Confirming Cerebral Malaria Deaths in Resource-Limited Settings

A 4-year-old Papua New Guinean girl presented with unresponsive coma (Blantyre coma score = 2) after a short febrile illness. She did not have neck stiffness, a positive Kernig’s sign, or other clinical features of bacterial meningitis. Microscopy confirmed a peripheral blood Plasmodium falciparum asexual parasite density of 33,960/mL. Despite parenteral artemether and intensive supportive therapy, she died within 6 hours of admission. Supraorbital post-mortem brain biopsy revealed P. falciparum in the cerebral microvasculature (Figures 1 and 2). As part of renewed global efforts to eradicate malaria, the World Health Organization has recently emphasized the need for improved surveillance and case management, including accurate documentation of malaria-related deaths. The supraorbital post-mortem biopsy technique used in this case can be performed rapidly, and it is well-validated, is minimally invasive, and leaves no visible scars. Appropriately stained brain tissue can be examined by microscopy without the need for conventional autopsies and histological examination even in resource-limited settings, thus providing evidence