 70%, headache in 60%, and seizures in 35%. On admission 80% patients were in coma grade II to IV. Hepatomegaly was present in 48%, splenomegaly in 50% and both hepatosplenomegaly in 52% patients. Bilateral upgoing planters were present in 76% patients, bilateral upper motor neuron signs in 32%, and one patient had both 6th and 7th cranial nerve palsy. Hypoglycemia was observed in 24%, severe anaemia in 40%, renal failure in 24%, septicaemia in 10%, DIC in 7.5%, aspiration pneumonia in 05%, shock in 05%, and still birth in 2.5%. Peripheral blood smears revealed gametocytes in 32%, trophozoites in 44% and both gametocytes and tophozoites 24% patients. Thrombocytopenia less than 50000/mm3 were seen in 22%. Four pregnant ladies expired due to multiple complications. CSF opening pressure was raised in 16% and CSF proteins were raised in 26% patients. MRI brain showed cerebral oedema in 8% patients. All the patients were given quinine for 7 days. Most of the patients regained consciousness in less than 48 hours after the 1st dose of quinine. Fever resolution time was on average 72 hours and parasite clearance time was 96 hours. An overall mortality of 16% was noticed. Conclusions: Cerebral malaria is more common in males. The most vulnerable group is pregnant ladies, carrying high mortality i.e., 66.6% because of parasitization of placenta with PRBCs. Quinine remains the drug of first choice for the management of cerebral malaria.

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