Cerebral malaria in Indian adults: a prospective study of 441 patients from Bikaner, north-west India.

AIMS OF THE STUDY: As per WHO (1993) the assessment and analysis of local problems and an appropriate epidemiological information system is an essential part of a control programme before embarking any control activity. METHODOLOGY: Four hundred and fourty one (441) adults of strictly defined admitted cerebral malaria patients were studied. Detailed clinical/neurological examination was done at the time of admission, daily thereafter, at the time of regaining consciousness, at the time of discharge and at weekly intervals in those having neurological sequelae. All patients were treated by i.v./oral quinine and specific syndromes were managed according to WHO guidelines. RESULTS: Apart from fever and unconsciousness in all the patients, other features were convulsion (21.31%), neck rigidity (19%), psychosis (5.21%), conjugate deviation of eyes (2.26%), extrapyramidal rigidity (2.25%), trismus (1.31%), decorticate rigidity (1.13%) and decerebrate rigidity (0.90%). One hundred forty five (32.87%) patients expired and mortality was highest in pregnant ladies (39.28%). The important neurological sequelae in survivors were psychosis in 15 (5.06%), cerebellar ataxia in 14 (4.72%), hemiplegia in five (1.68%), extrapyramidal rigidity (EPR) in four (1.35%), peripheral neuropathy in three (1.01%), EPR with trismus in one (0.33%) and isolated sixth nerve palsy in one (0.33%) patients and all showed complete recovery in further follow up. CONCLUSION: The important observations of this study were stormy presentation, increased incidence of haemoglobinuria and jaundice, presence of neck rigidity, no prognostic relation to fundus abnormalities and high incidence of cerebellar ataxia and psychosis as neurological sequelae in survivors. Knowledge of self-limiting course of neurological sequelae may be helpful in reducing economic strain of expensive investigations and treatment.

Brainstem auditory evoked potentials and somatosensory evoked potentials in cerebral malaria--a prognostic significance.

OBJECTIVE: To study the changes in brainstem auditory evoked potentials (BAEPs) and somatosensory evoked potentials (SSEPs) in cerebral malaria and to see their prognostic significance. METHODS: BAEPs and right median nerve SSEPs were performed in 25 adult patients of strictly defined cerebral malaria in acute stage in a semi-dark, sound proof chamber on four channel computerized multi-basis OTE-Biomedica machine in department of neurology, SP Medical College, Bikaner. RESULTS: The abnormalities of BAEPs were delayed peak latency of wave III in 13/25 (52%) and wave V in 20/25 (80%) patients and delayed interpeak latencies (IPLs) of wave I-III in 9/25 (36%), wave I-V in 15/25 (60%) and wave III-V in 12/25 (48%) patients. In SSEPs delayed N20 was seen in 11/25 (44%); delayed IPLs of N13-N20 (central conduction time; CCT) in 12/25 (48%) patients. Distorted N20 was recorded in 12/25 (48%) patients. Both N13-N20 IPLs in SSEPs and wave III-V IPLs in BAEPs were delayed in five patients and all of them expired. Delayed N13-N20 with normal III-V IPLs was present in seven patients and two of them died, whereas delayed III-V IPLs with normal N13-N20 was present in seven patients, and one of them expired. In remaining six patients both the parameters were normal and one of them died. CONCLUSIONS: The values of BAEPs and SSEPs were abnormal in patients of cerebral malaria and it was observed that BAEPs/SSEPs alone was not useful for predicting the outcome of coma, whereas abnormalities in both was predictive of worst prognosis. The changes in evoked potentials (BAEPs and SSEPs) could be due to either interruption of conduction in central pathways because of structural changes due to petechial hemorrhages and malarial granuloma at multiple levels in the brain including brainstem or due to metabolic abnormalities.