Cerebral malaria — DTM&H MCQ

Correct answer: C — Cerebral malaria

The correct answer is C, cerebral malaria. This child has heavy P. falciparum parasitaemia and remains unrousable after hypoglycaemia (a common reversible cause of coma in severe malaria) has been corrected, meeting the operational definition of cerebral malaria: unarousable coma in a patient with falciparum parasitaemia once other treatable causes of encephalopathy have been excluded. The absence of neck stiffness argues against meningitis, and the persistence of coma beyond the immediate post-ictal period (rather than a brief post-convulsive drowsiness) confirms a true encephalopathy rather than a simple febrile fit. In UK and WHO practice, severe falciparum malaria with impaired consciousness (Blantyre or Glasgow coma score reduced) is a defining feature of severe malaria requiring IV artesunate and intensive supportive care, glucose monitoring and seizure control. Why the other options are wrong: E. Acute schistosomal encephalopathy: This is a rare complication of acute Katayama-type schistosomiasis, not associated with heavy falciparum parasitaemia, and there is nothing in the stem (eg exposure history, eosinophilia) pointing to schistosomiasis. B. Febrile convulsion from a viral illness: Simple febrile convulsions are brief, self-limiting and followed by full recovery of consciousness within a short period; persistent unrousable coma after correcting hypoglycaemia excludes this diagnosis. D. Bacterial meningitis without malaria: The absence of neck stiffness makes bacterial meningitis less likely, and the heavy parasitaemia points to malaria as the cause; meningitis would not explain the parasitaemia even if co-existing. A. Tetanus with autonomic instability: Tetanus produces trismus, rigidity and spasms with a clear preceding wound history, not coma with parasitaemia, and there are no autonomic or spasm features described here. Key point: Cerebral malaria is unarousable coma with falciparum parasitaemia once hypoglycaemia and other reversible causes have been excluded, regardless of coexisting seizures.

Reference: UK Malaria Treatment Guidelines Writing Group, Journal of Infection 2016 (PHE/UK guidelines), 'Severe malaria: definitions and management', https://www.journalofinfection.com/article/S0163-4453(16)00047-5/fulltext