Following Severe Pediatric Malaria, Epilepsy Screening Is Needed Even Among Children Without Coma: Findings From a
Archana A Patel1,2,3, Shaida Nishat4, Rasesh B Joshi3
1Department of Neurology, Division of Pediatric Neurology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA.
Insights
Pediatric malaria with neurological signs, even without coma, leads to post-malaria epilepsy (PME) in 15-20% of children within a year. This highlights a significant epilepsy risk following severe malaria with neurological involvement.
Area of Science:
- Neurology
- Infectious Diseases
- Pediatrics
Background:
- Severe pediatric malaria presents with neurological signs, ranging from coma (Cerebral Malaria, CM) to impaired consciousness without coma (CNS-M).
- Post-malaria epilepsy (PME) affects 9-16% of pediatric CM survivors, but PME rates after CNS-M are less understood.
Purpose of the Study:
- To determine and compare PME rates in children with CM versus CNS-M.
- To investigate the relationship between acute malaria presentation and long-term epilepsy risk.
Main Methods:
- A prospective cohort study enrolled 141 children (6 months-11 years) with CM or CNS-M in Zambia.
- Children were assessed for PME at 1 year using standardized screening and physician review (ILAE criteria), with EEG analysis.
- Covariates included coma status, age, neurodevelopment, hospitalization data, and EEG findings.
Main Results:
- 18.4% of the cohort developed PME, with similar rates in CNS-M (20.4%) and CM (14.6%) groups.
- Focal epilepsy was more prevalent in the CNS-M group (78.9% vs. 28.6%).
- Quantitative EEG indicated more severe cortical dysfunction in CM, despite similar PME incidence.
Conclusions:
- Malaria with central nervous system signs (CNS-M) was more frequent than cerebral malaria (CM) in this setting.
- PME risk is significant (15-20%) within one year for children with severe malaria and neurological involvement, irrespective of coma.
- These findings underscore the substantial risk of secondary epilepsy following severe pediatric malaria with neurological signs.
Background:
Severe pediatric malaria with neurological presentation has a spectrum of severity, from frank coma (Cerebral Malaria (CM)) to impaired consciousness and/or complex seizures without coma (malaria with central nervous system signs, CNS-M). Approximately 9-16% of pediatric CM survivors develop post-malaria epilepsy (PME), but rates after CNS-M are understudied.
Objective:
Determine PME rates following severe pediatric malaria with neurologic signs, with and without coma (CM and CNS-M).
Design:
Prospective cohort study.
Methods:
Children 6 months-11 years who presented to a district level hospital in Zambia with CM or CNS-M between Nov 2021-June 2024 were enrolled. Children were excluded for pre-existing epilepsy or alternative explanation for acute neurologic symptoms. Primary outcome was PME at 1 year. Important covariates included coma, age, pre-illness neurodevelopment, acute hospitalization data, acute and follow-up EEG, and 1-year neurodevelopmental outcomes. Acute, 1-, 6-, and 12-month data were collected. EEGs were analyzed with conventional and quantitative methods. PME was determined by standardized screening and physician review using ILAE criteria.
Results:
141 children met inclusion criteria, 48 had CM, 93 CNS-M. CNS-M children were younger (mean 40.8 vs. 54.3 months, p=0.005) and male predominant (64.8% vs. 43.8%, p=0.006). 18.4% of the cohort developed PME, with no significant incidence difference between CNS-M (20.4%) and CM (14.6%) groups, p=0.495. Focal epilepsy was more common in CNS-M 78.9% vs. CM 28.6% (p=0.028). There were no differences in qualitative EEG findings. Quantitative EEG measures demonstrated more severe and prolonged cortical dysfunction in CM (p<0.01).
Conclusions:
CNS-M presentation was twice as frequent as CM at this district hospital. Quantitative EEG supports CM as a more severe acute illness, but PME developed in 15-20% of children within one year regardless of malarial coma. These findings suggest that severe malaria with neurologic involvement-regardless of coma during acute presentation-has significant secondary epilepsy risk.
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