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Coma in fatal adult human malaria is not caused by cerebral oedema

Isabelle M Medana1, Nicholas PJ Day23, Navakanit Sachanonta4, Nguyen TH Mai5, Arjen M Dondorp23, Emsri Pongponratn4, Tran T Hien5, Nicholas J White23 and Gareth DH Turner234*

Author Affiliations

1 Nuffield Department of Clinical Laboratory Sciences, The John Radcliffe Hospital, University of Oxford, Oxford, UK

2 Nuffield Department of Clinical Medicine, The John Radcliffe Hospital, University of Oxford, Oxford, UK

3 Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand

4 Department of Tropical Pathology, Faculty of Tropical Medicine, Mahidol University, 3rd Floor, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok 10400, Thailand

5 Hospital for Tropical Diseases, Ho Chi Minh City, Viet Nam

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Malaria Journal 2011, 10:267  doi:10.1186/1475-2875-10-267

Published: 17 September 2011



The role of brain oedema in the pathophysiology of cerebral malaria is controversial. Coma associated with severe Plasmodium falciparum malaria is multifactorial, but associated with histological evidence of parasitized erythrocyte sequestration and resultant microvascular congestion in cerebral vessels. To determine whether these changes cause breakdown of the blood-brain barrier and resultant perivascular or parenchymal cerebral oedema, histology, immunohistochemistry and image analysis were used to define the prevalence of histological patterns of oedema and the expression of specific molecular pathways involved in water balance in the brain in adults with fatal falciparum malaria.


The brains of 20 adult Vietnamese patients who died of severe malaria were examined for evidence of disrupted vascular integrity. Immunohistochemistry and image analysis was performed on brainstem sections for activation of the vascular endothelial growth factor (VEGF) receptor 2 and expression of the aquaporin 4 (AQP4) water channel protein. Fibrinogen immunostaining was assessed as evidence of blood-brain barrier leakage and perivascular oedema formation. Correlations were performed with clinical, biochemical and neuropathological parameters of severe malaria infection.


The presence of oedema, plasma protein leakage and evidence of VEGF signalling were heterogeneous in fatal falciparum malaria and did not correlate with pre-mortem coma. Differences in vascular integrity were observed between brain regions with the greatest prevalence of disruption in the brainstem, compared to the cortex or midbrain. There was a statistically non-significant trend towards higher AQP4 staining in the brainstem of cases that presented with coma (P = .02).


Histological evidence of cerebral oedema or immunohistochemical evidence of localised loss of vascular integrity did not correlate with the occurrence of pre-mortem coma in adults with fatal falciparum malaria. Enhanced expression of AQP4 water channels in the brainstem may, therefore, reflect a mix of both neuropathological or attempted neuroprotective responses to oedema formation.