What is the treatment for cerebral malaria with cerebrospinal fluid (CSF) pleocytosis?

Treatment of Cerebral Malaria with CSF Pleocytosis

Intravenous artesunate is the first-line treatment for cerebral malaria with CSF pleocytosis, administered at 2.4 mg/kg at 0,12,24, and 48 hours until clinical improvement and parasitemia is <1%. 1

Initial Management

• Immediate hospitalization is required for patients with suspected cerebral malaria, with prompt diagnostic tests including thick blood film, hemoglobin measurement, blood glucose, and lumbar puncture 2, 1
• If artesunate is unavailable, administer intravenous quinine: initial dose of 20 mg(salt)/kg body weight in 10 mL/kg 5% dextrose infused over 3 hours, followed by 10 mg/kg every 12 hours 2
• For patients who have already received quinine before admission, the initial dose should be reduced to 10 mg/kg 2
• Switch to oral medications as soon as the patient's condition allows 2
• For patients returning from malaria-endemic areas, rapid blood malaria antigen tests and three thick and thin blood films should be examined for malaria parasites 2

Management of CSF Pleocytosis

• Perform lumbar puncture to rule out other causes of meningitis or encephalitis, as cerebral malaria can present with CSF pleocytosis 2, 3
• Despite the presence of CSF pleocytosis, continue antimalarial treatment as the primary intervention 1, 4
• Do NOT administer steroids, as they have an adverse effect on outcomes in cerebral malaria 2, 1

Supportive Care and Management of Complications

• Carefully manage fluid therapy to prevent fluid overload, which can precipitate pulmonary edema or ARDS and worsen cerebral edema 2, 3
• Use 5% dextrose with 1/2 normal saline as the IV fluid of choice to prevent hypoglycemia and minimize salt leakage into pulmonary and cerebral tissues 2, 3
• Monitor blood glucose levels regularly, as hypoglycemia is a common complication and risk factor for fatal outcome 2
• Treat hypoglycemia with 50 mL of 50% IV dextrose 2
• For seizures, administer paraldehyde 0.2 mL/kg by IM injection, and repeat if convulsions recur 3
• For persistent convulsions, give phenobarbital 10 mg/kg IM 1, 3
• Provide blood transfusion when hemoglobin is below 4 g/dL, or below 6 g/dL with signs of heart failure 2

Monitoring and Follow-up

• Monitor parasitemia every 12 hours until decline to <1%, then every 24 hours until negative 1
• Monitor for post-artemisinin delayed hemolysis (PADH) at days 7,14,21, and 28 1
• Start antibiotics if concomitant bacterial infection is suspected, but continue only if blood cultures are positive 1
• Monitor for renal failure by tracking fluid intake and output 2
• In case of oliguria, a fluid challenge followed by furosemide injection can help differentiate acute renal failure from prerenal causes 2

Special Considerations

• For patients with cerebral malaria who cannot swallow or have persistent vomiting, use IV antimalarial therapy 2
• Despite advances in treatment, cerebral malaria can still result in long-term neurological sequelae even with appropriate treatment 4, 5
• Exchange blood transfusion is no longer indicated with the availability of artesunate 1