Cerebral malaria
Cerebral malaria is caused by the falciparum parasite, and is not uncommon in southern Africa. Coma is characteristic, and is an ominous feature, since it is associated with a mortality of 20% in spite of treatment.

It is not just coma which should be taken seriously. Any degree of behaviour change, decrease in consciousness or delirium is potentially very serious.

The onset of coma may be gradual or sudden, and generally follows a convulsion.

Patients with cerebral malaria commonly have anaemia and jaundice as well. Convulsions occur in 50% of adults and higher proportion of children with cerebral malaria.

Around 10% of children with cerebral malaria, particularly those with hypoglycaemia, repeated seizures and deep coma, will have some evidence of brain damage when they regain consciousness.

Hypoglycaemia
Hypoglycaemia, or low blood glucose, is an important and common complication of severe falciparum malaria, and indicates a poor outlook. It is a particular problem in children and pregnant women.

It happens as a result of problems with the liver's glucose-producing cycles, and from increased use of glucose by both the body and the parasite. To make matters worse, quinine, used in treatment, stimulates the release of insulin, which drives the blood glucose down still further.

Hypoglycaemia is also difficult to diagnose, since the clinical signs of sweating, gooseflesh and a fast heart beat are absent, and other signs cannot be distinguished from those of malaria itself.

Lactic acidosis
Lactic acidosis, a metabolic derrangment, is common along with hypoglycaemia. It is caused by both the abnormal metabolism of the red blood cells and the liver. Again, the outlook is poor.

Pulmonary oedema
Pulomary oedema, or fluid on the lungs, may develop in severe falciparum malaria, even after several days of treatment. The mortality is over 80%.

Kidney problems
These are common in adults with severe falciparum malaria, but rare in children. It is a marker of serious disease, and carries a high mortality, unless the acute stage can be dealt with successfully.

Blood problems
Anaemia is common, and in severe infection transfusion may be required.

Other complications
Pneumonia, in this case caused by aspiration of stomach contents while fitting, is a common cause of death in cerebral malaria. Other infections caused by bacteria are relatively common in those with malaria, including life-threatening septicaemia.

Special cases of falciparum malaria...