Sudden Onset of Coma and Fulminant Progression to Brain Death in a 48-Year-Old Male With Cerebral Malaria

Cerebral malaria is the most severe complication of Plasmodium falciparum infection. Left untreated, it is universally fatal. Coma is the clinical hallmark, emerging between the first and third days of fever. Adults typically present with mild cerebral edema, usually with a more favorable prognosis compared to the pediatric population. We present a case of a 48-year-old man with a recent travel to Angola who presented comatose on the second day of a febrile illness with clinical signs of cerebral herniation and diffuse cerebral edema and cerebellar tonsil ectopia on cranioencephalic computed tomography. He had a missed diagnosis on a first visit to the emergency department 2 days prior. The diagnosis of cerebral malaria was confirmed after the identification of the parasite in peripheral blood. He was admitted to an intensive care unit; however, progression to brain death was inevitable within a few hours. Malaria affects 5% of the world's population. In Portugal, it has an incidence of 0.01 in every 1000 inhabitants, and all cases are imported. Despite its rarity in a nonendemic country, its severity alerts to the consideration of this syndrome in the etiologic workup of coma. The early recognition of the diagnosis is of major importance for the establishment of definitive treatment, as its timely administration has a crucial impact on the outcome.