Dr. Gadadhar Sarangi Cuttack, Orissa

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CEREBRAL MALARIA

• Dr. Gadadhar SarangiCuttack, Orissa

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Malaria Threatens 40 world population
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From Near Extinsion in 1976 India contributes 85
of cases in South East Asia 1st clinical
description Hippocrates Elaborated
Celsus Peruvian Bark in therapy 17th
Century Quinine 1820 Man to Mosquito Cycle
Sir Ronald Ross 1998-99
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Definition

• Complication of plasmodium falciparum
• Unarousable coma more than 30 mts
• Exclusion of other causes

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Aetio Pathogenesis

• Sequestration of Cerebral Capillaries and Venules

• Ring like lesions in the Brain

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Mechanical Hypothesis
P. falciparum parasites in brain capillary
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Section of brain showing blood vessels blocked
with developing P. falciparum parasites
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• Selective Cytoadherance results in rosetting
• Reduction of Microvascular Blood flow
• Hypoxia
• Dose not explain selective absence of
  Neurological Deficits

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Humoral Hypothesis

• Malaria Toxin
• Stimulates Production of TNF- alpha Cytokines
• Stimulate Endothelial cells
• Uncontrolled production of NO
• COMA

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CLINICAL MANIFASTATIONS

• The seasonal Trend

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• Earliest Manifestations -
• Fever
• Loss of Appetite
• Vomiting
• Cough
• Specific for Cerebral Malaria
• Impaired consiousness
• Gen. Convulsion with Sequelae
• Coma

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Coma Scale for Children

• Best Motor response Localizes painful stimulus 2
• Withdraws limb from pain 1
• Non-specific or Absent
• response 0
• Verbal Response Appropriate Cry 2
• Moan or Inappropriate cry 1
• None 0
• Eye Movements Directed 1
• (e.g. follows mothers face)
• Not directed 0
• Total 0-5

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Associated Presentation

• Hypoglycaemia
• Metabolic Acidosis
• Shock
• Neurological deficits
• Other forms can Co-exist

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LABORATORY DIAGNOSIS
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Diagnosis of Falciparum Malaria

• Conventional Microscopy
• Giemsa Stain
• Field Stain

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Stages of P. falciparum
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LABORATORY DIAGNOSIS Contd.

• Fluorescence Microscopy (QBC)
• Nucleic Acid Staining with acridine
• Parasite Count (TLC / Cuml X Parasite / 100
  WBC) / 100 Parasite / Cuml of Blood
• Serology
• Anti body detection
• Antigen detection (HRP)
• Biochemical Test - Optimal test (Parasite LDH)
• PCR Culture

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CEREBRAL INVOLVEMENT

• Clinical
• CSF - Increased Lactic Acid
• CT, MRI

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THOUGHTS AT BEDSIDE

• Haemoglobin
• Urobilinogen

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THERAPEUTIC OPTIONS

• CHEMOTHERAPY
• Quinine
• Artemisinins - Artesunate
• - Arte- ether
• - Arte - mether

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SUPPORITIVE ADJUNCTIVE THERAPY

• Nursing Care
• Catherization
• Nasogastric tube
• Fluid Electrolyte
• Monitor level of coma vital signs
• Antipyretics
• Anticonvulsants
• Reduction in ICT
• Correction of Hypoglycaemia
• Exchange Transfusion
• IncreaseMicrocirculatory Flow - Pentoxyfylline
• Desferrioxamine
• Correction of - Anaemia, Acidosis, Dehydration

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NEWER HORIZON

• Inhibition of Endothelial Activity
• - LMP 420 - Decrease of TNF alpha LT activity
• Vaccine Development

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The End