Dr. Gadadhar Sarangi Cuttack, Orissa

Malaria Threatens 40% world population

From Near Extinsion in 1976 India contributes 85% of cases in South East Asia 1 st clinical description – Hippocrates Elaborated – Celsus Peruvian Bark in therapy – 17 th Century Quinine – 1820 Man to Mosquito Cycle – Sir Ronald Ross –

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

Aetio Pathogenesis Sequestration of Cerebral Capillaries and Venules Ring like lesions in the Brain

Mechanical Hypothesis P. falciparum parasites in brain capillary

Section of brain showing blood vessels blocked with developing P. falciparum parasites

Selective Cytoadherance results in rosetting Reduction of Microvascular Blood flow Hypoxia Dose not explain selective absence of Neurological Deficits

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

c

CLINICAL MANIFASTATIONS The seasonal Trend

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

Coma Scale for Children Best Motor responseLocalizes painful stimulus2 Withdraws limb from pain1 Non-specific or Absent response0 Verbal ResponseAppropriate Cry2 Moan or Inappropriate cry1 None0 Eye MovementsDirected 1 (e.g. follows mother’s face) Not directed0 Total 0-5

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

LABORATORY DIAGNOSIS

Diagnosis of Falciparum Malaria Conventional Microscopy »Giemsa Stain »Field Stain

Stages of P. falciparum

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

CEREBRAL INVOLVEMENT Clinical CSF - Increased Lactic Acid CT, MRI

THOUGHTS AT BEDSIDE Haemoglobin Urobilinogen

THERAPEUTIC OPTIONS CHEMOTHERAPY Quinine Artemisinins - Artesunate » - Arte- ether » - Arte - mether

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

NEWER HORIZON Inhibition of Endothelial Activity - LMP Decrease of TNF alpha & LT activity Vaccine Development