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ACUTE DISSEMINATED ENCEPHALOMYELITIS FOLLOWING PLASMODIUM FALCIPARUM MALARIA CAUSED BY VARICELLA ZOSTER VIRUS REACTIVATION

Neurologic complications in the course of Plasmodium falciparum infections are commonly diagnosed as cerebral malaria, but bacterial or viral meningitis may exhibit similar symptoms. One to three weeks after P. falciparum malaria, acute disseminated encephalomyelitis (ADEM) can also mimick the symptoms of cerebral malaria. We describe a 31-year-old woman with life-threatening ADEM five days after successful treatment of P. falciparum malaria. The detection of IgG and IgM antibodies in serum and cerebrospinal fluid (CSF) against multiple viruses and bacteria reflected a non-specific polyclonal B cell activation and was more confusing than helpful for diagnostic decisions. Varicella zoster virus was identified with a reverse transcriptase multiplex polymerase chain reaction in the initially obtained and frozen CSF. This case and findings from the literature indicate that P. falciparum-associated ADEM might not be immune mediated, but of infectious origin. With unclear cerebral complications during or after P. falciparum malaria, prompt initiation of empirical antiviral and antibacterial treatment in addition to antimalarials may reduce mortality.

Received March 29, 2004. Accepted for publication August 12, 2004.

Acknowledgments: We thank Dr. Thomas Grewing (Bernhard-Nocht Instititute) for sequencing the PCR product, and Dr. Friedrich W. Moeller, and Diana Riebold for excellent technical assistance.

Authors’ addresses: Matthias Lademann, Peggy Gabelin, Michael Lafrenz, and Emil C. Reisinger, Department of Medicine, Division of Tropical Medicine and Infectious Diseases, University of Rostock Medical School, Ernst-Heydemann-Strasse 6, D-18055 Rostock, Germany, Telephone: 49-381-494-7510, Fax: 49-381-494-7509, E-mail: emil.reisinger{at}medizin.unirostock.de. Christiane Wernitz, Intensive Care Unit, Department of Medicine, University of Rostock Medical School, Ernst-Heydemann-Strasse 6, D-18055 Rostock, Germany. Heidrun Ehmke, Intensive Care Unit, Department of Medicine, and Department of Anaesthesia, University of Rostock Medical School, Ernst-Heydemann-Strasse 6, D-18055 Rostock, Germany. Herbert Schmitz, Department of Virology, Bernhard-Nocht Institute for Tropical Diseases, Bernhard-Nocht-Strasse 74, 20359 Hamburg, Germany.