Malaria and Relation to Epilepsy

What is a parasite? What is malaria?

  • A parasite is an organism that lives on or in a host organism and gets its food from or at the expense of its host
  • Malaria is caused by a parasite (Plasmodium species) that is most often transmitted by a mosquito to a human to cause infection
  • Malaria can cause a number of different symptoms throughout the body and brain
  • Brain (cerebral) malaria has been found to be a potential cause of epilepsy in tropical regions of the world
  • Malaria can lead to serious and potentially life-threatening illness

How does someone get malaria? How is malaria transmitted?

  • Malaria is most commonly caused by a parasite that infects a type of mosquito (the female Anopheles mosquito), which later feeds on humans to transmit the disease
  • The disease can be less commonly transmitted other ways, including,
    • Blood transfusion
    • Sharing of contaminated needles or syringes
    • Organ transplantation
    • From mother to child (congenital)
  • When the organism infects humans, it lives in their red blood cells and because of this can lower a person’s red blood cell count

Who is impacted by malaria?

  • 219 million people worldwide were impacted by malaria in 2017
  • Occurs in tropical and subtropical regions of the world
  • According to the World Health Organization (WHO), malaria occurred most frequently in Africa, South-East Asia, and the Eastern Mediterranean region
    • 92% of these cases were seen in Africa, followed by 5% in South-East Asia.
      CDC-Malaria.png
       
  • In areas where malaria is most common (particularly in Africa), people who are most vulnerable to developing infection include,
    • Young children (particularly if between 6 months to 59 months)
    • Pregnant women
    • People who are sick with other conditions
  • Healthy adults can develop malaria
  • It is important for people visiting at-risk areas to tell their doctor before traveling to these areas, and to watch out for signs and symptoms of malaria

What are the symptoms of malaria?

  • After a person gets bitten by a mosquito infected with the parasite, there is usually a delay of 12-14 days (incubation period) before a person develops signs and symptoms of malaria
  • Malaria can cause a wide range of signs and symptoms
  • Fever is the most common symptom
  • Other symptoms include flu-like symptoms, chills, fatigue, sweating, headache, weight loss, nausea, vomiting, diarrhea, cough, stomach pain, joint pain, and muscle aches

What happens when malaria involves the brain?

  • Sometimes malaria can involve the brain and when this happens it is called cerebral malaria
  • When the brain is affected malaria is considered severe
  • Blood cells infected by the parasite block small blood vessels to your brain and this can cause brain swelling and bleeding in the brain that result in brain damage
  • Cerebral Malaria is usually a very serious condition. Some notable statistics include:
    • Each year, brain injury occurs in about 135,000 children who develop severe malaria in Africa
    • About 33% of children with cerebral malaria will have persistent neurologic symptoms later in life
    • Between 15 to 25% of children can die from this condition
  • Factors that make people more likely to develop cerebral malaria include:
    • Living in areas where malaria is the most common (such as sub-Saharan Africa)
    • Pregnancy
    • Poor nutritional status
    • HIV
    • Having certain genes that make a person more prone to malaria
    • Having a person’s spleen removed (splenectomy)
    • Being a young child or older adult
  • Symptoms of brain involvement include confusion, behavioral changes, seizures, and decreased responsiveness
    • Seizures can occur in about 4 out of 10 children with cerebral malaria
    • Brain involvement can be life threatening due to brain swelling, increased pressure in the brain, and coma

What kinds of seizures do people with malaria have?

  • People with malaria may develop seizures due to high fever (febrile seizures) or from brain involvement itself
  • Seizures from malaria are most often generalized seizures, meaning they are seizures that involve all areas of the brain, and can cause a bilateral tonic-clonic seizure (link).
  • About one third of people with seizures may have focal seizures. Focal seizures are seizures that arise from one region of the brain on one side (hemisphere) of the brain.
    • Symptoms depend on the areas of the brain that are affected, and may include loss of awareness, confusion, eye movement to one side, salivation, difficulty speaking, shaking movements, or other neurological signs
    • Sometimes focal seizures can spread to all areas of the brain, leading to a bilateral tonic-clonic seizure

How is malaria diagnosed? 

  • Malaria is usually diagnosed by review of blood samples to look for evidence of the parasite
  • In certain cases, doctors may start treatment on people suspected to have malaria before the diagnosis is confirmed, to prevent development to severe infection
  • To determine whether malaria is affecting the brain, close inspection of the eyes (doctors use a special tool called an ophthalmoscope to do this), MRI or CT imaging of the brain, or lumbar puncture (spinal tap) may help make the diagnosis

What are the treatment options?

  • Malaria is usually treated with drugs directed against the parasite
  • The most commonly used medications are chloroquine, Artemisinin-based combination therapy (ACT), and atovaquone-proguanil
  • The medications used may depend from what region of the world the infection came from
  • In people with seizures from malaria, first line treatment is anti-seizure medications
  • Antiseizure medications can help to reduce the risk of seizures and are taken in addition to the antimicrobial medications
  • Examples of some medications that are used include phenobarbital, levetiracetam (Keppra) and diazepam (Valium)

What is the prognosis of malaria with brain involvement?

  • When malaria involves the brain, it can be serious and life-threatening.
  • Between 15 to 25% of children can die from this condition
  • People who recover from initial infection can be left with significant physical or cognitive (thinking, remembering) complications as a result of the illness
    • Children are most prone to this, and may develop weakness, cerebral palsy, blindness, deafness, developmental delays, and language problems.
    • Some children are left with chronic seizures and may need longstanding ASM.
    • Children who have seizures are more likely to have persistent neurologic problems later in life

REFERENCES

Birbeck GL, Herman ST, Capparelli EV, et al. A clinical trial of enteral Levetiracetam for acute seizures in pediatric cerebral malaria. BMC Pediatr 2019;19(1):399. 

Breman J. Clinical manifestations of malaria in nonpregnant adults and children. In: UpToDate, Post TW and Baron EL (Eds). UpToDate, Waltham, MA: UpToDate, Inc. https://www.uptodate.com (Accessed on 16 November 2019). 

Crutcher JM, Hoffman SL. Malaria. In: Baron S, editor. Medical Microbiology. 4th edition. Galveston (TX): University of Texas Medical Branch at Galveston; 1996. Chapter 83.

Daily J. Treatment of uncomplicated falciparum malaria in nonpregnant adults and children. In: UpToDate, Post TW and Baron EL (Eds). UpToDate, Waltham, MA: UpToDate, Inc. https://www.uptodate.com (Accessed on 16 November 2019). 

Hopkins H. Diagnosis of Malaria. In: UpToDate, Post TW and Baron EL (Eds). UpToDate, Waltham, MA: UpToDate, Inc. https://www.uptodate.com (Accessed on 16 November 2019). 

Idro R, Ndiritu M, Ogutu B, et al. Burden, features, and outcome of neurological involvement in acute falciparum malaria in Kenyan children. JAMA. 2007;297(20):2232–2240. doi:10.1001/jama.297.20.2232
 
Ogutu, B. R., & Newton, C. R. J. C. (2004). Management of Seizures in Children with Falciparum Malaria. Tropical Doctor 34(2), 71–75.

World Health Organization. World Malaria Report 2018. http://www.who.int/malaria/publications/world-malaria-report-2018/report... (Accessed on 14 November 2019).

Authored By: 
Charles Casassa MD
Elaine Kiriakopoulos MD, MSc
Authored Date: 
08/2020