Delayed-Onset White Matter Lesions on Brain MRI in Recurrent Non-cerebral Plasmodium falciparum Imported Malaria Without Neurological Symptoms

Plasmodium falciparum malaria affects millions of people in certain regions of the world, with neurological involvement and/or cerebral malaria as potential manifestations. Brain magnetic resonance imaging (MRI) abnormalities have been well-documented in cerebral malaria. However, MRI abnormalities in non-cerebral malaria, especially in neurologically asymptomatic patients, are not well understood and have been less frequently reported, especially in non-endemic regions. Additionally, there are no known studies that observe and analyze the presence and progression of these radiological abnormalities over long periods. Here, we present the case of a patient with recurrent non-cerebral imported malaria infections spanning two decades. Despite a normal brain MRI three years prior, the patient was found to have extensive subcortical white matter fluid-attenuated inversion recovery abnormalities on MRI. This case highlights the possibility that even neurologically subclinical malaria infections can result in significant, long-standing brain changes, raising important questions about the pathophysiology of malaria's effects on the brain, the potential for cumulative neurological damage over time, and the clinical significance of such findings. In addition, the significance of the location of these lesions in non-cerebral cases remains unclear, particularly in terms of their clinical implications and reversibility. Our findings suggest the need for further studies to evaluate the long-term consequences of malaria infections on the brain, particularly in non-cerebral cases, and to explore whether these radiological abnormalities are reversible or lead to lasting neurological impairment.