Definition

Malaria is an infectious disease caused by the bite of an Anopheles mosquito. In Indonesia, as a developing country, malaria is a significant public health issue. Each year, over 30 million cases are reported, and more than 100,000 people die from malaria. Several factors exacerbate the situation in Indonesia, including the vast area, numerous malaria vectors, population movements, and irrigation developments that inadvertently create breeding grounds for malaria vectors. Cerebral malaria is a complication of malaria infection, with an incidence rate of 2%, especially among those with low immunity, pregnant women, and children in endemic areas. Cerebral malaria itself is a disease with a high mortality rate.

Causes

The cause of cerebral malaria is a Plasmodium infection that damages the blood-brain barrier and results in neurological syndromes. The most severe malaria infection causing cerebral malaria is Plasmodium falciparum infection. Cerebral malaria typically occurs within two weeks after a mosquito bite or 2-7 days of fever. The malaria parasite does not enter brain tissue directly; instead, it damages the blood-brain barrier, causing rupture and bleeding. Malaria can be transmitted if an uninfected mosquito bites an infected person and then bites a healthy person, transmitting the parasite.

Risk factor

Risk factors for malaria include living in endemic areas where malaria is very common. In Indonesia, endemic areas include Papua, East Nusa Tenggara (NTT), Maluku, North Maluku, South Kalimantan, and North Sulawesi. Globally, malaria-endemic areas include Africa, Southeast Asia, Central America, and South America. Some people have a higher and more severe risk of malaria, such as children and infants, the elderly, and pregnant women.

Symptoms

The main symptom of cerebral malaria is a decreased level of consciousness and shock, which can be accompanied by seizures. Other symptoms include:

• Fever
• Chills
• General discomfort
• Headache
• Nausea and vomiting
• Diarrhea or abdominal pain
• Muscle and joint pain
• Fatigue
• Rapid breathing and pulse
• Cough

Some people may experience malaria attacks, where they feel cold and shiver, followed by high fever, sweating, and then the body temperature returns to normal. These symptoms usually appear weeks after being bitten by an infected mosquito.

Diagnosis

Cerebral malaria diagnosis can be established through a thorough interview (anamnesis) with the patient or the patient's family regarding symptoms, travel history, especially to endemic areas, and malaria history in the surrounding environment. Before experiencing cerebral malaria, patients usually have initial malaria symptoms like paroxysmal fever every 48-72 hours, flu-like symptoms, headache, vomiting, and muscle and joint pain. The doctor will conduct a physical examination to assess complications such as anemia, liver enlargement, kidney, and spleen enlargement. Thick or thin blood smear tests are necessary to detect parasites in the blood due to Plasmodium. Three negative blood smear tests are required to rule out malaria. A head CT scan can also be performed if there is suspicion of cerebral edema (brain swelling) or brain bleeding. Lumbar puncture and cerebrospinal fluid analysis help rule out other diagnoses like brain infections.

Management

When a malaria parasite infects our bodies, the parasite has several growth stages. The treatment given to malaria sufferers serves to kill all the growth stages of the malaria parasite. The principle of malaria treatment is classified as ordinary malaria (without complications) patients treated with artemicine-based therapy. In severe malaria patients or with complications can be treated using injection drugs, namely an artesunate intravena/intramuscular or an intramuscular armemeter. If both are not available, Kina can provide it. Treatment by artemisin must be based on the results of blood tests. Implementation of severe malaria cases in general includes the administration of antimalarial drugs, treatment of complications, and symptomatic treatment (symptomatics).

The implementation of cerebral malaria is similar to the implementation of other severe malaria. Most severe malaria involves several organs. Thus, in the case of cerebral malaria, it is necessary to be aware of the presence of other organs that are disturbed. The focus on patients with cerebral malaria is cerebral malaria patients who experience a decrease in consciousness, inflammation (inflammatory) in the brain, and high pressure/increase pressure in the brain. 

Complications

Cerebral malaria can lead to several complications such as recurrent seizures, coma, increased intracranial pressure, and mental status changes. Plasmodium falciparum infection can cause various complications, including respiratory failure, and internal organ failure, leading to liver, kidney, and spleen damage. This condition can be life-threatening. Malaria complications can also cause anemia and low blood sugar.

Prevention

Cerebral malaria prevention can be achieved by controlling the malaria-causing parasite or preventing bites from Anopheles mosquitoes. Several measures can be taken to prevent malaria, including:

• Sleeping under mosquito nets
• Introducing larvivorous fish
• Using mosquito repellent or applying mosquito repellent lotion on the body
• Cleaning drains and surroundings
• Installing wire mesh screens
• Filling water puddles
• Keeping livestock pens away from the house
• Avoiding hanging used clothes
• Wearing long-sleeved clothing when going out at night

When to see a doctor?

It is advisable to see a doctor or visit the nearest healthcare facility if you experience the following symptoms:

• Fever when in a malaria-endemic area or after returning from a malaria-endemic area
• Severe fever with decreased consciousness or seizures
• High-risk factors such as children or infants, the elderly, and pregnant women

Prompt and appropriate management of cerebral malaria patients can improve quality of life and prevent further complications.