Am. J. Trop. Med. Hyg., 80(6), 2009, p. 881 Copyright © 2009 by The American Society of Tropical Medicine and Hygiene Images in Clinical Tropical Medicine Severe Retinal Whitening in an Adult with Cerebral Malaria Richard J. Maude,* Mahtab Uddin Hassan, and Nicholas A. V. Beare Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Clinical Vaccinology and Tropical Medicine, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, Oxford, United Kingdom; Chittagong Medical College, Chittagong, Bangladesh; St. Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom A composite digital photograph of the right retina of a 24-year-old Bangladeshi man with non-fatal cerebral malaria was taken on admission to hospital (Figure 1). He presented with 1 day of unconsciousness, pulmonary edema, and black- water fever. Peripheral blood parasitemia was 79 Plasmodium falciparum per 1,000 red cells and hemoglobin was 10.9 g/dL. He recovered consciousness within 48 hours of starting intra- venous artesunate and was discharged home after 6 days. Visual function and neurologic examination were normal on discharge. The image is comprised of 14 separate photographs taken with a Genesis D (Kowa, Japan) handheld retinal camera. It shows severe malarial retinopathy with small patches of ret- inal whitening involving the entire macula and extensive areas of the peripheral retina, in particular temporal to the central fovea and nasal to the optic nerve head (some glare is present Figure 1. Composite digital photograph of the right retina of a 24-year-old man with cerebral malaria and severe malarial retinopa- thy. This figure appears in color at www.ajtmh.org. *Address correspondence to Richard J. Maude, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Rajthevee, Bangkok 10400, Thailand. E-mail: richardmaude@gmail.com or richard@tropmedres.ac 881 along the temporal vascular arcades). Malarial retinal whiten- ing has a distribution that is unique to malaria1 and is present in 50% of children with cerebral malaria.1 In adults, it has pre- viously only been described in two Malawians with cerebral malaria, both of whom had mild changes.2 The handheld retinal camera can be used at the bedside and, unlike conventional retinal photography with a table-top cam- era, does not require a cooperative, sitting patient. Received December 19, 2008. Accepted for publication February 23, 2009. Acknowledgments: The authors thank Dr. Arjen Dondorp for kind assistance with drafting the manuscript and the staff at Chittagong Medical College Hospital, Chittagong, Bangladesh, for assistance with this case. Financial support: Mahidol-Oxford Tropical Medicine Research Unit is funded by the Wellcome Trust of Great Britain. Disclosure: There are no conflicts of interest. Ethical approval: Ethical permission for retinal photography was obtained from Chittagong Medical College Ethics Committee, Chittagong, Bangladesh, and Oxford Tropical Medicine Research Ethics Committee, Oxford, UK. Authors’ addresses: Richard J. Maude, Mahidol-Oxford Tropical Med- icine Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F, 60th Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Rajthevee, Bangkok 10400, Thailand, E-mail: richardmaude@gmail .com or richard@tropmedres.ac. Mahtab Uddin Hassan, Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh, E-mail: mahtabnipu@yahoo.com. Nicholas A. V. Beare, St. Paul’s Eye Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK, E-mail: nbeare@btinternet.com. REFERENCES 1. Beare NAV, Taylor TE, Harding SP, Lewallen S, Molyneux ME, 2006. Malarial retinopathy: a newly established diagnostic sign in severe malaria. Am J Trop Med Hyg 75: 790–797. 2. Beare NAV, Lewis DK, Kublin JG, Harding SP, Zijlstra EE, 2003. Retinal changes in adults with cerebral malaria. Ann Trop Med Parasitol 97: 313–315.