Malaria, caused by the Plasmodium genus of parasites and transmitted through the bite of infected female Anopheles mosquitoes, remains a significant public health concern, particularly in tropical regions [1]. In Indonesia, malaria cases have declined over the years, particularly in East Nusa Tenggara, where a study in Sumba showed a decrease from 31.7 % to 6.08 % in the past decade [2]. In 2017, Indonesia declared over half of its district malaria-free, with 72 % of the population living in malaria-free area [3]. However, Sikka Regency, which was previously classified as a low-endemic in 2021, experienced a rise in cases and was reclassified in 2022 as a moderate-endemic area, with 515 positive cases and an Annual Parasite Incidence (API) of 1.59 [4,5].

Severe malaria is characterized by asexual parasitemia of P. falciparum asexual and at least one of the following: altered consciousness, multiple convulsions, acidosis, hypoglycemia, severe anemia, renal impairment, jaundice, pulmonary edema, significant bleeding, shock, and hyperparasitemia. The World Health Organization (WHO) defines cerebral malaria (CM) as severe Plasmodium falciparum malaria characterized by reduced consciousness, defined as a Glasgow Coma Scale (GCS) score below 11, that lasts for more than 1 h following a seizure [6]. Fever commonly occurs before the onset of neurological manifestations of cerebral involvement [7]. In adult CM, coma typically develops gradually with drowsiness, confusion, and high fever over about five days. Seizures, seen in 15 % of adults and 80 % of children, often signal its onset [8].

Severe malaria typically has a mortality rate exceeding 5 %, which means it increases the risk of death by more than 50 times [9]. Timely diagnosis and immediate treatment is crucial to prevent complications and death [10]. This report illustrates an atypical, abrupt-onset coma from malaria, managed without full diagnostics.