Confirming Cerebral Malaria Deaths in Resource-Limited Settings

Abstract

A 4-year-old Papua New Guinean girl presented with unresponsive coma (Blantyre coma score = 2) after a short febrile illness. She did not have neck stiffness, a positive Kernig's sign, or other clinical features of bacterial meningitis. Microscopy confirmed a peripheral blood Plasmodium falciparum asexual parasite density of 33,960/μL. Despite parenteral artemether and intensive supportive therapy, she died within 6 hours of admission. Supraorbital post-mortem brain biopsy revealed P. falciparum in the cerebral microvasculature (Figures 1 and ​and22 ). Figure 1. Brain smear showing ruptured P. falciparum schizonts within a capillary. Giemsa stain immersion (100× magnification). Figure 2. A phagocytic microphage containing the malaria pigment (hemozoin) identified on brain smear. Giemsa stain immersion (100× magnification). As part of renewed global efforts to eradicate malaria, the World Health Organization has recently emphasized the need for improved surveillance and case management, including accurate documentation of malaria-related deaths.1 The supraorbital post-mortem biopsy technique used in this case can be performed rapidly, and it is well-validated, is minimally invasive, and leaves no visible scars.2 Appropriately stained brain tissue can be examined by microscopy without the need for conventional autopsies and histological examination even in resource-limited settings, thus providing evidence for a diagnosis of cerebral malaria or perhaps other non-malarial central nervous system disease. Greater certainty regarding the cause of a child's death benefits public health policy makers as well as families and clinicians.