malaria is one of the most common parasitic infections in the developing countries and cerebral malaria ( cm ) is one of the most common causes for non - traumatic encephalopathy in the world . malaria is caused by five species of plasmodium namely plasmodium vivax , plasmodium falciparum , plasmodium malariae , plasmodium ovale and plasmodium knowlesi . however , they are increasing reports of complicated malaria by other species as well . clinical presentation of malaria varies from uncomplicated acute febrile illness to a severe form of malaria when infections are complicated by serious organ failures or abnormalities in the patient 's blood or metabolism . the manifestations of severe malaria include cm , severe anemia , hemoglobinuria due to hemolysis , acute respiratory distress syndrome , abnormalities in blood coagulation , hypotension , acute kidney injury , hyperparasitemia ( more than 5% of the red blood cells ( rbcs ) infected by malarial parasites ) , metabolic acidosis and hypoglycemia . severe malaria is a medical emergency and should be treated urgently and aggressively . in the indian scenario , for the same reason , these physicians should be aware of the complications , so that earlier and effective treatment can be initiated and patients who need a referral to a tertiary care can also be identified . this was a prospective study done from september 2005 to december 2006 at jiwan jyoti christian hospital in eastern uttar pradesh in india . all the patients above the age of 14 years diagnosed with cm were included in the study . cm was defined as a clinical syndrome of coma ( inability to localize a painful stimulus ) at least 1 hour after termination of a seizure or correction of hypoglycemia , detection of asexual forms of falciparum malarial parasite on peripheral blood smear and exclusion of other causes of encephalopathy . there were a total of 53 patients with cm of which 38 ( 71.7% ) of them were females . among them 35 ( 66% ) patients were less than 30 years of age [ figure 1 ] all of them had presented with fever and altered sensorium with documented malarial parasite on the peripheral blood film . other clinical features [ figure 2 ] noted were pallor ( 35% ) , icterus ( 16.98% ) , hypotension ( 13.2% ) , bleeding ( 3.7% ) , hepatomegaly ( 5.66% ) and splenomegaly ( 5.66% ) . age distribution of patients with cerebral malaria clinical features of patients with malaria majority ( 84.9% ) of the patients had anemia . co - infection with plasmodium vivax was present in 13 ( 24.53% ) of them . treatment received included artesunin compounds ( artesunate in 37 and arteether in 3 ) , quinine ( 9 ) and quinine  doxycycline combination therapy ( 2 ) . in view of clinical failure 3 of them others included patients who were referred to higher center and those who left the hospital against medical advice . cm is defined as severe p. falciparum malaria with cerebral manifestations , usually coma ( glasgow coma scale < 11 , blantyre coma scale < 3 ) . malaria with coma persisting for > 30 min after a seizure is also considered to be cm . the 2010 revised criteria for severe malaria are the presence of one or more of the following : prostration , impaired consciousness , failure to feed , respiratory distress ( " air hunger " ) , multiple seizures ( more than two episodes in 24 h ) , circulatory collapse , pulmonary edema ( on radiological imaging ) , abnormal spontaneous bleeding , jaundice , hemoglobinuria , severe anemia , hypoglycemia , acidosis , renal impairment , hyperlactatemia , and hyperparasitemia . according to the latest world health organization ( who ) estimates , there were about 219 million cases of malaria in 2010 and an estimated 660,000 deaths . africa is the most affected continent : about 90% of all malaria deaths occur there . among the 53 patients with cm , 71.7% were females and 66% were less than 30 years of age . however wasnik et al . noted a higher incidence in males ( 75% ) most of whom were in the age group of 21 - 30 years of age . seizures are a prominent feature in cm and repeated seizures have been associated with poor outcome . patel noted that 46.8% of the patients with falciparum malaria had anemia whereas wasnik et al . noted that 65% of the cases had anemia . in our cohort 84.9% had anemia . the causes for anemia in cm patients are obligatory destruction of rbcs containing parasites at merogony , accelerated destruction of non - parasitized rbcs and bone marrow dysfunction . hypoglycemia in cm patients are due to increased peripheral requirement of glucose consequent upon anaerobic glycolysis , increased metabolic demands of febrile illness , obligatory demand of parasites , failure of hepatic gluconeogenesis and glycogenolysis ( parasites consume up to 70 times as much glucose as uninfected cells ) . it is compounded by the stimulation of insulin secretion from pancreatic beta cells by quinine . blood sugars of all the patients in the present study were closely monitored and glucose supplementation was given . renal dysfunction causes morbidity in these patients . biochemical evidence of renal dysfunction was noted in 37.6% patients . out of 526 cases of cm reported from rourkela , in sundargarh district of orissa state , 28.9% had acute renal failure ( arf ) . mortality in this series was particularly high ( 59% ) specifically in those with multiorgan failure . the effect of associated arf on mortality in cm patients indicated , mortality was as high as 39.5% when associated with arf , while it was only 13.9% when unassociated with arf . hyperventilation ( kussmaul breathing ) with a clear chest on auscultation suggests metabolic acidosis . at our center since there was no facility for estimation of blood gases , we made a clinical diagnosis based on this and was initiated on soda bicarbonate infusion and fluids . clinical improvement as indicated by normal respiratory rate guided us in our management . in our study , 16.9% patients had non cardiogenic pulmonary edema . case fatality rate is very high in these patients and they should be referred to a facility were mechanical ventilation and intensive care is available . the world health organization now recommends using intravenous artesunate in preference to quinine for the treatment of severe p. falciparum malaria in adults . these are derivatives of chinese drug qinghaosou . in a large open label , randomized trial of asian adults with severe malaria , artesunate significantly reduced mortality by 34.7% . majority ( 75.47% ) of our patients . out of these except for 3 patients rest of them had responded to artesunate . noted that the cause of death were arf , metabolic acidosis , aspiration pneumonia and circulatory failure . case fatality rates in the other studies from africa have shown a high mortality rate of 13 - 21% . primary care physicians should be able to diagnose cm from the clinical presentation , which should be supported by detection of p. falciparum or in some cases the other species of malaria on the peripheral blood film . artesunin components as combination therapy are the drug of choice as per who recommendations and can be easily administered with hardly any side effects . non cardiogenic pulmonary edema needing ventilator care and renal failure needing dialysis should be referred to a higher facility . cm once considered a fatal disease has shown remarkable improvement in the outcome with the wide availability of artesunin components . most of the complications of severe falciparum malaria including cm can be managed by a primary care physician . considering the health system in our country if primary care physicians can manage these patients , it will go a long way in reducing the morbidity and mortality of these cases .