Delayed cerebellar ataxia: A rare self limiting complication of plasmodium falciparum malaria
A 23-year-old pre-morbid healthy male patient was referred to our hospital with complaints of giddiness and loss of balance while walking since 1 month associated with mild, throbbing, generalized headache. There was no history of nausea, vomiting, seizure, syncope, preceding head injury or any addictions. About 1 month back, patient was admitted to a local hospital with complaints of fever with chills, for which patient was treated with Ceftriaxone and Amikacin for 3 days. No history of patient having received anti-malarial in any form. Patient's fever did subside but then he developed giddiness and started requiring support for walking. Patient received symptomatic treatment but had no symptom relief hence a CT scan of head was done, which was apparently normal. There was no drug-history suggestive of cause for his ataxia. Due to persistence of symptoms the patient was referred to our center for further management. On admission to our hospital, his pulse was 72/min, blood pressure 100/70 mm of Hg, respiratory rate 18 cycles/min, afebrile, pallor was present; no icterus, cyanosis, clubbing, edema; jugular venous pressure was normal. There was no evidence of any neurocutaneous markers. Cardiovascular and respiratory systems’ examination were unremarkable. Per abdomen examination was suggestive of splenomegaly (palpable 2 cm below the left costal margin), no hepatomegaly. On neurological examination, he was fully alert, conscious and oriented to time, place and person. On higher mental examination only attention span was reduced. All cranial nerves and sensory system were normal. On motor system examination, he had hypotonia in all limbs. All superficial reflexes were normal with bilateral plantars flexors. Deep tendon reflexes were normal in upper limbs and exaggerated in lower limbs with pendular knee jerks in both the lower limbs. Finger-Nose Test, Knee-Heel test, Dysdiadokokinesis, Tandem Gait were bilaterally impaired. Nystagmus-Absent. There were no signs of meningeal irritation. His laboratory investigations were as follows: Hb-9.9 G%, WBC-5800 cumm of blood, Polymorphs-70% Lymphocytes-26%, Monocytes-1%, Eosinophils-3%, Platelet Count-1.8 lakh. Erythrocyte sedimentation rate 110 mm at the end of 1 h.\nPeripheral smear showed gametes and rings of plasmodium falciparum malaria with parasitic index-2.8%. Random blood sugar-83 mg/dl, blood urea-22 mg/dl, serum creatinine-1.2 mg/dl, serum sodium-136 mEq/L, serum potassium-3.8 mEq/L.\nMRI Brain-Normal study.\nCerebrospinal Fluid Analysis-Normal study.\nSerum Vitamin B12 levels-Within normal limits.\nSerum Thiamine levels-Within normal limits.\nChest X-Ray PA View-Within normal limits.\nECG 12 Leads-Within normal limits.\nUSG (Abdomen + Pelvis)-Splenomegaly (16 cms).\nHe was started on quinine sulphate orally, along with pyrimethamine and sulfadoxine on doses recommended by WHO 2010 guidelines for treatment of malaria. His cerebellar signs showed a complete recovery in 14 days with waxing and waning phenomenon. He did not require any steroids. He was discharged after 14 days in a hemodynamically stable condition and with no neurodeficit.