Redefining cerebral malaria by including malaria retinopathy

Abstract

Accurate diagnosis of cerebral malaria (CM) is important for patient management, epidemiological and end point surveillance, and enrolling patients with CM in studies of pathogenesis or therapeutic trials. In malaria-endemic areas, where asymptomatic Plasmodium falciparum parasitemia is common, a positive blood film in a comatose individual does not prove that the coma is due to malaria. A retinopathy consisting of two unique features - patchy retinal whitening and focal changes of vessel color - is highly specific for encephalopathy of malarial etiology. White-centered retinal hemorrhages are a common but less specific feature. Either indirect or direct ophthalmoscopy can be used to identify the changes, and both procedures can be learned and practiced by nonspecialist clinicians. In view of its important contributions to both clinical care and research, examination of the retina should become a routine component of the assessment of a comatose child or adult when CM is a possible diagnosis.

Figure 1. Central and temporal macula showing patchy retinal whitening

Three white-centered hemorrhages are also present.

Figure 2. Retinal vessel whitening

Shown in the lower section of the photograph.

Figure 3. Multiple white-centered blot hemorrhages to an extent typical of malaria retinopathy

Retinal whitening and small vessel changes are also present. There is artefactual glare along and below the vascular arcade.