Radiological findings in fulminant cerebral malaria: a rare neuroimaging presentation

Cerebral malaria (CM) is a life-threatening complication of Plasmodium falciparum infection, characterized by coma, seizures, and multiorgan dysfunction. MRI findings in adult CM are underreported, particularly in cases with fulminant progression despite treatment.

A 54-year-old woman with a history of hypertension and hypothyroidism presented with fever, seizures, and altered sensorium. On admission, the patient was in shock with severe metabolic acidosis and multiorgan failure. A rapid diagnostic test and peripheral smear confirmed P. falciparum infection. CT brain was normal. However, MRI revealed bilateral T₂/FLAIR hyperintensities in the basal ganglia, thalami, centrum semiovale, and periventricular white matter, with patchy diffusion restriction, findings suggestive of cytotoxic oedema. Despite the timely initiation of artesunate, dialysis, and organ support, the patient succumbed to refractory multiorgan failure.

The imaging findings reflect microvascular sequestration and cytotoxic injury, consistent with the known CM pathology. Deep gray and white matter involvement, along with diffusion restriction suggestive of cytotoxic and vasogenic oedema and associated haemorrhagic transformation, are critical MRI markers correlating with disease severity and poor prognosis.

This case highlights the diagnostic value of MRI in adult CM, especially when CT findings are inconclusive. Recognition of cytotoxic oedema patterns without haemorrhagic transformation may aid in early diagnosis and risk stratification.