Falciparum malaria with haemorrhagic stroke in a 26-year male patient: report of a rare case

Abstract

Background

Malaria continues to cause unacceptably high levels of disease and death despite increased global efforts and is still significant public health problem. African countries are disproportionately affected by malaria. The objective of this study was to describe a rare case of haemorrhagic stroke as a possible complication of malaria in a 26-year-old male patient.

Case presentation

A 26-year-old male from southwest Ethiopia presented with complaint of loss of consciousness (LOC) of 12 h duration. He had fever, headache, vomiting, chills, rigors and shivering three days prior to the loss of consciousness. On physical examination, pulse rate 116 beats/min, blood pressure of 120/90 mmHg, respiratory rate was 24 breaths/min, a temperature of 38.9◦C and oxygen saturation of 94%. Nervous system examination; stuporous with Glasgow Coma Scale (GCS) 10/15(M₅, E₃, V₂). Blood film and RDT confirmed a Plasmodium falciparum infection and a non-contrast CT scan found a right cerebral parenchymal haemorrhage.

Discussion and conclusion

The presented case described a very rare case of a 26-year-old male patient who was diagnosed with left side hemiparesis secondary to a haemorrhagic stroke, associated with P. falciparum malaria. This report highlights the fact that malaria with stroke should be considered a differential diagnosis in a patient presenting with body weakness in a malaria endemic area and in individuals who had travel history to malaria endemic areas.

Background

Malaria is a disease caused by a protozoan parasite (Plasmodium) transmitted by the bite of infected female Anopheles mosquitoes. Plasmodium falciparum accounts for the overwhelming majority of malaria mortality, accounting for over 99% of all malaria-associated deaths globally. Although Plasmodium vivax has been traditionally considered to cause uncomplicated malaria, there is evidence of its potential to cause severe disease [1, 2]

Malaria continues to cause unacceptably high levels of disease and death despite increased global efforts [2,3,4]. In 2021, the global burden for malaria cases was 247 million, with an estimated mortality of 619,000 [5]. Severe malaria could result in neurological consequences which includes cerebral malaria [6, 7] and post-malaria neurological syndromes (PMNS) [8]. The neurologic manifestations includes loss of consciousness, hemiplegia (rarely), cranial nerve palsies, myelitis-like syndrome, psychosis, cerebellar ataxia and peripheral neuropathy [9]. A haemorrhagic stroke happens when blood from an artery or veins abruptly begins bleeding into the brain. In case of malaria it can occur when a patient has cerebral malaria [10].

The objective of this study was to describe a rare case of haemorrhagic stroke which appears to be a complication of severe malaria in a 26-year-old male patient.

Case presentation

A 26-year-old male was presented by his family with a chief complaint of loss of consciousness (LOC) and of left side body weakness of 12 h duration. In addition, he had high grade intermittent fever, global headache, vomiting of ingested matter, chills, rigors and shivering three days prior to the loss of consciousness. Otherwise, he had no known self and family history of chronic illnesses. He was not taking any anti-coagulant or antithrombotic medications. He has been living in malaria endemic area since he was 10 years old, and has a recurrent history of malaria infection for which he was prescribed tablets and IV medications at a health centre.

Physical examination at presentation, the patient was acutely sick looking, stuporous; however, he was not in cardiorespiratory distress. The vital signs were; blood pressure of 120/90 mmHg, pulse rate 116 beats/min, respiratory rate was 24 breaths/min, a temperature of 38.9 ◦C, BMI 18.4 and oxygen saturation of 94% on atmospheric air. The Glasgow Coma Scale (GCS) was 10/15(M₅, E₃, V₂), pupil reactive bilaterally and mid-sized and on motor examination there was a left side hemiparesis along with positive Babinski sign, hypertonia and exaggerated deep tendon reflex (DTR) at the same side. Sensory examination of both extremity and motor examination of the right extremity showed normal finding and the meningeal signs were negative. There were no abnormal findings in other body part examination.

At admission, his CBC (complete blood count) investigation showed WBC of 9600/mm³, HCT of 34.2%,platelet of 284, 000/mm³; however, the thick film confirmed malaria infection (trophozoites of P. falciparum) with a parasitic load of 3. Subsequent daily parasitic load was not done, but at fourth day his blood smear was negative. The rapid diagnostic test also confirmed that the patient was infected with P. falciparum.

Head CT revealed right cerebral parenchymal haemorrhage with intraventricular extension (Figs. 1, 2 and 3). Random Blood Sugar (RBS), Anti-Nuclear Antibody (ANA), Antineutrophilic cytoplasmic antibody (ANCA), and Antiphospholipid antibodies (APLA), were all normal. Renal Function Test (RFT), serum electrolyte, coagulation profile, and erythrocyte sedimentation rate all normal. Serology for syphilis was negative. Chest radiograph (initial), echocardiogram, EKG and carotid Doppler was normal. A cerebro-spinal fluid (CSF) analysis was in normal range.

Fig. 1

Sagittal section showing acute lobar haemorrhage with ventricular extension

Fig. 2

Coronal section showing unilateral acute lobar haemorrhage with ventricular extension

Fig. 3

Axial section showing unilateral acute lobar haemorrhage with ventricular extension

Consequently, the patient was diagnosed with cerebral malaria+aspiration syndromes+left side hemiparesis secondary to haemorrhagic stroke was considered. After 24 h of admission, his condition deteriorated with increase ICP and aspiration pneumonia. When he developed this, he was intubated and put on mechanical ventilator.

He was managed with intranasal oxygen 5L/minute, artesunate 2.4 mg/kg at 0, 12, 24, 48, 72, and 96 h. Oral airway inserted. Naso-gastric tube (NGT) inserted and feeding 200 ml every 2 h administered. Catheterized with amber colour urine output 0.8 ml/kg/hr. Broad spectrum antibiotics with ceftriaxone 1 g IV two times a day, Vancomycin 1gm IV twice a day, metronidazole 500 mg IV every 8 h, Cimetidine 200 mg IV every 12 h, paracetamol 1 gm po every 6 h, and admitted to adult ICU and coma care given. Transferred to ward after 5 days when the airway status improved.

The patient’s family was given advise for the definitive management of haemorrhage; however, the patient’s family responded that they could not cover the cost required for the management as it required referral to specialized centres. After completing the treatment at medical ward, the patient was discharged with improvement of the left-side weakness, after referral to the physiotherapy clinic for the treatment of the weakness. He gained full consciousness on the 7th day of admission and started self-feeding on the same day. He was on home physiotherapy and was advised about repositioning, diet and adherence to follow up visit. He has presented to medical referral clinic at different occasions within 2 months and there were no observed apparent complications except the left side weakness which has not resolved.

Discussion

The presented case demonstrated a 26-year-old male patient who was diagnosed with left side hemiparesis secondary to haemorrhagic stroke, presumed to be caused by cerebral malaria. There are reports of neurologic complications of severe malaria, but very few reports of similar cases of stroke as a complication of malaria [10, 14, 15]. However, to the best of the investigators knowledge there was only one case of haemorrhagic stroke in a patient with cerebral malaria [10].

The WHO defined cerebral malaria as clinical syndrome characterized by impaired consciousness (Glasgow coma scale < 11, Blantyre coma scale < 3) persisting for > 1 h of termination of a seizure or correction of hypoglycaemia with the asexual forms of P. falciparum malaria parasites on peripheral blood smears, and the other causes of encephalopathy excluded [3]. Cerebral malaria (CM) is one of the most severe, life-threatening neurological complication of malaria, caused predominantly by P. falciparum [3, 11, 12].

Knowledge of the local malaria-endemicity and disease pattern, clinical judgment and appropriate and prompt treatment with the first-line anti-malarial medications is curative and is significant to reduce the severe complications of malaria [3, 13, 16]. Recently, rapid diagnostic tests and artemisinin derivatives have become the two of the main pillars of the management of malaria [2, 3].

Conclusion

This report highlights the fact that malaria with stroke should be considered a differential diagnosis in a patient presenting with body weakness in a malaria endemic area and in individuals who had travel history to malaria endemic areas. It is very rare to find stroke caused by malaria in a young patient with no known associated comorbidities and normal investigational studies for the commonly known risk factors for stroke. Knowledge and experience working in malaria endemic areas and disease epidemiology guide in clinical judgment and decision-making.