Cerebral Malaria in Children: A Review of ... - Sudanjp.org

SUDANESE JOURNAL OF PAEDIATRICS AND CHILD HEALTH VallO: 2010Like most countries in sub-Saharan Africa, Sudancarries a heavy malaria disease burden. It ranks highas the one of the most endemic country of the world.It accounts for 50% of malaria cases in the EasternMediterranean Region. It is estimated that more than8 million cases and about 35,000 deaths occur peryear. The disease accounts for 20% of all hospitaldeaths and the malaria case fatality rate for paediatrichospitals ranges between «515- per cent».5The epidemiological pattern of severe malariavaries considerably from that of hyperdynamic regionsin sub-Saharan Africa and there is considerablevariation between the individual complications ofsevere malaria.6Severe MalariaSevere malaria occurs when P. falciparuminfections are complicated by serious organ failuresor abnormalities. It is usually manifests in Africanchildren growing up in malarious endemic areas.7Many factors thought to contribute to P. falciparumvirulence these include:-a- The Redundancy and multiplicative Capacityof P. falciparumP. falciparum is able to infect the entirepolymorphic human population; this is due to variantsurface antigens such as Plasmodium falciparumerythrocyte membrane protein-I (PfEMP I) whichspecifically binds to adhesion molecule CD36 andthrombospondin which assists the parasite adherenceto various receptors and removal from the circulationavoiding the snlenic clearance.8b- Parasitized RBCs Membrane Modification:These includefor mation of knob-like structurescomposed of proteins (PfEMP-l), protruding fromtheir surfaces increasing cell wall rigidity and alteringthe metabolites transport. 9c- Cyto-adherence and sequestration of parasitizederythrocytes. This is a specific interaction betweenRBCs and the vascular endothelium leading tosequestration of parasitized RBCs in deep organspredominantly in the brain, heart, lungs and submucosaof the small intestine.10d- Rosetting and Agglutination;e- RBC Deformability: In severe malaria bothparasitized (PRBCs) and non-parasitized RBCs(NPRBCs) become rigid due to oxidative damage tothe RBCs comprising their flow through capillaries.This has strong predictive value for fatal outcome.I IThe polymorphism of genes coding four humanadhesion molecules; intercellular adhesion molecule-l(ICAM-I), endothelial selectin (E-selection), CD36are important variable in the susceptibility to severemalaria.12The manifestations of severe malaria includeamong others; cerebral malaria with abnormalbehaviour, impairment of consciousness, seizures,coma or other neurologic abnormalities and metabolicacidosis presenting as respiratory distress or severeanaemia. Compared with adults, children have ahigher incidence of seizures.12The incidence andpattern of neurological complications are differentand the patients often die with features of braindeath. African children rarely develop renal failure orpulmonary oedema.13Cerebral malaria (CM)There is a clear need for a strict definition ofcerebral malaria in order to properly diagnose andassess the condition. The term «cerebral malaria»often been loosely used in the medical literature todescribe any disturbance of the CNS in a malariainfection. CM collectively involves the clinicalmanifestations of P. falciparum malaria that induceschanges in mental status and coma.13, CM hence,is an acute widespread disease of the brain which isaccompanied by fever.In older children CM can be defined as in adults.15