Hemorrhagic Stroke in Severe Falciparum Malaria: An Unusual Case Report with Review of Literature.

INTRODUCTION: Severe Plasmodium falciparum malaria is a potentially fatal illness associated with diverse systemic and neurological manifestations. While cerebral malaria is a wellrecognized complication, hemorrhagic stroke remains an exceptionally uncommon presentation. We report a rare case of severe malaria complicated by an acute left intracerebral hematoma, resulting in right-sided hemiparesis with facial nerve palsy. This report adds to the limited existing literature on malaria-associated hemorrhagic stroke and underscores its neurovascular implications.

CASE PRESENTATION: A 16-year-old female presented with a 6-day history of high-grade fever with chills, jaundice, and a 2-day history of altered sensorium. On admission, her Glasgow Coma Scale (GCS) score was E2V3M4, with splenomegaly and bilateral lung crepitations. Investigations revealed severe thrombocytopenia, hepatic dysfunction, hemolysis on peripheral smear, and Plasmodium falciparum parasitemia. Chest radiography showed bilateral perihilar opacities. She was treated with artemisinin-based combination therapy, doxycycline, and supportive care, with her GCS improving to 14. On day 10, she developed seizures and right-sided hemiparesis with right upper motor neuron (UMN) facial nerve palsy. Computed tomography of the brain demonstrated a left acute intracerebral hematoma. A diagnosis of severe P. falciparum malaria with multiorgan involvement and post-malaria neurological syndrome complicated by hemorrhagic stroke was made. The clinical course was notable for severe thrombocytopenia and a delayed onset of intracerebral hemorrhage during the recovery phase, underscoring the evolving and dynamic nature of neurological complications in severe malaria. With rehabilitation, she achieved complete neurological recovery at 3 months.

CONCLUSION: This case highlights a possible association between severe malaria and hemorrhagic stroke, with proposed mechanisms including microvascular sequestration, coagulopathy, thrombocytopenia, and endothelial dysfunction. Prompt recognition, early neuroimaging, and a multidisciplinary management approach are essential to improve outcomes in these complex neurovascular presentations.