Treatment of Cerebral Malaria with CSF Pleocytosis

Initial Management

The Centers for Disease Control and Prevention recommends immediate hospitalization for patients with suspected cerebral malaria, with prompt diagnostic tests including thick blood film, hemoglobin measurement, blood glucose, and lumbar puncture 2, 1
If artesunate is unavailable, the World Health Organization suggests administering intravenous quinine: initial dose of 20 mg(salt)/kg body weight in 10 mL/kg 5% dextrose infused over 3 hours, followed by 10 mg/kg every 12 hours 2
For patients who have already received quinine before admission, the Centers for Disease Control and Prevention recommends reducing the initial dose to 10 mg/kg 2
The World Health Organization advises switching to oral medications as soon as the patient's condition allows 2
For patients returning from malaria-endemic areas, the American Society of Tropical Medicine and Hygiene recommends rapid blood malaria antigen tests and three thick and thin blood films should be examined for malaria parasites 3

The Infectious Diseases Society of America suggests performing lumbar puncture to rule out other causes of meningitis or encephalitis, as cerebral malaria can present with CSF pleocytosis 3, 4
Despite the presence of CSF pleocytosis, the American College of Physicians recommends continuing antimalarial treatment as the primary intervention 1
The Centers for Disease Control and Prevention advises against administering steroids, as they have an adverse effect on outcomes in cerebral malaria 2, 1

The World Health Organization recommends carefully managing fluid therapy to prevent fluid overload, which can precipitate pulmonary edema or ARDS and worsen cerebral edema 2, 4
The American Thoracic Society suggests using 5% dextrose with 1/2 normal saline as the IV fluid of choice to prevent hypoglycemia and minimize salt leakage into pulmonary and cerebral tissues 2, 4
The Endocrine Society recommends monitoring blood glucose levels regularly, as hypoglycemia is a common complication and risk factor for fatal outcome 2
The American Heart Association advises treating hypoglycemia with 50 mL of 50% IV dextrose 2
For seizures, the Neurocritical Care Society recommends administering paraldehyde 0.2 mL/kg by IM injection, and repeat if convulsions recur 4
For persistent convulsions, the American Academy of Neurology suggests giving phenobarbital 10 mg/kg IM 1, 4
The American Society of Hematology recommends providing blood transfusion when hemoglobin is below 4 g/dL, or below 6 g/dL with signs of heart failure 2

The Centers for Disease Control and Prevention recommends monitoring parasitemia every 12 hours until decline to <1%, then every 24 hours until negative 1
The World Health Organization suggests monitoring for post-artemisinin delayed hemolysis (PADH) at days 7, 14, 21, and 28 1
The Infectious Diseases Society of America advises starting antibiotics if concomitant bacterial infection is suspected, but continue only if blood cultures are positive 1
The American Society of Nephrology recommends monitoring for renal failure by tracking fluid intake and output 2
In case of oliguria, the National Kidney Foundation suggests a fluid challenge followed by furosemide injection can help differentiate acute renal failure from prerenal causes 2

The World Health Organization recommends using IV antimalarial therapy for patients with cerebral malaria who cannot swallow or have persistent vomiting 2
The American College of Physicians notes that despite advances in treatment, cerebral malaria can still result in long-term neurological sequelae even with appropriate treatment 1
The Centers for Disease Control and Prevention advises that exchange blood transfusion is no longer indicated with the availability of artesunate 1