Evaluation of the Efficacy and Safety of Inhaled Nitric Oxide as Adjunctive Treatment for Cerebral Malaria in Children

Despite very effective antimalarial treatment, there is a residual and unacceptable high mortality rate of malaria, especially amongst young children. Recent progress has been made in understanding the role of Nitric Oxide (NO) in severe malaria, indicating that NO supplementation is likely to have a beneficial action in severe malaria possibly through down-regulation of inflammatory cytokines like TNF. Of the various ways to supplement NO, iNO appears to be the safest since it is very well studied in critically ill patients and does not cause systemic vasodilation. The safety of NO inhalation has been clearly demonstrated through its wide use in the treatment of persistent pulmonary hypertension in neonates and pulmonary hypertension in children and adults. Extensive data on its safety has been collected. This study is a phase 2 clinical trial that aims at demonstrating the efficacy of iNO when added to antimalarial treatment to treat cerebral malaria. This study will also provide a better understanding of the pathophysiological mechanisms involved in severe malaria.

Inclusion criteria

• Age between 2 months and 12 years.
• With malaria infection confirmed by a malaria antigen test and/or a positive blood smear examination
• AND sustained coma: achieving a Blantyre Coma Score less than 3 for 2, or more, hours after ruling out and treating hypoglycemia (blood glucose less than 2.2 mmol/l), ruling out meningitis, and ruling out and treating active clinical seizures.

Exclusion criteria

• Refusal to participate
• Other cause of coma (toxic or pre-existing severe neurological disease)
• Terminal respiratory failure (due to brainstem coning)
• Coagulopathic
• Clinically unstable enough to preclude venipuncture and phlebotomy
• Severe malnutrition defined by edema or a weight-for-height minus 3 SD;
• Evidence of pre-existing brain injury
• Advanced AIDS defined by WHO clinical staging 4;