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Case Reports Indian Pediatrics 2007;44:433-434 |
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Plasmodium vivax Cerebral Malaria |
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Rajoo Thapa From the Department of Pediatrics, The Institute of
Child Health, 11, Dr. Biresh Guha Street, Correspondence to: Dr. Rajoo Thapa, The Institute of
Child Health, 11, Dr. Biresh Guha Street, Manuscript received: August 18, 2006; Initial review
completed: October 10, 2006; Abstract: Key words: Cerebral malaria, Meningoencephalitis, Plasmodium vivax, Seizures. Cerebral malaria is usually secondary to P. falciparum infection. However, there are infrequent reports of cerebral malaria associated with P. vivax infection. To our knowledge, only 45 cases of central nervous system P. vivax malaria are reported in the English literature since 1920; about half of these cases have occurred in children(1,2). Case Report Two boys, each aged 12 years presented with high grade intermittent fever of more than 4 days duration. Both of them were in altered conscious-ness at the time of admission. There was history of generalized tonic clonic convulsion prior to admission in each case. Both were severely dehydrated. Their capillary blood sugar level was normal at presentation. Beside these, the differentiating features between the two are depicted in Table 1.TABLE I Differentiating Features Between the Two Cases
In both the cases, routine count, liver function tests and serum electrolytes were within normal limits. Peripheral blood smear revealed trophozoites of P. vivax. Antigen test (OptiMAL) for P. vivax was positive while that for P. falciparum was negative in both the cases. Their cerebrospinal fluid and electroencephalogram (EEG) findings were normal. They were put on supportive therapy and intravenous artesunate in the recommended dose. Repeat blood smear after 2 days showed clearance of the parasite. Both were discharged in a clinically stable condition and advised primaquine for 14 days. Follow up after one month showed no residual neurological deficit. Discussion Organ dysfunction characteristic of P. falci-parum malaria is unusual in P. vivax infections. Any patient infected with P. vivax who exhibits severe malaria is presumed to be suffering from mixed infection(2). However, that may not be always true. As evident from the present report, P. vivax infection can also present as cerebral malaria. Clinical data provided by Kochar, et al. indicates that P. vivax can cause both sequestration-related and non-sequestration related complications of severe malaria, all of which are commonly associated with P. falciparum infections(3). The exact pathogenetic mechanism however remains elusive. Sachdev and Mohan(4) studied the clinico-laboratory profile of six patients with vivax cerebral malaria. The presenting features were of an acute febrile encephalopathy, convulsions and coma. Focal neurological signs were observed in one patient. Ozen, et al.(1) have recently described a case of cerebral vivax malaria that presented with status epilepticus. Some experts also suggest that cerebral malaria subjects might have an underlying seizure disorder and those seizures are precipitated by the high fever associated with the disease. Contributors: RT–diagnosis, manuscript design and writing; VP–data compilation and manuscript drafting and RK–guarantor, overall co-ordinator and guide. Funding: None. Competing interest: None stated.
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