Mohammad Fakhrul Huda, Nasib Iqbal Kamali, V.K. Srivastava & Mohammad Kaif

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J Vector Borne Dis 48, December 2011, pp. 247–248Spontaneous acute subdural hematoma in malaria : a case reportMohammad Fakhrul Huda, Nasib Iqbal Kamali, V.K. Srivastava & Mohammad KaifNeurosurgery Unit, Department of Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, IndiaKey words   Cerebral complications; malaria; Plasmodium falciparum; spontaneous acute subdural hematomaMalaria is a major health problem in tropical coun-tries. Among its complications, cerebral malaria is the mostdevastating and can present as hemiplegia, convulsions,disorientation, delirium, coma and finally death1,2. Rarecomplications of cerebral malaria such as spontaneoussubdural empyema and subarachnoid hemorrhage has alsobeen reported in literature1,3,4. We report development ofspontaneous acute subdural hematoma in a patient ofPlasmodium falciparum malaria.Case reportA 70-yr male presented in our emergency departmentin altered sensorium. The patient was being treated at aprivate set up for P. falciparum malaria from past 10 days.The patient developed right-sided weakness and becamedisoriented on the ninth day and for which a non contrastcomputed tomography scan of the head was done that re-vealed massive acute left-sided  subdural hematoma withmass effect and midline shift. There was subfalcine andtranstentorial herniation (Fig. 1).The patient was hencereferred to our centre for expert management. There wasno history of head trauma or fall from height.At the time of admission patient was febrile (102° F)and Glasgow coma scale (GCS) was 6. Pupils were un-equal and not reacting to light. Respiratory examinationwas within normal limits. Laboratory investigations re-vealed hemoglobin of 4 g/dl.  Peripheral blood examina-tion revealed P. falciparum, thrombocytopenia (plateletcount 42000/cc) and hypochromic anemia. Renal func-tion, electrolytes, coagulation profile was also within nor-mal limits.A left-sided frontotemporal osteoplastic flap cran-iotomy was performed. On opening, the dura thick clotwas removed completely. A small cortical vessel was foundbleeding actively which was coagulated. Dura was closedwithout any difficulty and the bone flap was replaced whileclosure of the wound. Post-operatively the patient was kepton antibiotics, antimalarials and antiepileptics. Since thepatient had presented with severe malaria and was previ-ously being treated at a private clinic for several days, itwas presumed that malaria may be multidrug resistant.So, the patient was treated with intravenous artesunate asper standard protocol. Post-operative scan revealed complete removal of theclot and re-expansion of the brain. GCS started improv-ing from second post-operative day. By fourth day thepatient started localizing the painful stimulus, had spon-taneous eye opening and spoke inappropriate words andbecame afebrile. The patient was recovering satisfacto-rily but unfortunately he developed severe chest infectionto which he succumbed.Malaria is a major heath problem in developingcountries and out of the four species, P. falciparum is themost dangerous. Majority of deaths are caused by P.falciparum2. Severe falciparum malaria is characterizedby hypoglycemia, lactic acidosis, non-cardiogenic pulmo-nary edema, renal impairment and cerebral complications5.Cerebral malaria is the most dreaded complication anddespite treatment, is associated with death rates of ~20%among adults and 15% among children2. Cerebral ma-laria presents as diffuse symmetric cerebral encephalopa-thy with focal signs being exceedingly rare2. Coma is thehallmark of cerebral malaria. Convulsions are more com-Fig. 1: Non-contrast computed tomographic scan of head showingleft-side acute subdural hematoma with mass effect and midlineshift. There is subfalcine and transtentorial herniation. J Vector Borne Dis 48, December 2011 248mon in children as compared to the adults6. CSF pressureis raised, probably due to increased cerebral blood flow.Unusual complications, such as subdural empyema andsubarachnoid hemorrhage are exceedingly rare. Only twocases of each has been reported so far1,3,4. In the case re-ported by Dwarkanath et al4 subdural empyema was as-sociated with subdural hematoma which was evacuatedsurgically. Smythe & Cairns3 reported a case of subduralabscess complicated falciparum malaria which was treatedwith repeated aspirations, antimalarials and antibiotics.This is the first case report of spontaneous acute subduralhematoma in a patient of falciparum malaria presentingas neurosurgical emergency. Subdural hemorrhage in ourpatient may have been caused by the rupture of a smallvessel plugged by red cells in combination with severethrombocytopenia. The likely mechanism in formation ofhematoma may be due to an increase in serum TNF-,whose concentrations correlate well with the severity ofdisease6. By up-regulating endothelial adhesion molecules,TNF- may promote cerebral sequestration of plateletsand red cells  thus leading to hemorrhage7.CONCLUSIONIt is thus concluded that apart from diffuse cerebralencephalopathy, cerebral malaria can also present as spon-taneous subdural hemorrhage. If the patients of cerebralmalaria develop focal neurologic deficit this complication,though rare, should be considered and prompt imagingshould be done to treat this life threatening emergency.REFERENCES1. Murugavel K, Saravanapavananthan S, Anapalahan A, JamesRF. Subarachnoid haemorrhage in Plasmodium falciparummalaria. Postgrad Med J 1989; 65: 236–7.2. Nicholas JW, Joel GB. Malaria. In: Fauci AS, Kasper DL, LongoDL, Braunwald E, Hauser SL, Jameson JL, et al, editors.Harrison’s principles of internal medicine, 17 edn. New York:McGraw-Hill 2008; p. 1280–93.3. Smythe A, Cairns J. Ultrasound diagnosis of subdural abscesscomplicating meningitis. Trop Doctor 1997; 27: 54–5.4. Dwarakanath S, Suri A, Mahapatra AK. Spontaneous subduralempyema in falciparum malaria: a case study. J Vector BorneDis 2004; 41: 80–2.5. Newton CRJC, Hien TT, White N. Neurological aspects of tropi-cal disease: cerebral malaria. J Neurol Neurosurg Psychiatry2000; 69: 433–41.6. Grau GE, Taylor TE, Molyneux ME, Wirima JJ, Vassali P,Hommel M,  Lambert PH. Tumor necrosis factor and diseaseseverity in children with falciparum malaria. N Engl J Med 1989;320: 1586–91.7. Mannel DN, Grau GE. Role of platelet adhesion in homeostasisand immunopathology. Mol Pathol 1997; 50: 175–85.Correspondence to: Dr Nasib Iqbal Kamali, Senior Resident Neurosurgery, Department of Surgery, Aligarh Muslim University,Aligarh–202 002, India.E-mail: nikaajournal@gmail.comReceived: 25 January 2011 Accepted in revised form: 20 October 2011

Spontaneous acute subdural hematoma in malaria : a case report

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