Cerebral Malaria: A case Report
Shanthi D
Nursing Supervisor, Kauvery Hospital Trichy Cantonment, Tamil Nadu, India.
Abstract
Cerebral malaria may be the most common non traumatic encephalopathy in the world. The pathogenesis is heterogeneous and the neurological complications are often part of a multisystem dysfunction. The clinical presentation and pathophysiology differs between adult and children. Recent studies have showed the molecular mechanism of pathogenesis and suggested possible interventions. Antimalarial drugs however remain the only interventions that unequally affect the outcome. Increasing resistance to the established anti-malarial drugs is of grave concern. With appropriate anti-malarial drugs, the prognosis of cerebral malaria often depends on the management of other complications, for example renal failure and acidosis. Neurological sequelae are increasingly recognized. But further research on the pathogenesis of coma and neurological damage is required to develop other treatments.
Background
Malaria remains one of the most prevalent infectious diseases in the world. WHO reports that 50% of the world’s population living in 109 countries is still at risk of Malaria. More than 300 million clinical cases of malaria and one million deaths occur annually. Especially, Cerebral Malaria is the most severe neurological complication of the infection, with Plasmodium Falciparum, with over 57,500 cases annually. Severe Malaria may manifest as anemia, hypoglycemia, metabolic acidosis, repeated seizures, coma or multiple organ failure and is estimated to cause one million deaths annually. Recent reports show that the incidence of severe Malaria is on the decline. In Falciparum infection mortality is high. Surviving patients sustain brain injury which manifest as long-term neurocognitive impairment. And this deadliest feature is mostly prevalent on the African continent. My patient who went to Africa for work stayed there for 3 months and came back to India with fever. In this paper we review studies that have provided current understanding of pathogenesis of brain injury due to Falciparum and explore prospects for neuro protection and improved outcome.
Case Presentation
A 27 years old male patient was admitted with intermittent high-grade fever for past 2 months on and off with chills, and vomiting, weight, loss high colored urine and joint pain since a month. He traveled to Africa for his work and returned back to India because he became sick. As soon as he came back to India and he directly got admitted to the hospital.
Social History
He is not habituated to cigarette smoking, nor did he have alcohol addiction. He is not known to have any allergy.
Past medical History
He is having the history of psoriasis since 1 ½ year
Past Surgical History
No known surgical history.
Travel History
He had travel history recently to South Africa.
Physical Examinations
Vital signs
Temperature: 103.5 F, HR 98/min, RR 16 /min, BP 140/90mmHg, SpO2 98%
GCS – E4V5M6
Initial Evaluation
USG abdomen scan: Hepatomegaly, Splenic infarct. Liver enlarged in size 17.7 cm.
CT scan Brain: There is no intracranial abnormality.
CT chest: Mild basal atelectasis in bilateral lower lobes.
ECG: Normal
Serology studies: Scrub Typhus IgM positive,
Dengue IgM IgG Negative.
Peripheral smear study: Plasmodium Falciparum infection, , parasite load 9%
Urine Culture: No growth.
Mantoux test: Negative
Platelet count: 40,000 cell/cu mm
INR: 1.06
Electrolytes:
- Na:138
- K: 4.22
- Cl2 :108
- Hco3: 19.7
Anti-nuclear antibody: positive
Cytoplasmic complement: Weak positive
Blood culture and Tracheal culture: Acinetobacter positive,
My client was admitted on 16/11/23. With all investigations and signs and symptoms he was diagnosed to have Cerebral Malaria and Meningitis.
Patient was conscious and on cardiac monitoring. Initially patient GCS was 15/15, after 3 hours GCS dropped, he was not responding E2V2M5, hence intubated after obtaining consent from the relatives.
Patient was on ventilator support. He developed seizures after 2days.And had cardiac arrest on 4th days which was reverted. After almost 10days of artificial ventilator support he was gradually weaned and NIV support was connected. Blood culture reports indicated Acinetobacter with MDR, and was managed with antibiotics.
Patient was on effective anti- malarial treatment anticonvulsive and electrolyte management.
After 10days of invasive and non invasive ventilation patient GCS gradually improved, hence he was extubated and shifted to general ward for further management.
Management of Cerebral malaria
Combinations of drug
Day 1: Tab.Artesunate 240mg+Sulfadoxine 150mg+Pyrimethamine 75mg.
Day 2: Tab.Artesunate 200mg + Tab.Primaquine 45mg
Day 3: Tab.Artesunate 200mg
Along with that he was on Inj.Albumin 100ml OD, Inj.Colistin, Inj.Azithromycin 500mg IV TDS, Minocycline 100mg, Etiquin 2.5mg and Low molecular heparin also was started.
Follow up treatment
Patient GCS became normal. Vital signs improved. No fever. Patient was ambulating hence discharged from the hospital (Total Length of Stay 17 days) in a stable condition, with follow up.
Skilled Nursing care – Nursing care planning and goals
- Prevent infection.
- Reduce increase in and regain normal body temperature.
- Improve tissue perfusion.
- Improve fluid volume of the body.
- Gain information on malarial disease process, treatment, and prognosis.
Nursing Interventions
- Improve body temperature: Warm water compress on forehead and both axilla (not more than 15 minutes each time); maintain warm environment by using warm blankets, adequate clothing); patient may sweat excessively, make sure to avoid exposing patient to wet clothes and linens; administration of antipyretic drugs as ordered.
- Improve tissue perfusion: Patient may need supplemental oxygen if condition is severe; maintain a well-ventilated room; head of the bed at 30º.; lessen activities that require moderate to high exertion.
- Improve fluid volume: Expect loss of fluid through sweat; provide information about fluid balance and guideline for fluid replacement; encourage increase in oral fluid intake; administer parenteral fluids as ordered.
- Educate the patient and family: Review the disease process and therapy, focusing on patient’s concerns; discuss importance of adhering to therapy; go over medication, purpose, frequency, dosage, and side effects; have a family member or trusted individual listen to and understand guideline of treatment as the patient chooses.
Evaluation
Nursing evaluation of patients with malaria includes meeting the following goals:
- Prevention of infection.
- Reduced increase in body temperature.
- Improved tissue perfusion.
- Improved fluid volume of the body.
- Gained and retained information on malarial disease process, treatment, and prognosis.
Documentations guidelines
Nursing documentation in a patient with malaria include:
- Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual behavior.
- Cultural and religious beliefs and expectations.
- Plan of care.
- Teaching plan.
- Responses to interventions, teaching, and actions performed.
- Attainment or progress toward the desired outcome.
Conclusion
- Without treatment cerebral Malaria is invariably fatal. But even with treatment 15–20% die. In adults however, mortality was lower if patients were treated with intravenous Aresunate.This treatment is currently being evaluated in African Children.
- Furthermore, Cerebral Malaria is not a single discrete syndrome. In different patients, coma develops through multiple mechanisms of brain injury. Combinations of adjuvant therapies targeting specific mechanisms of brain injury may be needed to improve neuron cognitive outcome.
- Eradication of Malaria is not that easy since male gametocytes and female gametocytes are transmitted through the Anopheles’ mosquito during a blood meal. They have a complex life cycle. Female mosquitoes often live longer than male. They need a blood meal to produce eggs. A malaria infected female Anopheles inoculates sporozoties into the human host. Sporozites infect liver cells and mature into schizonts which rupture and release merozoites.
- Hence prevention is better than cure. Taking extra precaution especially traveler who visits African countries can use things like repellents, using mosquito net, wearing long pants and sleeves would be helpful.
- Antimalarial prophylaxis is available. WHO and CDC web sited offer valuable information on the appropriate choices for prophylaxis. National guidelines can be studies and travel clinics consulted.
Shanthi D
Nursing Supervisor