The review on assessment and management of encephalopathy in children
by Davies et al is welcome(1). However, it might have included specific
consideration of risk of cerebral malaria. We recognise that providing an
exhaustive list of potential causes of encephalopathy risks diverting
attention from those that are most common. However, cerebral malaria,
whilst rare in the UK, is one of the most important causes of childhood
encephalopathy worldwide with high case-fatality if untreated. Laboratory
assessment for parasitaemia is mandatory in all children with
encephalopathy, fever and recent travel to an endemic area. Clinicians
should be aware that while most cases of P. falciparum malaria will
present within a month of infection, there are reports of longer
incubation times, and a high index of suspicion is important(2). In
Europe, children whose family is originally from a malaria-endemic country
and who have visited their relatives may be especially at risk as
prophylaxis use is less common(3). Retinopathic features may support the
diagnosis (retinal vessel discolouration, exudates, haemorrhages with or
without papilloedema)(4). Because of these features, and the possibility
of raised intracranial pressure from other causes, we suggest that
fundoscopy is an important part of the evaluation of all encephalopathic
children.
We also wish to highlight the importance of considering testing for
sickle cell disease and HIV in children with ischaemic stroke, since these
are common causes of stroke in at-risk groups(5).
Kelsey DJ Jones (1,2), James A Berkley (1,3), Neema Mturi (1,4),
Charles RJC Newton (1,5)
1. KEMRI-Wellcome Trust Research Programme, Centre for Geographical
Medicines Research (Coast), Kilifi, Kenya
2. Wellcome Centre for Clinical Tropical Medicine, Imperial College,
London, UK
3. Nuffield Department of Clinical Medicine, University of Oxford, UK
4. Ministry of Medical Services, Kilifi District Hospital, Kilifi,
Kenya
5. Department of Psychiatry, University of Oxford, UK
Correspondence to Kelsey Jones, KEMRI-Wellcome Trust Research
Programme, Kilifi 80108, Kenya
References:
1. Davies E, Connolly DJ, Mordekar S. Encephalopathy in children: an
approach to assessment and management. Arch Dis Child
doi:10.1136/adc.2011.300998
2. Greenwood T, Vikerfors T, Sjoberg M, Skeppner G, Farnert A.
Febrile Plasmodium falciparum malaria 4 years after exposure in a man with
sickle cell disease. Clin Infect Dis. 2008 Aug 15;47(4):e39-41.
3. Ladhani S, Garbash M, Whitty CJ, Chiodini PL, Aibara RJ, Riordan
FA, Shingadia D. Prospective, national clinical and epidemiologic study on
imported childhood malaria in the United Kingdom and the Republic of
Ireland. Pediatr Infect Dis J. 2010 May;29(5):434-8.
4. Beare NA, Lewallen S, Taylor TE, Molyneux ME. Redefining cerebral
malaria by including malaria retinopathy. Future Microbiol. 2011
Mar;6(3):349-55.
5. Roach ES, Golomb MR, Adams R, Biller J, Daniels S, Deveber G,
Ferriero D, Jones BV, Kirkham FJ, Scott RM, Smith ER; American Heart
Association Stroke Council; Council on Cardiovascular Disease in the
Young. Management of stroke in infants and children: a scientific
statement from a Special Writing Group of the American Heart Association
Stroke Council and the Council on Cardiovascular Disease in the Young.
Stroke. 2008 Sep;39(9):2644-91.
Conflict of Interest:
None declared
The review on assessment and management of encephalopathy in children by Davies et al is welcome(1). However, it might have included specific consideration of risk of cerebral malaria. We recognise that providing an exhaustive list of potential causes of encephalopathy risks diverting attention from those that are most common. However, cerebral malaria, whilst rare in the UK, is one of the most important causes of childhood encephalopathy worldwide with high case-fatality if untreated. Laboratory assessment for parasitaemia is mandatory in all children with encephalopathy, fever and recent travel to an endemic area. Clinicians should be aware that while most cases of P. falciparum malaria will present within a month of infection, there are reports of longer incubation times, and a high index of suspicion is important(2). In Europe, children whose family is originally from a malaria-endemic country and who have visited their relatives may be especially at risk as prophylaxis use is less common(3). Retinopathic features may support the diagnosis (retinal vessel discolouration, exudates, haemorrhages with or without papilloedema)(4). Because of these features, and the possibility of raised intracranial pressure from other causes, we suggest that fundoscopy is an important part of the evaluation of all encephalopathic children.
We also wish to highlight the importance of considering testing for sickle cell disease and HIV in children with ischaemic stroke, since these are common causes of stroke in at-risk groups(5).
Kelsey DJ Jones (1,2), James A Berkley (1,3), Neema Mturi (1,4), Charles RJC Newton (1,5)
1. KEMRI-Wellcome Trust Research Programme, Centre for Geographical Medicines Research (Coast), Kilifi, Kenya
2. Wellcome Centre for Clinical Tropical Medicine, Imperial College, London, UK
3. Nuffield Department of Clinical Medicine, University of Oxford, UK
4. Ministry of Medical Services, Kilifi District Hospital, Kilifi, Kenya
5. Department of Psychiatry, University of Oxford, UK
Correspondence to Kelsey Jones, KEMRI-Wellcome Trust Research Programme, Kilifi 80108, Kenya
References:
1. Davies E, Connolly DJ, Mordekar S. Encephalopathy in children: an approach to assessment and management. Arch Dis Child doi:10.1136/adc.2011.300998
2. Greenwood T, Vikerfors T, Sjoberg M, Skeppner G, Farnert A. Febrile Plasmodium falciparum malaria 4 years after exposure in a man with sickle cell disease. Clin Infect Dis. 2008 Aug 15;47(4):e39-41.
3. Ladhani S, Garbash M, Whitty CJ, Chiodini PL, Aibara RJ, Riordan FA, Shingadia D. Prospective, national clinical and epidemiologic study on imported childhood malaria in the United Kingdom and the Republic of Ireland. Pediatr Infect Dis J. 2010 May;29(5):434-8.
4. Beare NA, Lewallen S, Taylor TE, Molyneux ME. Redefining cerebral malaria by including malaria retinopathy. Future Microbiol. 2011 Mar;6(3):349-55.
5. Roach ES, Golomb MR, Adams R, Biller J, Daniels S, Deveber G, Ferriero D, Jones BV, Kirkham FJ, Scott RM, Smith ER; American Heart Association Stroke Council; Council on Cardiovascular Disease in the Young. Management of stroke in infants and children: a scientific statement from a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. Stroke. 2008 Sep;39(9):2644-91.
Conflict of Interest:
None declared