Case presentation:
A 49- year-old female presented to a hospital in Khartoum state, central Sudan with slurred speech, tremors affecting her upper limbs, and a sense of imbalance and dizziness while walking which lasted for five days. Twelve days prior, she reported a 3-day history of fever with chills for which she took paracetamol tabs 500 mg four time per day. The patient had no history of a rash, common cold, nor headache as well as no neck pain, sensory or motor deficit. Also, she has no history of bulbar symptoms, vomiting, recent vaccination, or alcohol abuse as well as no smoking, joint pains, or fluctuation in body weight. Before admission, she was not diagnosed with malaria, nor did she receive any antimalarial therapy.
On the clinical examination, the patient was conscious and oriented to time, place and person. She had a normal pulse rate (76/min), respiratory rate (17/min), blood pressure (90/50), and temperature (39°C). Neurological examination showed no evidence of meningism. However, the patient had an ataxic gait, dysarthria, tremor of the upper limbs, dysdiadochokinesia, and hypotonia, but no bradykinesia, rigidity and nystagmus. Furthermore, she had normal sensation. Magnetic resonance imaging (MRI) of the brain was done in order to rule out the possibility of post-infectious cerebellitis and it showed normal brain structures; ventricular system; no evidence of haemorrhage or infarct and no midline shift. An electroencephalogram was done and was normal.
A blood sample was collected from the patient and sent to the laboratory for routine investigations. Further investigations revealed microcytic hypochromic anaemia and confirmed the presence of Plasmodium falciparum gametocytes in the peripheral blood smear. Viral screening for Epstein-Barr virus (EBV), Cytomegalovirus (CMV), major endemic arboviruses, human immunodeficiency (HIV) and Hepatitis viruses were negative. Liver function test revealed a serum bilirubin 0.7 mg/dl, total protein 7.6 g/dl, serum albumin 5.8 g/dl, alkaline phosphatase 79 U/l, aspartate aminotransferase (AST) 21 U/L, and alanine aminotransferase (ALT) 26 U/l. Renal functional test showed a normal value of urea in blood (27 mg/dL) and serum creatinine (0.71 mg/dL). Complete blood count examination showed leucocytosis (12.3 x103), haemoglobin 11.0 g/dl and platelets count 149x103. A sputum sample was collected and was negative for acid-fast bacilli.
The patient received artemether/lumefantrine four tablets (20 mg artemether; 120 mg lumefantrine per tablet) orally (PO) as an initial dose, followed by four tablets P.O. 8 hours later, then four tablets P.O. twice daily (morning and evening) for two days for a total course of 24 tablets. She responded well after three days. The patient was discharged 21 days after admission. She has recovered and regained a normal health status.