A rare case of cerebrovascular accident in a child with cerebral malaria, East Africa: a case report

¹Department of Pediatrics and Child Health, Kilimanjaro Christian Medical Centre Moshi, Moshi, Tanzania, ²Department of Radiology and Diagnostic Imaging, Kilimanjaro Christian Medical Centre Moshi, Moshi, Tanzania, ³Institute of Public Health, Kilimanjaro Christian Medical University College (KCMUCo), Moshi, Tanzania, ⁴Department of Community Medicine, Kilimanjaro Christian Medical Centre (KCMC), Moshi, Tanzania

^&Corresponding author
Edwin Joseph Shewiyo, Department of Pediatrics and Child Health, Kilimanjaro Christian Medical Centre Moshi, Moshi, Tanzania

Introduction    

Malaria is a life-threatening disease caused by female anopheles´ mosquitoes. In 2019, there were an estimated 229 million cases, and 409,000 death of malaria worldwide. About 94% of malaria cases and deaths were from Africa, six African countries accounted for approximately half of all malaria deaths worldwide, including Tanzania (5%). In 2018, P. falciparum accounted for 99.7% of estimated malaria cases in Africa. Children under 5 years of age are the most vulnerable group affected by malaria; in 2019 they accounted for 67% of all malaria deaths worldwide [1]. The main complications of severe malaria are cerebral malaria, pulmonary edema, acute renal failure, severe anemia, bleeding, acidosis, hypoglycemia and rarely cerebral accident [2]. Any of the complications can develop suddenly and progress to death within hours or days and also can occur simultaneously or in succession with one another. In tropical countries with a high transmission of malaria, severe malaria is predominantly a disease of young children (6-59 months) [2].

Cerebral malaria is defined by the presence of P. falciparum parasitemia accompanied with altered mental status of Glasgow Coma Scale (GCS) of 9 or less, other causes of altered mental status such as hypoglycemia, electrolyte imbalance, and meningitis should be ruled out [3]. Cerebral malaria is the most common severe form of malaria. The mortality of cerebral malaria ranges from 10% to 50% with treatment. About 97% adults and 90% children who recover from cerebral malaria have no neurologic abnormalities on hospital discharge [4]. Cerebral malaria is associated with neurological sequelae such as cortical blindness, ataxia, hemiparesis, tetraparesis, epilepsy, memory impairment, cognitive, language and behavioral problems [5]. Cases reported of cerebral malaria with stroke or stroke like symptoms in Brazil and India are of adults [6-8]. There is limited data on occurrence of stroke like symptoms among paediatric patients with cerebral malaria. We present a rare case of cerebrovascular accident which occurred in a 2 years old boy with cerebral malaria, who presented with a left sided hemiplegia and right sided hemiparesis treated at our hospital.

Patient and observation     

Patient information: a 2 year and 6 months old boy from Tanga was admitted to paediatrics department with main complaints of fever and convulsions for 1 day. He had 2 episodes of left sided hemi-convulsions with retained awareness that lasted for over 30 minutes and were 1 hour apart. Fever was high grade, relieved by paracetamol, accompanied with non-projectile vomiting episodes. Previously admitted for severe Malaria and got a course of 3 artesunate injections and never finished the treatment.

Clinical findings: on admission was unconscious (GCS 7/15), febrile (39°C), with normal respiration and heart rate., equal sized pupils with normal reactivity to light with left sided hemiplegia and right sided hemiparesis. Other systems were normal.

Diagnostic assessment: on investigation results, mRDT was positive, blood smear showed hyperparasitemia. Full Blood Picture showed leucocyte count of 16.25 with elevated neutrophil count of 8.6, and leucocyte count of 6.2, hypochromic microcytic anaemia with Haemoglobin of 9.8g/dl and normal platelets. Cerebrospinal fluid (CSF) studies were normal. Blood culture was negative. He had raised LDH 876 U/L and low calcium of 1.85. The computer tomography scan showed right basal and thalamus hypoperfusion versus infarction (hemorrhagic versus ischemic stroke), as shown in the images below (Figure 1).

Therapeutic interventions and follow up: he was started on IV artesunate and IV ceftriaxone. Phenobarbital was also given but did not help with the seizures, and carbamazepine was added. The seizures were not controlled yet, he was then changed to sodium valproate. The child was also kept on physiotherapy started improving after 10 days, and he regained full neurological functions and was discharged home, upon subsequent follow up for 3 months, he was doing well and did not develop any sequalae of cerebral malaria (Figure 1).

Discussion     

Cerebral malaria is the serious complication of plasmodium falciparum malaria. Even with adequate treatment about 6-29% will develop sequelae of cerebral malaria. Transient neurological sequelae occur in 10%-18% and generally the symptoms subside in about 4 to 8 weeks. The sequelae are more severe in children than in adults [9]. The most common sequelae are psychosis and ataxia while hemiplegia, cerebral palsy, deafness, impairment of cognition and learning and blindness rarely occurs [5,9]. The pathogenesis behind cerebral malaria is poorly understood. Two main theories have provided an explanation to the mechanism behind cerebral malaria, they include the mechanical hypothesis which is based on intravascular sequestration of affected RBCs resulting into vascular congestion, hypoperfusion and localized hypoxia [10], whereas the cytokine storm hypothesis is based on peripheral inflammation, neutrophil activation and increased circulations of serum cytokines such as TNF, IFNγ, and IL-2, IL-6, IL-8, and IL-10 as a cause of cerebral malaria manifestations [11,12]. Hemiplegia rarely occurs as a presentation of cerebral malaria, in our case the male child presented with convulsions, high grade fever, non-projectile vomiting, anaemia, left sided hemiplegia and right sided hemiparesis, the child was mRDT positive and the CT scan showed hypoperfusion on the right basal and thalamus regions, our patient also had history of incomplete antimalarial therapy, this is in line with a case reported in Eastern India of a 7 month old male baby who presented with hemiplegia, however this baby had low grade fever and altered sensorium and the CT scan revealed hypoperfusion on the left parietal-temporal region and the baby had no history of incomplete antimalarial therapy [13], adult cases in Brazil and India had similar presentations and evidence of hypoperfusion or ischemia on imaging studies with presence of malaria parasite [6-9].

The child was treated with artesunate injections, intravenous antibiotics, paracetamol for the fevers, and sodium valproate which relieved the seizures, he was also kept on physiotherapy, improved after 10 days, and he regained full neurological functions and was discharged home, upon subsequent follow up he was doing well and did not develop any sequalae of cerebral malaria, however the 7 month old baby reported in Eastern India was also given blood transfusion since his Hb was lower (4g/dl) compared to our patient moreover the baby also improved after 7 days and was discharged and was doing well on follow up [13]. The 28-year-old male case reported in Brazil with stroke like symptoms did not regain normal neurological function despite being treated with similar therapy and was still on physical therapy after 2 years follow up [7], the reason why children recover with full neurological function compared to adults is yet to be determined. We recommend to rule out malaria in children presenting with acute or subacute neurological manifestations with signs of infection especially in endemic areas.

Conclusion     

We report and treated a rare case of ischemic stroke in a 2 year old child with cerebral malaria who presented with convulsions, left sided hemiplegia and right sided hemiparesis. Although the occurrence of stroke in patients with severe forms of malaria is rare especially in paediatrics as literature suggests, a high clinical suspicion can be made in children with sudden onset of neurological manifestations especially in malaria endemic areas like our setting, a rapid antigen test (mRDT) and a blood slide (BS) for malaria can be done to rule out malaria infection.

Consent: written informed consent was obtained from the patients´ mother for publication for this case report and the accompanying images.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

EJS and KN were involved in diagnosis, management and writing of manuscript. AS was involved in interpreting radiological image. AMS and DM were involved in investigation, writing part of manuscript. All authors reviewed and approved final manuscript.

Acknowledgements     

The authors would like to acknowledge the mother for permission to share her child's medical history for educational purposes and publication.

Figures     

Figure 1: CT axial views show right cerebral hemispheric hypodensity with loss of grey white matter differentiation involving the right basal and thalamus. Findings are in keeping with hypoperfusion of the right cerebral hemisphere vs. hemispheric infarction

References