What is the treatment for cerebral malaria with seizures?

Treatment of Cerebral Malaria with Seizures

Intravenous artesunate is the first-line treatment for cerebral malaria, administered at 2.4 mg/kg at 0,12,24, and 48 hours, with seizures managed using a stepwise anticonvulsant protocol starting with benzodiazepines while avoiding prophylactic anticonvulsants. 1, 2

Immediate Antimalarial Treatment

Intravenous artesunate is the definitive treatment for cerebral malaria, providing faster parasite clearance and superior outcomes compared to quinine. 1, 2 The dosing regimen is:

• 2.4 mg/kg IV at 0,12,24, and 48 hours 2
• Continue until clinical improvement occurs and parasitemia drops below 1% 1, 2
• Once able to take oral medications and parasitemia <1%, switch to a full course of artemisinin combination therapy (ACT) 1

If artesunate is unavailable, use intravenous quinine: 20 mg salt/kg loading dose over 4 hours, then 10 mg/kg every 8 hours. 1 Omit the loading dose if the patient received quinine or mefloquine in the previous 24 hours. 1

Seizure Management Protocol

Do NOT use prophylactic anticonvulsants - prophylactic phenobarbital increased mortality in children with cerebral malaria, particularly when combined with multiple doses of diazepam due to respiratory depression. 1

For active seizures, follow this stepwise algorithm:

1. Immediate supportive care:

   • Position patient in left lateral position 3
   • Administer high-flow oxygen 1
   • Check blood glucose immediately (hypoglycemia precipitates seizures) 1
   • Secure airway and provide respiratory support 1

2. First-line anticonvulsant:

   • Lorazepam 0.1 mg/kg IV/IO 1
   • If seizure persists >10 minutes, repeat lorazepam 0.1 mg/kg 1

3. Second-line if seizures continue:

   • Paraldehyde 0.4 mg/kg (0.8 mL/kg) rectally OR
   • Paraldehyde 0.2 mL/kg IM 2, 4

4. Third-line for refractory seizures:

   • Phenytoin 18 mg/kg IV over 20 minutes OR
   • Phenobarbital 15-20 mg/kg IV over 10 minutes (10 mg/kg IM for persistent convulsions) 1, 2, 4

5. If still uncontrolled:

   • Call anesthetist for rapid sequence intubation with thiopental 4 mg/kg IV 1

Important caveat: About 25% of seizures in cerebral malaria are subtle or subclinical, manifesting only as eye deviation, irregular breathing, or drooling. 1, 3 Close monitoring is essential to detect these.

Critical Supportive Care Measures

Hypoglycemia management:

• Monitor blood glucose regularly - hypoglycemia is a common complication and risk factor for death 2, 4
• Treat with 50 mL of 50% IV dextrose if hypoglycemia detected or suspected 2, 4

Fluid management:

• Use restrictive fluid therapy to avoid pulmonary or cerebral edema 1, 2, 4
• Fluid overload can precipitate ARDS and worsen cerebral edema 2, 4
• Use 5% dextrose with 1/2 normal saline as IV fluid of choice 4

Raised intracranial pressure (if develops):

• Treat as medical emergency with rapid intubation and mechanical ventilation 1
• Maintain PaCO2 in normal range 1
• Mannitol 0.5 mg/kg IV over 5-10 minutes may be effective but requires repeated doses 1
• Do NOT use steroids - they worsen outcomes in cerebral malaria 1, 2, 4

Monitoring Requirements

Parasitemia monitoring:

• Every 12 hours until decline to <1%, then every 24 hours until negative 1, 2, 4
• Parasitemia may initially increase in first 24 hours with quinine (not treatment failure) 1

Post-treatment surveillance:

• Monitor for post-artesunate delayed hemolysis (PADH) at days 7,14,21, and 28 1, 2, 4
• Check hemoglobin, haptoglobin, and lactate dehydrogenase 1

Additional monitoring:

• Continuous cardiorespiratory monitoring in ICU 1
• Blood glucose, plasma bicarbonate, and lactate 1
• Renal function (fluid intake/output) 4

Additional Considerations

• Blood transfusion indicated when hemoglobin <4 g/dL or <6 g/dL with heart failure signs 2, 4
• Antibiotics only if bacterial co-infection suspected; continue only if blood cultures positive 1, 2, 4
• Exchange transfusion is NOT indicated with artesunate availability 1, 2, 4
• Perform lumbar puncture to rule out other causes of meningitis/encephalitis 4