Abstract
BackgroundPost-malaria neurological syndrome (PMNS) is a debated entity, defined by neurological complications following a post-malaria symptom-free period and a negative blood smear. Four cases of PMNS are hereby reported and a review the literature performed to clarify the nosological framework of this syndrome.MethodsA French teaching hospital infectious diseases database was investigated for all PMNS cases occurring between 1999 and 2016 and the PubMed database for cases reported by other institutions after 1997. A case was defined by the de novo appearance of neurological signs following a post-malaria symptom-free period, a negative blood smear, and no bacterial or viral differential diagnoses.ResultsFour patients from the database and 48 from PubMed, including 4 following Plasmodium vivax infection were found matching the definition. In the institution, the estimated PMNS incidence rate was 1.7 per 1000 malaria cases overall. Of the 52 patients (mean age 33 years), 65% were men. Malaria was severe in 85% of cases, showed neurological involvement in 53%, and treated with quinine in 60%, mefloquine in 46%, artemisinin derivatives in 41%, antifolic drugs in 30%, doxycycline in 8% and other types in 8%. The mean symptom-free period was 15 days. PMNS signs were confusion (72%), fever (46%), seizures (35%), cerebellar impairment (28%), psychosis (26%), and motor disorders (13%). Cerebrospinal fluid analyses showed high protein levels in 77% (mean 1.88 g/L) and lymphocytic meningitis in 59.5% (mean 48 WBC/mm3) of cases. Electroencephalograms were pathological in 93% (14/15) of cases, and brain MRIs showed abnormalities in 43% (9/21) of cases with white matter involvement in 100%. Fourteen patients were treated with steroids. The 18 patients with follow-up data showed no sequelae. The mean time to recovery was 17.4 days.ConclusionPMNS is a rare entity englobing neurological signs after severe or non-severe malaria. It appears after a symptom-free period. PMNS occurred following treatment of malaria with a wide range of anti-malarials. The disease is self-limiting and associated with good outcome. MRI patterns underline a possible link with acute disseminated encephalomyelitis (ADEM) or auto-immune encephalitis. Plasmodium falciparum and Plasmodium vivax should be added to the list of pathogens causing ADEM.
Highlights
Post-malaria neurological syndrome (PMNS) is a debated entity, defined by neurological complications following a post-malaria symptom-free period and a negative blood smear
Case definition of PMNS PMNS was defined as the occurrence of de novo neurological signs after a symptom-free period following acute malaria, associated with a negative blood smear and no retainable differential diagnosis
In September 2016 he presented with fever, headaches and vomiting, and thereafter received treatment in Paris for severe malaria with hepatic impairment (SGOT/ SGPT 92/105 U/L and hyperbilirubinaemia (93 μmol/L, Table 1 Main clinical characteristics for cases of post-malaria neurological syndrome following P. falciparum (A), P. vivax (B) and mixed (C) infections
Summary
Post-malaria neurological syndrome (PMNS) is a debated entity, defined by neurological complications following a post-malaria symptom-free period and a negative blood smear. Four cases of PMNS are hereby reported and a review the literature performed to clarify the nosological framework of this syndrome. A work by Senanayake et al [3] published in 1994 may be the first large report on this phenomenon. The authors described 74 Sri Lankan patients, who, during a large epidemic in the 1980s, presented an isolated, self-limiting, delayed cerebellar ataxia (DCA) syndrome 3–41 days after the onset of fever due to falciparum malaria. It was difficult to establish a clear relationship with a post-malaria phenomenon as the onset of neurological signs occurred while almost half (34/74) of the patients still had positive blood smears, and 11 of them had not received any anti-malarial treatment
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
