Purchase this article with an account.
S. J. Glover, S. P. Harding, M. E. Molyneux, S. Lewallen, T. E. Taylor, N. A. V. Beare; Fundus Fluorescein Angiography in Paediatric Cerebral Malaria. Invest. Ophthalmol. Vis. Sci. 2008;49(13):5047. doi: https://doi.org/.
Download citation file:
© ARVO (1962-2015); The Authors (2016-present)
To study the retinal circulation in children with malarial coma. The brain and retina are embryologically and structurally related. Previous studies have shown retinal changes in children with cerebral malaria to be prognostic. Unlike the brain, study of the retina allows visualisation of an infected CNS microvasculature in vivo.
With parental informed consent we performed fluorescein angiograms within 6 hours of admission on comatose children admitted with a clinical diagnosis of cerebral malaria to a paediatric research ward during jan-june 2007. This was repeated if the child was unconscious for more than 24hrs.
We studied 38 patients. Some patients had areas of retinal non perfusion which co-localised precisely with areas of retinal whitening. These non perfused areas decreased in size or resolved by day 4 in one patient with prolonged coma . In 4 patients with large areas of non perfusion [> 5 disc areas], coma and convulsions were prolonged [up to 4 days], all survived although 3 had persisting neurological sequelae. In a patient with marked orange vessels the angiogram showed filling defects along affected blood vessel walls, which resolved by the next day. 2 patients had areas of retinal oedema on clinical examination and marked fluorescein leakage, both died. Prior to death one developed multiple serous retinal detachments, most marked peripherally.
We suggest that the intravascular filling defects represent parasitized red blood cells adhering to blood vessel walls [ sequestration]. This is the first time sequestration has been seen in neural tissue in vivo to our knowledge. Retinal whitening commonly co-localizes with impaired tissue perfusion , suggesting whitening is due to tissue hypoxia. Areas of non perfusion are common , and likely to be also occurring in the brain. Marked fluorescein leakage is a new finding and may be relevant to thinking about the pathophysiology of fatal paediatric cerebral malaria in some cases. Further studies are needed to show how commonly this is a pre-terminal event in cerebral malaria. Studies linking retinal appearance with cerebral lesions shown by magnetic resonance imaging and at autopsy may help to clarify the relevance of retinal findings to understanding the pathogenesis of cerebral dysfunction in malaria and improving it’s management.
This PDF is available to Subscribers Only