Published cases of post-malaria neurological syndrome (PMNS) invariably report clinical and radiological encephalopathy. We report a case of brainstem and spinal cord inflammation without supratentorial involvement following recovery from Plasmodium falciparum infection. A 48-year-old woman was diagnosed with P falciparum malaria while on holiday in Sierra Leone, during which she did not take malaria prophylaxis. She responded well to artesunate and amiodaquine. Ten days later, back in the UK, she was admitted to hospital with progressive sensorimotor symptoms in both legs and urinary retention. Neurological examination revealed upbeat nystagmus, minimal neck and shoulder muscle weakness (MRC 4+/5) with hyperreflexia, flaccid paraplegia with retained reflexes, reduced anal tone and a sensory level at T3/4. MRI of the neuraxis showed high signal in the pons, cerebellar peduncles, medulla and most of the spinal cord. The rest of the brain parenchyma was normal. Lumbar puncture was omitted due to brainstem swelling. An extensive infective and autoimmune screen, including aquaporin-4 antibodies, was normal. The patient received 3 days of IV methylprednisolone. Toe movement returned within 36 h and she had minimal paraparesis by 2 weeks. A repeat MRI after 3 weeks showed improvement in signal change with resolution of brainstem swelling. It is argued that the recognised clinical spectrum of PMNS should be expanded to include brainstem and/or spinal cord involvement.
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