Abstract

Introduction: Unconscious young patients are admitted to hospitals in Dhaka nearly on a daily basis, mostly due to intoxications. However, the following case underscores that routine laboratory and imaging investigations do not replace a detailed history.

Case:
A 17-year old man was found unconscious in the early morning. His family mentioned he had complained about headaches for the last month, but no other complaints or fever. At the emergency department his temperature was 1020F, respiratory rate 32/min and pulse 125/min. He was unresponsive and had uncontrolled jerky movements, without signs of lateralisation and with normal brainstem reflexes. Empiric therapy with broad-spectrum antibiotics, aciclovir and dexamethasone was initiated on low suspicion of infectious meningo-encephalitis

Blood Chemistry:
C-reactive protein 326 mg/l
Haemoglobin 5.2 mmol/l
Total Count 6.4*109/l
Platelets 131*109/l
Lactate dehydrogenase 575 U/l

Cerebrospinal Fluid Study:
Leukocytes 9/mm3
Glucose 4.4 mmol/l
Protein 0.26 g/l

CT Brain:
No abnormalities detected

Follow up:
 At the intensive care unit he developed a fever up to 1040F and haemoglobin level decreased to 3.6 mmol/l. Further interrogation of the parents reported a visit to Sajek, Rangamati month before. He had not taken any prophylaxis. A thick smear was positive: plasmodium falciparum with a parasitemia of 0.3%. Also ICT for Malaria was also positive for plasmodium falciparum. after artesunate 2.4 mg/kg twice daily intravenously the patient recovered rapidly. On follow up he had minor concentration problems.

Conclusions:
Cerebral Malaria is a diffuse encephalopathy caused by a systemic infection with plasmodium falciparum. Children are at a higher risk than adults. Focal signs are unusual and both CT and CSF are usually unremarkable. It is important to note that cerebral malaria may have a prolonged incubation time and may be lethal even with low parasitemia. Early treatment is vital.

Essential Messages in Cerebral Malaria:
• Cerebrospinal fluid cell count can be normal
• May present a long time after the primary infection