CASE REPORT
A 26-year-old male was admitted to a hospital in a coma state with a previous history of malaria. He had no significant systemic history of diabetes, hypertension, and TB but the patient was tachycardic at the time of admission.
As the patient recovered from the coma after a week, his visual acuity was tested which was found to be decreased in both eyes. RE: 6/24 (unaided), LE: 6/36 (unaided).
Blood films of this patient confirmed the presence of malaria. Dilated Indirect ophthalmoscopy was done which reported the detailed fundus with marked bilateral retinal hemorrhages, discoloration of vessels in the peripheral retina, and retinal whitening.
OCT was also performed which revealed hyperreflectivity of vessels. This hyperreflectivity confirmed the presence of malarial parasites in retinal blood vessels. Fluorescein Angiography showed retinal occlusion and associated retinal ischemia.
Diagnosis of Malarial Retinopathy was confirmed.
Malarial Retinopathy DISEASE entity
Malaria is a serious disease that occurs when humans are bitten by parasitic infected mosquitoes. It is such a toxic disease that it can change the mental status of patients leading to cerebral Malaria and sometimes fatal to such an extent that causes death.
When this Malaria enters into the phase of severity it also affects the eye. In the eye, it affects the most sensitive inner layer which is responsible for providing sharp and clear vision called the retina.
In 1993, retinal changes due to severe malaria were the first time noticed in Malawian children. Malarial retinopathy was mostly seen in infections caused by Plasmodium falciparum and Plasmodium vivax.
It is commonly seen in children with cerebral Malaria. These children are presented with the following symptoms
- Coma
- Seizures
- Hypertonia
- Hyperventilation
- Anemia
The person with malarial retinopathy shows the following signs:
Retinal whitening:
When malaria affects the central retina(macula), it is referred to as macular whitening. When it affects the retina other than the macula, it is called peripheral whitening.
Vessels discoloration:
Color of vessels changes to white or orange in the peripheral retina.
Retinal hemorrhages:
These intra-retinal blot hemorrhages show a resemblance with Roth spots. When severe malarial retinopathy occurs, the hemorrhages increase in number reaching>120 in each eye.
Optic disc edema:
It is called papilloedema when increased intracranial pressure is associated with retinal whitening, vessel discoloration, and retinal hemorrhages, etc.
But if only intracranial pressure is raised and no above symptoms are present then it might be another problem, not Malarial retinopathy.
Malarial Retinopathy MANAGEMENT
Systemic and local antimalarial therapy is given otherwise no specific treatment for malarial retinopathy has been described.
Would you have interest in taking retina images by smartphone?
Fundus photography is superior to fundus analysis as it enables intraocular pathologies to be photo-captured and encrypted information to be shared with colleagues and patients.
Recent technologies allow smartphone-based attachments and integrated lens adaptors to transform the smartphone into a portable fundus camera and Retinal imaging by smartphone.
RETINAL IMAGING BY YOUR SMARTPHONE
REFERENCES
- Lewallen S, Taylor TE, Molyneux ME, Wills BA, Courtright P. Ocular fundus findings in Malawian children with cerebral malaria. Ophthalmology. 1993;100(6):857-861.
- Beare NAV, Taylor TE, Harding SP, Lewallen S, Molyneux ME. Malarial retinopathy: a newly established diagnostic sign in severe malaria. Am J Trop Med Hyg. 2006;75(5):790-797.
- Conroy AL, Glover SJ, Hawkes M, et al. Angiopoietin-2 levels are associated with retinopathy and predict mortality in Malawian children with cerebral malaria: a retrospective case-control study. Crit Care Med. 2012;40(3):952-959.
-
World Health Organization. Severe falciparum malaria. Trans R Soc Trop Med Hyg. 2000;94:S1–S90.
-
Reyburn H, Mbatia R, Drakeley C, Carneiro I, Mwakasungula E, Mwerinde O, Saganda K, Shao J, Kitua A, Olomi R, Green-wood BM, Whitty CJ. Overdiagnosis of malaria in patients with severe febrile illness in Tanzania: a prospective study. BMJ. 2004;329:1212–1217.
-
Mwangi TW, Ross A, Snow RW, Marsh K. Case definitions of clinical malaria under different transmission conditions in Kilifi District, Kenya. J Infect Dis. 2005;191:1932–1939.
