malaria is one of the most common parasitic infections in the developing countries and cerebral malaria ( cm ) is one of the most common causes for non - traumatic encephalopathy in the world .
malaria is caused by five species of plasmodium namely plasmodium vivax , plasmodium falciparum , plasmodium malariae , plasmodium ovale and plasmodium knowlesi .
however , they are increasing reports of complicated malaria by other species as well . clinical presentation of malaria varies from uncomplicated acute febrile illness to a severe form of malaria when infections are complicated by serious organ failures or abnormalities in the patient 's blood or metabolism .
the manifestations of severe malaria include cm , severe anemia , hemoglobinuria due to hemolysis , acute respiratory distress syndrome , abnormalities in blood coagulation , hypotension , acute kidney injury , hyperparasitemia ( more than 5% of the red blood cells ( rbcs ) infected by malarial parasites ) , metabolic acidosis and hypoglycemia .
severe malaria is a medical emergency and should be treated urgently and aggressively . in the indian scenario ,
for the same reason , these physicians should be aware of the complications , so that earlier and effective treatment can be initiated and patients who need a referral to a tertiary care can also be identified .
this was a prospective study done from september 2005 to december 2006 at jiwan jyoti christian hospital in eastern uttar pradesh in india .
all the patients above the age of 14 years diagnosed with cm were included in the study .
cm was defined as a clinical syndrome of coma ( inability to localize a painful stimulus ) at least 1 hour after termination of a seizure or correction of hypoglycemia , detection of asexual forms of falciparum malarial parasite on peripheral blood smear and exclusion of other causes of encephalopathy .
there were a total of 53 patients with cm of which 38 ( 71.7% ) of them were females . among them
35 ( 66% ) patients were less than 30 years of age [ figure 1 ] all of them had presented with fever and altered sensorium with documented malarial parasite on the peripheral blood film .
other clinical features [ figure 2 ] noted were pallor ( 35% ) , icterus ( 16.98% ) , hypotension ( 13.2% ) , bleeding ( 3.7% ) , hepatomegaly ( 5.66% ) and splenomegaly ( 5.66% ) .
age distribution of patients with cerebral malaria clinical features of patients with malaria majority ( 84.9% ) of the patients had anemia .
co - infection with plasmodium vivax was present in 13 ( 24.53% ) of them .
treatment received included artesunin compounds ( artesunate in 37 and arteether in 3 ) , quinine ( 9 ) and quinine  doxycycline combination therapy ( 2 ) . in view of clinical failure 3 of them
others included patients who were referred to higher center and those who left the hospital against medical advice .
cm is defined as severe p. falciparum malaria with cerebral manifestations , usually coma ( glasgow coma scale < 11 , blantyre coma scale < 3 ) .
malaria with coma persisting for > 30 min after a seizure is also considered to be cm .
the 2010 revised criteria for severe malaria are the presence of one or more of the following : prostration , impaired consciousness , failure to feed , respiratory distress ( " air hunger " ) , multiple seizures ( more than two episodes in 24 h ) , circulatory collapse , pulmonary edema ( on radiological imaging ) , abnormal spontaneous bleeding , jaundice , hemoglobinuria , severe anemia , hypoglycemia , acidosis , renal impairment , hyperlactatemia , and hyperparasitemia . according to the latest world health organization ( who ) estimates ,
there were about 219 million cases of malaria in 2010 and an estimated 660,000 deaths .
africa is the most affected continent : about 90% of all malaria deaths occur there . among the 53 patients with cm , 71.7% were females and 66% were less than 30 years of age .
however wasnik et al . noted a higher incidence in males ( 75% ) most of whom were in the age group of 21 - 30 years of age .
seizures are a prominent feature in cm and repeated seizures have been associated with poor outcome .
patel noted that 46.8% of the patients with falciparum malaria had anemia whereas wasnik et al . noted that 65% of the cases had anemia . in our cohort 84.9% had anemia .
the causes for anemia in cm patients are obligatory destruction of rbcs containing parasites at merogony , accelerated destruction of non - parasitized rbcs and bone marrow dysfunction .
hypoglycemia in cm patients are due to increased peripheral requirement of glucose consequent upon anaerobic glycolysis , increased metabolic demands of febrile illness , obligatory demand of parasites , failure of hepatic gluconeogenesis and glycogenolysis ( parasites consume up to 70 times as much glucose as uninfected cells ) .
it is compounded by the stimulation of insulin secretion from pancreatic beta cells by quinine .
blood sugars of all the patients in the present study were closely monitored and glucose supplementation was given .
renal dysfunction causes morbidity in these patients . biochemical evidence of renal dysfunction was noted in 37.6% patients .
out of 526 cases of cm reported from rourkela , in sundargarh district of orissa state , 28.9% had acute renal failure ( arf ) .
mortality in this series was particularly high ( 59% ) specifically in those with multiorgan failure .
the effect of associated arf on mortality in cm patients indicated , mortality was as high as 39.5% when associated with arf , while it was only 13.9% when unassociated with arf .
hyperventilation ( kussmaul breathing ) with a clear chest on auscultation suggests metabolic acidosis . at our center
since there was no facility for estimation of blood gases , we made a clinical diagnosis based on this and was initiated on soda bicarbonate infusion and fluids .
clinical improvement as indicated by normal respiratory rate guided us in our management . in our study , 16.9% patients had non cardiogenic pulmonary edema .
case fatality rate is very high in these patients and they should be referred to a facility were mechanical ventilation and intensive care is available .
the world health organization now recommends using intravenous artesunate in preference to quinine for the treatment of severe p. falciparum malaria in adults .
these are derivatives of chinese drug qinghaosou . in a large open label , randomized trial of asian adults with severe malaria , artesunate significantly reduced mortality by 34.7% . majority ( 75.47% ) of our patients
. out of these except for 3 patients rest of them had responded to artesunate .
noted that the cause of death were arf , metabolic acidosis , aspiration pneumonia and circulatory failure .
case fatality rates in the other studies from africa have shown a high mortality rate of 13 - 21% .
primary care physicians should be able to diagnose cm from the clinical presentation , which should be supported by detection of p. falciparum or in some cases the other species of malaria on the peripheral blood film .
artesunin components as combination therapy are the drug of choice as per who recommendations and can be easily administered with hardly any side effects .
non cardiogenic pulmonary edema needing ventilator care and renal failure needing dialysis should be referred to a higher facility .
cm once considered a fatal disease has shown remarkable improvement in the outcome with the wide availability of artesunin components .
most of the complications of severe falciparum malaria including cm can be managed by a primary care physician .
considering the health system in our country if primary care physicians can manage these patients , it will go a long way in reducing the morbidity and mortality of these cases .
 introduction : cerebral malaria ( cm ) is one of the most common causes for non - traumatic encephalopathy in the world . 
 it affects both the urban and rural population . 
 it is a challenge to treat these patients in a resource limited setting ; where majority of these cases present.materials and methods : this was a prospective study carried out from september 2005 to december 2006 at jiwan jyoti christian hospital in eastern uttar pradesh in india . 
 this is a secondary level care with limited resources . 
 we studied the clinical profile , treatment and outcome of all the patients above the age of 14 years diagnosed with cm.results:there were a total of 53 patients with cm of which 38 ( 71.7% ) of them were females . among them , 35 ( 66% ) patients were less than 30 years of age . 
 the clinical features noted were seizure ( 39.62% ) , anemia ( 84.9% ) , icterus ( 16.98% ) , hypotension ( 13.2% ) , bleeding ( 3.7% ) , hepatomegaly ( 5.66% ) , splenomegaly ( 5.66% ) , non - cardiogenic pulmonary edema ( 16.98% ) and renal dysfunction ( 37.36% ) . 
 co - infection with plasmodium vivax was present in 13 ( 24.53% ) of them . 
 treatment received included artesunin compounds or quinine . 
 median time of defervescence was 2 ( interquartile range1 - 3 ) . 
 complete recovery was achieved in 43 ( 81% ) of them . 
 two ( 3.7% ) of them died.conclusion:cm , once considered to be a fatal disease has shown remarkable improvement in the outcome with the wide availability of artesunin and quinine components . to combat the malaria burden , 
 physicians in resource limited setting should be well trained to manage these patients especially in the endemic areas . 
 the key to management is early diagnosis and initiation of treatment based on a high index of suspicion . 
 anticipation and early recognition of the various complications are crucial . 
Introduction
Materials and Methods
Results
Discussion
Conclusion