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To: Journal of PRACTICAL NEUROLOGY Letters

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Papers: J A Carter, V Mung’ala-Odera, B G R Neville, G Murira, N Mturi, C Musumba, and C R J C Newton Persistent neurocognitive impairments associated with severe falciparum malaria in Kenyan children J Neurol Neurosurg Psychiatry 2005; 76: 476-481 [Abstract] [Full text] [PDF]

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Severe malaria and persistent neurocognitive impairments

Khichar Shubhakaran, Rajasthan, India   (31 May 2005)

Severe malaria and persistent neurocognitive impairments 31 May 2005
Khichar Shubhakaran, Doctor S.P. Medical College, Bikaner, Rajasthan, India Send letter to journal: Re: Severe malaria and persistent neurocognitive impairments s.khichar{at}rediffmail.com Khichar Shubhakaran, et al.	Dear Editor, We read with interest an article “persistent neurocognitive impairments associated with severe falciparum malaria in Kenyan children” by Carter et al.[1] in which the authors have studied children admitted up to 9 years earlier with cerebral malaria, (CM) (n=152), Malaria and complicated seizures (M/S) (n=156) or those unexposed to either condition (n=179). Twenty four percent of the CM and M/S groups had at last one impairment in the major domains assessed in the study group, compared with 10% of the unexposed group. It is also worth mention that in the same issue of the esteemed journal other authors Birbeck and Taylor [2] have given an excellent comments about the study under “editorial commentary” in which the authors have further added that” in this observational study, preexisting neurologic abnormalities that predisposed to M/S cannot be excluded. Children with underlying brain abnormalities would be more likely to present with complicated seizures in the setting of malaria and hyperthermia. Among the CM group the possibility of subtle status epilepticus related to premorbid ‘bad brain’ is difficult to eliminate. Finally, the authors in the editorial said that “regardless of these limitations, this work should increase awareness of the potential for childhood malaria to produce chronic neurologic disorders”. Here we would like to share our comments/work which would widen the relevance of the article further. The authors in the study have observed that the prevalence of stunting, wasting and underweight was generally higher among children with history of cerebral malaria. So this finding requires further observation in subsequent studies that how much contribution is there of nutrition per se for predisposition to malaria or subtle neurocognitive changes predisposing to frank neurocognitive impairment subsequent to exposure to malaria as the authors themselves have observed that “the comparatively high level of impairment found in the unexposed group may have moderated the adds of impairment associated with CM or M/S.” In this study there is also important finding which has been rarely observed in earlier studies that neuropsychiatric/neurocognitive impairment can also be found in patients of falciparum malaria without loss of consciousness (in the absence of seizure) as we have observed in a study on adult patients.[3] The same authors in a separate publication have commented “our results suggest that an association occurs between malaria and epilepsy but give no indication regarding causality”.[4] We have observed in earlier large scale studies on adult patients of falciparum malaria that hypoglycaemia is an important factor which contributes significantly to mortality and morbidity due to malaria and at times it is difficult to differentiate between cerebral malaria and severe falciparum malaria with hypoglycaemia. “As hypoglycaemia increases the chances of convulsions, neurological deficit and sequelae, it should be recognized and corrected as early as possible before it produces permanent brain damage. In our series severe hypoglycemia (FBS 40 mgjl) was presents in 18 (4.08%) patients; eight of them were having associated severe convulsions at the time of admission and all of them expired during treatment while out of remaining 10 patients without convulsions only two expired ; four had neurological sequelae after recovery from coma and 4 patients recovered completely oral quinine can also cause hypoglycents so a close watch on blood glucose is very essential through out the course of treatment.” 5-6 As glycaemic status and nervous system has an immense relationship which might be responsible for the persistent neurocognitive impairment in patients with malaria besides genetic, nutritional, geographic, malarial species mutations/variations, other metabolic factors like hyponatraemia and lactic acidosis. So in further studies we should also incorporate data regarding hypoglycaemia/glycaemic status and give more aggressive attention towards hypoglycaemia in paediatric malaria. There is also role of single dose phenobarbitone in patients of severe falciparum malaria both in preventing seizure development in those without seizures and also subsequent development of seizures in those with seizures.[5,6] Besides this phenoberbitone also has got neuroprotective action in the setting of hyperthermia as the authors of “editorial comment” have pointed out that. “could intervention aimed at neuroprotection reduce the incidence of neurologic squealae in this population.”[4] Further more in the third word countries like Indian subcontinent a great proportion of such patients are initially being treated by semi/unqualified health care workers and quack, so looking to the dimension of persistent neurocongitive impairment in patients of server malaria the health infrastructure would have to increase awareness in this regard besides further studies/research. References 1. Carter JA, Mungala-odera V, Neville BGR, et al. Persistent neurocognitive impairment associated with severe falciparum malaria. J Neurol, Neurosurg, psychiatry 2005; 76 :476-481. 2. Birbeck GL, Taylor TE. Severe malaria; still counting the costs. J Neurol, Neurosurg, Psyehiarty 2005: 76:467-468. 3. Kochar DK, Shubhakaran , Thanvi i, et al. Neurological complication of falciparum malaria. J.Assoc physicians India 1997;45:897-899. 4. Carter JA, Neville BRG, white S, et al. Increased prevalence of epilepsy associated with severe falciparum malaria in children. Epilepsia 2004;45(8):978-981. 5. Kochar DK, shubhakaran, kumawat. I, cerebral malaria in Indian adults: Aprospective study of 441 patients from Bikaner, Northwest India. J.Assoc physicians India 2002;50;234-241. 6. Kochar DK,Shubhakaran, Kumawat BL. et al. Seizures in cerebral malaria. Quart J.Med. 1997;90:605-7.