Case of the Week
Section Editors: Matylda Machnowska1 and Anvita Pauranik2
1University of Toronto, Toronto, Ontario, Canada
2BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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July 26, 2018
Cerebral Malaria
- Background:
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Cerebral malaria is a life-threatening complication of P. falciparum infestation that occurs in approximately 2% of patients.
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Pathogenesis may be explained by 2 mechanisms: vascular sequestration of parasitized erythrocytes and the potential cerebral toxicity by cytokines.
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- Clinical Presentation:
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Progressive clinical changes occur, along with high fever and chills.
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Neurologic manifestations are nonspecific because of diffuse involvement of the brain.
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Patients can become drowsy and disorientated, with associated seizures and progressive deterioration in consciousness before they become comatose.
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- Key Diagnostic Features:
- Appearances may be normal on CT.
- The reported MRI appearances of cerebral malaria are variable but include:
- Focal hyperintensities on T2WI and FLAIR sequences involving the centrum semiovale/corona radiata/periventricular white matter
- These may have:
- Restricted diffusion representing infarcts
- No restricted diffusion, as with this patient, thought to be secondary to an inflammatory/demyelinating etiology
- These may have:
- Acute infarcts, which are frequently hemorrhagic, tend to involve the thalami/basal ganglia due to involvement of perforator arteries or cortical/subcortical involvement, represented by T2-FLAIR hyperintensity, diffusion restriction, and susceptibility effects.
- Presence of enhancement may reflect the evolution of acute infarcts or be related to active inflammation/demyelination.
- Focal hyperintensities on T2WI and FLAIR sequences involving the centrum semiovale/corona radiata/periventricular white matter
- Differential Diagnoses:
- Vasculitis
- Demyelination including ADEM
- Neuropsychiatric SLE
- Treatment:
- Antimalarial therapy such as artemisinin derivatives
- Supportive management based on clinical and biochemical abnormalities
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