Can malaria cause meningism?

Malaria and Meningism: Clinical Relationship

Yes, malaria can cause meningism, particularly in cases of cerebral malaria, though it's important to distinguish this from actual meningitis when evaluating patients with fever returning from endemic areas. 1

Neurological Manifestations in Malaria

• Malaria, especially caused by Plasmodium falciparum, can present with neurological symptoms including meningism (signs of meningeal irritation without actual meningitis) 1
• Cerebral manifestations may include drowsiness, mental confusion, coma, and seizures, which are signs of abnormal central nervous system function 2
• In a study of adult cerebral malaria, 22% of patients had features of meningeal irritation and/or meningism 3
• Neurological symptoms can persist even after parasites are cleared from the bloodstream 4

Diagnostic Considerations

• When evaluating patients with fever and neurological symptoms returning from endemic areas, both malaria and meningitis should be considered in the differential diagnosis 5
• In patients with altered consciousness or repeated convulsions, a lumbar puncture should be performed if possible to distinguish between cerebral malaria and bacterial meningitis 1
• If the CSF is cloudy, treatment for meningococcal meningitis is indicated and anti-malarial treatment should be discontinued 1
• If lumbar puncture cannot be performed, treatment for both meningitis and malaria should be administered concurrently 1

Clinical Approach to Suspected Malaria with Meningism

• For suspected malaria: Three thick films/rapid diagnostic tests over 72 hours should be performed to exclude malaria with confidence 5
• For suspected meningitis: Lumbar puncture should be performed if there are no contraindications 5
• The presence of Plasmodium on blood smears does not prove that malaria is the cause of febrile illness with meningism, even in areas where malaria is highly prevalent 1
• Other causes of fever and meningism, including pneumonia, acute lower respiratory infections, or bacterial meningitis should be considered and ruled out 1

Management Considerations

• If cerebral malaria with meningism is diagnosed, treatment should be initiated immediately with appropriate antimalarial therapy 1, 2
• For severe malaria with neurological symptoms, intravenous artesunate is the first-line treatment 2, 5
• Steroids should not be used for cerebral malaria as they have an adverse effect on outcome 1
• Careful fluid management is essential, as fluid overload can precipitate pulmonary edema or adult respiratory distress syndrome and worsen cerebral edema 2

Important Clinical Pitfalls

• Plasmodium vivax, traditionally considered a benign form of malaria, can also cause cerebral manifestations including meningism in rare cases 6
• The clinical features of meningitis are often nonspecific and may overlap with those of malaria, making differential diagnosis challenging 7
• Delay in diagnosis and treatment of either condition can lead to increased mortality 3
• Early hospitalization and proper nursing care can significantly reduce mortality in patients with cerebral malaria and meningism 3