Teaching NeuroImages: Hippocampal sclerosis in cerebral malaria

A 39-year-old woman presented with fever, malaise, and headache after visiting Tanzania. Peripheral smear showed Plasmodium falciparum and Plasmodium ovale with parasitemia >14%. Within hours, she became unresponsive. MRI demonstrated punctate foci of microhemorrhage throughout the deep white matter, and hippocampal restricted diffusion (figure). Five days of video-EEG were negative for seizure. She was discharged after 3 weeks of quinidine, doxycycline, and primaquine. Repeat MRI showed bilateral hippocampal sclerosis; repeat EEG was normal. Follow-up examination was only notable for short-term memory impairment.