Cerebral malaria

UTG Medical Students’ Association

Malaria is a household name in The Gambia simply because of its prevalence and being a widely diagnosed disease and major public health concern. But most Gambians do not know its power to kill.

Malaria is not regarded as a life-threatening disease by many Gambians. Many people, most of the time, will just take pain killers for the fatigue or herbal medications and continue their daily activities, which definitely increases the damage caused by the parasite inside the body.

Many a time, it is over-diagnosed and few will even go to the extent of taking anti-malaria drugs without any clinical or laboratory diagnoses but because they have some symptoms which resemble malaria. Recently, The Gambia has lost a lot of young people to this disease which is very preventable and treatable.

As I will say, the most painful death is dying of a preventable and treatable disease.

What is cerebral Malaria?

Cerebral means brain.

Malaria is from a latin word meaning “bad air” because it was initially thought to be an air contaminated by particles of decomposed matter disease.

Cerebral malaria simply means malaria that has involved/ risen to the brain. It is a complication/severe form of malaria and it is one of the most common forms patients present with at the hospital.

Malaria is a life-threatening parasitic disease transmitted to humans via infected female anopheles mosquito, and is caused by a parasitic protozoans of the genus plasmodium. The plasmodium parasite infects red blood cells and cause them to breakdown and leads to high fever which patients experience; it can even lead to anemia if the breakdown of red blood cell is more than the production of red blood cell.

Transmission is through the bite of an infected female anopheles mosquito and may also be transmitted through blood transfusions and needle sharing with infected persons.

Prevalence and epidemiology

Malaria is very common in tropical countries hence Gambia is not excluded. Most cases and deaths occur in sub-Saharan Africa but is also present in certain parts of southeast Asia, the eastern Mediterranean, America etc.

In 2020, there were more than 240 million cases of malaria worldwide and 627,000 deaths and the majority of the deaths occur in the children younger than 5 years.

Malaria in The Gambia is seasonal with peak incidence of clinical cases and mortality between September and November. According to statistics, the annual malaria incidence has also declined by 43% across all seven regions over the past four years from 149 to 1000 population in 2011 to 74 in 2016.

Below are graphs from a research done in The Gambia’s only referral hospital (EFSTH):

Courtesy of Dr. Sheikh Omar Bittaye

Species that cause malaria

o          Plasmodium falciparum (commonest cause)

o          Plasmodium malariae

o          Plasmodium vivax (hide in the liver and cause relapse and chronicity)

o          Plasmodium ovale (hide in the liver and cause relapse and chronicity)

o          Plasmodium knowlesi

Plasmodium falciparum is the commonest and deadliest cause and has recently developed resistance to most of the drugs available in The Gambia.

High-risk groups

o          Children under 5 years

o          Pregnant women (maternal anemia, still birth, low birth weight).

o          HIV/AIDS

o          Non-immune travellers

How do we get malaria?

1.         The infected female mosquito bites the human and leaves the plasmodium in the blood

2.         The plasmodium travels through the blood to the liver where they multiply and rupture and go back to the blood and infect the red blood cells.

How do people with malaria present?

Malaria can be divided into complicated and uncomplicated

The most characteristic features of uncomplicated malaria are:

1.         Recurrent episodes of fever

2.         Flu-like symptoms such as fatigue, headache, joint pains and chills.

3.         Low blood and yellowing of the eyes and skin might also occur

4.         Nausea and vomiting

Features of complicated malaria are:

1.         Severe low blood(anaemia)

2.         Acute kidney injury (dark and low urine output)

3.         Acute chest syndrome (difficulty breathing, distress, deep breathing (acidosis)etc)

4.         Generalised weakness, person not able to sit or stand or walk without assistance.

5.         Low blood sugar (hypoglycemia)

6.         Shock

7.         Cerebral malaria

8.         Multi organ failure and diffuse bleeding

Symptoms of cerebral malaria:

o          Severe headache

o          Confusion, delirium

o          Loss of consciousness

o          Coma and seizures

Many are diagnosed of psychiatric condition while the culprit is cerebral malaria.

NOTE: Severe malaria is common in children in areas with high transmission whereas in areas with low transmission, all age groups are equally affected.

Many patients in The Gambia present with severe form of malaria.

How do we diagnose cerebral malaria?

Malaria can be diagnosed clinically or through lab testing.

Clinically

o          If patient presents with loss of consciousness, confusion, seizures or coma with a history of malarial infection.

o          Fever

o          Severe low blood and yellowing of skin

o          Very dark and low urine output

o          Difficulty breathing

Lab testing

o          RDT (rapid diagnostic test), which mostly only detect plasmodium falciparum

o          Thick and thin blood film (which shows the presence of the plasmodium and the specie type too)

But note that, most times, the lab might be negative but the patient has all the clinical features of malaria. Many doctors will go ahead with the treatment of malaria basing it on the fact that the plasmodium has cyclic patterns in which it shows in the blood hence there are certain times in the day when the parasite will not be in the blood hence any blood collected during that period for testing will be negative but not necessarily negative in the body.

How do we treat cerebral malaria?

Prompt treatment is required in patients with cerebral malaria.

1.         If severe low blood—- do blood transfusion

2.         Iv Artesunate is given for 24hrs then orally if tolerated.

3.         IV quinine can also be given

4.         IM arthemether ETC.

5.         Iv mannitol or steroids if there are signs of increase intercranial pressure

How do we prevent malaria?

o          Avoid the bite of the mosquito by:

o          Sleeping under treated mosquito net

o          Cutting all grasses around the compound hence eliminating their breeding site

o          Removing all stagnant waters in the surrounding

o          Wire gauze the windows and doors

o          Wearing long sleeves and socks at night if in an endemic area.

1.         Vector control

2.         Chemoprophylaxis to pregnant women by giving them Fansidar

3.         Vaccine— RTS,S/A Sol

There are currently other vaccines that are in trials to prevent this life-threatening disease.

Malaria is a serious disease and we must fight against it. I have seen many vibrant youths losing their lives to this easily preventable disease. Let’s tie up our treated mosquito nets and be sleeping under it comfortably and also protecting our loved ones.

I was told, “you should be worried seeing a young man lying not able to do anything for himself” Dr. Abubakar Jagne (deputy CMD OF EFSTH). This followed after presenting the case of a 22-year-old man who had severe malaria and was not able to do anything for himself.