What is the treatment for cerebral malaria?

Treatment of Cerebral Malaria

Intravenous artesunate is the first-line treatment for cerebral malaria, as it provides faster parasite clearance and better outcomes compared to quinine. 1

Initial Management

Emergency Treatment

• If diagnosed in an outpatient setting, refer for hospitalization immediately, but begin treatment without delay 1
• Perform immediate diagnostic tests: thick blood film, hemoglobin, blood glucose, and lumbar puncture (if possible) 1
• If hemoglobin is below 4 g/dL, perform blood grouping and cross-matching 1

First-Line Treatment

• Intravenous artesunate: 2.4 mg/kg at 0,12,24, and 48 hours 1
  • Continue for 3 doses until patient improves clinically and parasitemia is <1% 1
  • Once improved and able to take oral medication, switch to a full course of oral artemisinin-based combination therapy (ACT) 1

Alternative Treatment (if artesunate unavailable)

• Intravenous quinine dihydrochloride: Initial dose 20 mg/kg (salt) infused over 4 hours in 5% dextrose 1
  • If patient already received quinine before admission, reduce initial dose to 10 mg/kg 1
  • Subsequent doses: 10 mg/kg every 8-12 hours infused over 4 hours 1
  • Continue IV treatment for at least 48 hours before switching to oral medication 1

Management of Complications

Convulsions

• For acute seizures: Administer 0.2 mL/kg paraldehyde by IM injection 1
• If convulsions recur, repeat the treatment 1
• For persistent convulsions: Give phenobarbital 10 mg/kg IM 1

Hypoglycemia

• Monitor blood glucose levels regularly - hypoglycemia is a common complication and risk factor for fatal outcome 1
• Suspect hypoglycemia when there is deterioration in clinical status, especially with new neurological findings 1
• Treat with 50 mL of 50% IV dextrose if hypoglycemia is detected or suspected 1

Fluid Management

• Use caution with fluid therapy as overload can precipitate pulmonary edema or ARDS, worsening cerebral edema 1
• Preferred IV fluid: 5% dextrose with 1/2 normal saline (provides glucose to prevent hypoglycemia and less salt to prevent leakage into pulmonary and cerebral tissues) 1
• Restrictive fluid management is generally recommended to avoid pulmonary or cerebral edema 1

Anemia

• Blood transfusion indicated when Hb <4 g/dL, or Hb <6 g/dL with signs of heart failure (dyspnea, enlarging liver, gallop rhythm) 1
• Consider folic acid supplementation during recovery period 1

Renal Complications

• Replace fluid losses to prevent renal failure 1
• If renal failure is suspected, strictly monitor fluid intake and output 1
• For oliguria, perform fluid challenge followed by furosemide injection to differentiate acute renal failure from prerenal causes 1
• Acetaminophen (1g every 6 hours for 72 hours) may have a reno-protective effect 1

Important Considerations

Monitoring

• For severe malaria: Monitor parasitemia every 12 hours until decline to <1%, then every 24 hours until negative 1
• For patients treated with IV artesunate: Monitor for post-artemisinin delayed hemolysis (PADH) at days 7,14,21, and 28 1
• Continue monitoring for complications including cardiovascular, pulmonary, renal, and metabolic parameters 1

Contraindications

• Do not use steroids - they have an adverse effect on outcome in cerebral malaria 1
• Exchange blood transfusion is no longer indicated with the availability of artesunate 1

Antibiotics

• Start antibiotics if concomitant bacterial infection is suspected, but continue only if blood cultures are positive 1
• If lumbar puncture shows cloudy CSF, treat for meningitis and discontinue antimalarial treatment 1
• If lumbar puncture cannot be performed but meningitis is suspected, treat for both conditions 1

Special Considerations

• Artemisinin derivatives have shown superior efficacy in rapidly reducing parasite burden compared to quinine (90% clearance time: 16-18.9h vs 34.5h for quinine) 2
• Artemisinin derivatives have improved safety profile with reduced neurotoxicity compared to older antimalarials 3, 4
• Drug interactions should be considered when using artemisinin-based therapies, particularly with HIV antivirals, cardiovascular drugs, antibiotics, and antiparasitics 5