Classic image: peripheral blood smear in a case of Plasmodium falciparum cerebral malaria.

To cite: Parikh MP, Krishnan S, Ganipisetti VM, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014205820 DESCRIPTION A 29-year-old African-American woman presented with acute onset of altered mental status. She was obtunded with visible rigors and a fever of 102.8°F. Routine laboratory study showed platelet count of 59k/mm. Urine toxicology screening, blood alcohol level and cerebrospinal fluid analysis were within normal limits. CT of the head was non-revealing. A Giemsa-stained peripheral blood smear (figure 1) was obtained which showed many red blood cells (RBCs) infected with classic, ring-shaped (arrow A) and headphone-shaped (arrow B) trophozoites of Plasmodium falciparum parasite. High degree of parasitaemia and RBCs infected with two or more trophozoites were seen, a finding typical of P. falciparum malaria (figure 1, arrow C). There were no schizonts or gametocytes. Marked thrombocytopenia was also noted. The patient was diagnosed with cerebral malaria and treated with intravenous quinine. She improved dramatically over next 2–3 days. It was later learnt that she had travelled to Nigeria recently. Examination of Giemsa-stained peripheral blood smear is the standard test for the diagnosis of malarial infection. It is useful in establishing the diagnosis of malaria, identifying the Plasmodium spp as well as determining the degree of parasitaemia. Cerebral malaria is a complicated form of malaria associated with multisystem organ dysfunction and high degree of morbidity and mortality. These patients often present with impaired consciousness, delirium and convulsions. It is a medical emergency where prompt diagnosis and early institution of treatment can be lifesaving. Intravenous quinine or artesunate are the mainstays of treatment in cerebral malaria.