Plasmodium falciparum appears to have a particular propensity to involve the brain, but the burden, risk factors and full extent of neurological involvement have not been systematically described.
To determine the incidence and describe the clinical phenotypes and outcome of neurological involvement in African children with acute falciparum malaria.
Design, setting and patients
A review of records of all children younger than14 years admitted to a Kenyan District Hospital with malaria, from January 1992 through December 2004. Neurological involvement was defined as convulsive seizures, agitation, prostration, impaired consciousness or coma.
The incidence, pattern and outcome of neurological involvement.
Of 58,239 children admitted, 19,560(33.6%) had malaria as the primary clinical diagnosis. Neurological involvement was observed in 9,313(47.6%) children and manifested as seizures (6,563/17,517, 37.5%), agitation (316/11,193, 2.8%), prostration (3,223/15,643, 20.6%), impaired consciousness or coma (2,129/16,080, 13.2%). In children <5 years, the mean annual incidence of admissions with malaria was 2,694/100,000 and the incidence of malaria with neurological involvement was 1,156/100,000. However, re-admissions may have led to a 10% overestimate in the incidence. Children with neurological involvement were older (median [inter quartile range] age 26[15-41] vs 21[10-40] months, p<0.001), had a shorter duration of illness (2[1-3] vs 3[2-3] days, p<0.001) and a higher geometric mean parasite density (42.0 [95%CI 40.0-44.1] vs 30.4 [95%CI 29.0-31.8]×103/μl, p<0.001). Factors independently associated with neurological involvement included past history of seizures (adjusted OR 3.50 95%CI 2.78-4.42), fever ≤2 days (adjusted OR 2.02 95%CI 1.64-2.49), delayed capillary refill time (adjusted OR 3.66 95% CI 2.40-5.56), acidosis (adjusted OR 1.55 95% CI 1.29-1.87) and hypoglycemia (adjusted OR 2.11 95% CI 1.32-3.37). Mortality was higher in patients with neurological involvement (4.4% [95% CI, 4.2%-5.1%] vs 1.3% [95% CI, 1.1%-1.5%], p<0.001), and at discharge, 159 out of 7281 (2.2%) had neurological deficits.
Neurological involvement is common in children with acute falciparum malaria. It is associated with metabolic derangements, impaired perfusion, parasitemia and has increased mortality and neurological sequelae. The study suggests that malaria exposes many African children to brain insults.