Discussion:
In this communication, we reported a case of delayed cerebellar ataxia
due to P. falciparum infection with the onset of slurred speech,
bilateral tremors affecting both upper limbs, and an unsteady gait
during walking. Cerebellar involvement in P. falciparum malaria
can occur during the acute stage of fever, as a consequence of cerebral
malaria, as a delayed cerebellar ataxia (DCA), or as a side effect of
anti-malarial therapy [23 – 28]. This case of DCA that is induced
by malaria infection has occurred in a hyper endemic area in central
Sudan, Khartoum state. The development of DCA in this case could be
mainly attributed to the lack of detecting the malaria infection during
the initial presentation of the patient at outpatient clinic. This delay
in reaching a final accurate diagnosis is of high risk particularly in
settings like Sudan that are endemic with several life-threatening
infection like hemorrhagic fevers. Such delay commonly lead to the
development of disease severe sequelae and complication such as
neurological syndromes including Guillain‐Barre syndrome (GBS) [29]
and CA.
Cerebellar ataxia can be caused by many conditions including alcohol
misuse, stroke, brain degeneration, multiple sclerosis, drugs, genetic
and autoimmune diseases as well as several infectious diseases [23].
Malaria is one of the leading causes for the development of CA [24 -
28]. Malaria in humans is commonly caused by one of five species of
plasmodium, and P. falciparum is the species most associated with
the development of neurological complications [30].
Acute cerebellar ataxia can be caused by a wide range of infections
including viral, bacterial, fungal, and parasitic infections.
Interestingly, in our reported patient, there was no clinical or
molecular evidence of any infection other than P. falciparum .
Co-infection with main viral infections of public health importance in
the country with potential involvement in the development of CA were
excluded by screening the blood sample serologically and molecularly
[31 - 40]. Additionally, in our reported case, hyperpyrexia is
unlikely to cause cerebellar ataxia as our patient developed DCA after
an afebrile period. Therefore, the development of DCA can be directly
attributed to P. falciparum infection. The pathogenesis of DCA
due to malaria infection is attributable to an immune mechanisms that
include elevated levels of certain cytokines such as Interleukin (IL)-2,
IL-6, and tumour necrosis factor alpha (TNF-α), as these cytokines were
found in the cerebrospinal fluid of patients with DCA [41].
Therefore, in countries like Sudan that are endemic with malaria and
other infectious diseases that are involved in the development of CA, it
is very important to investigate patients with cerebellar ataxia for
these infections. Early diagnosis and effective case management of
patients with infectious diseases is the main strategy to reduce the
development and prevalence of CA in the country. Therefore, physicians
work in such settings should be vigilant and improve the differential
diagnosis of cerebellar ataxia by taking a comprehensive medical and
travel histories combined with a complete clinical examination and
recommendations for the corresponding laboratory investigation to
improve the diagnosis. Furthermore, in countries endemic with several
infectious diseases with overlapped clinical manifestation, more
investment should be made on improving the diagnostic capacity.
Although malaria is hyper endemic in Sudan with P. falciparum , as
the predominant species, yet development of neurological syndromes that
are associated with malaria infection including CA are understudied.
Therefore, more investment is needed to further study sequelae and
severe complications that are associated with endemic diseases.
Particularly that, such studies are warrant to generate evidence to
inform and guide policymaking and strategic intervention to reduce the
health and socioeconomic burden of such preventable health condition.