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 hours 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. Twenty-four hours (24h) after the onset of LOC, the patient was experiencing nonproductive cough and fast breathing. Otherwise, he had no known self and family history of chronic illnesses like DM (diabetes mellitus), hypertension, cardiac disease or history of bleeding tendency. He is not taking any anti-coagulant or antithrombotic medications.
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 120/90mmHg, 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. He had pink conjunctiva and non-icteric sclera. S1 and S2 well heard and no murmur and gallop. Chest was clear and resonant. No mass and organomegaly in abdominal examination. No oedema at the extremity. Nervous system examination; stuporous with Glasgow Comma Scale (GCS) 10/15(M5, E3, V2), pupil reactive bilaterally and mid-sized. On motor examination; increased tone (Spastic type), power was 5/5 in the right upper and lower extremity and 1/5 in the left upper and 2/5 in the left lower extremity. Babinski sign was positive on the left, Exaggerated Deep Tendon Reflex (DTR) ¾, and no sensory abnormality.
After 24 hours of admission, the vital signs were; blood pressure of 100/70mmHg, pulse rate 120 beats/min, respiratory rate was 28 breaths/min, a temperature of 37.6 ◦C and oxygen saturation of 88%. Diffuse crepitation on the anterior and posterior lung fields in chest examination. Nervous system examination; GCS of (E3, V1, M2), pupil reactive bilaterally and mid-sized, no cranial nerve abnormality. When he developed this, he was Intubated and put on Mechanical Ventilator after he had been admitted to ICU.
At admission, his CBC (complete blood count) investigation showed WBC of 9,600/mm3, HCT of 34.2%, platelet of 284, 000/mm3; however, the blood film test confirmed mixed malaria infection (Trophozoite stage of plasmodium falciparum and plasmodium Vivax) (Fig. 1). The rapid diagnostic test also showed similar result (Fig. 2). Head CT revealed right cerebral parenchymal haemorrhage with intraventricular extension (Figs. 3,4 and 5). 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. Therefore, the diagnose of Cerebral malaria + Aspiration pneumonia + left side hemiparesis 2ry to haemorrhagic stroke was considered.
He was managed with intranasal oxygen 5L/minute, artesunate 2.4mg/kg at 0, 12, 24, 48, 72, and 96hours. Oral airway inserted. Naso gastric tube (NGT) inserted and feeding 200ml every 2hour administered. Catheterized with amber colour urine output 0.8ml/kg/hr. Broad spectrum antibiotics with ceftriaxone 1g IV two times a day, Vancomycin 1gm IV two times a day, metronidazole 500 mg IV every 8hour, Cimetidine 200mg IV every 12hour, paracetamol 1 gm po every 6hour, and admitted to adult ICU and coma care given. Transferred to ward after 5 days when the airway status improved. The patient family was advised for the definitive management of haemorrhage; however, the patients family responded that they couldn’t have the cost required for the management as it require referral to high centres. After completing the treatment at medical ward, the patient was discharged with improvement with the left-side weakness after linked to our physiotherapy clinic for treatment of the weakness. He gained full conscious ness 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 been 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 (motor 3/5(on both left Upper and Lower extremity at last visit)