Artesunate-induced hemolysis in severe complicated malaria – A diagnostic challenge: A case report and literature review of anemia in malaria

Abstract

Malaria infection, which results due to the parasitic protozoan Plasmodium , has several known etiologies of hemolytic anemia as a possible complication in cases such as concurrent G6PD deficiency, severe parasitemia, or use of parenteral antimalarials. Although artemisinin-based antimalarial therapies are generally well-tolerated, several cases of severe post-artemisinin delayed hemolysis (PADH) have been recently reported, which present a diagnostic challenge, and affect morbidity and mortality in patients with malarial infection. We highlight the case of a young lady with Plasmodium falciparum severe parasitemia who developed hemolytic anemia after parenteral artesunate therapy.

In Vivo Antimalarial Activity of Cyperus rotundus and Its Combination with Dihydroartemisinin against Plasmodium berghei

“…In addition, artemisinin-induced and postartemisinin-delayed hemolysis have been reported [34,35]. Tis fnding is consistent with other reports on artemisinin-induced hemolysis in PbANKA-infected mice [36][37][38]. Te mechanism by which CRE prevents BW loss may involve the reduction of parasitemia in PbANKA-infected mice to enable normal metabolism and growth to continue unimpeded.…”

Intravenous Artesunate Treatment of Severe Malaria in a Patient With Systemic Lupus Erythematosus: A Case of Post-Artesunate Delayed Hemolysis

“…As evidenced by the 2021 World Malaria Report, malaria cases continue to surge globally, underscoring the significance of understanding any potential complications related to its treatment. PADH incidents demonstrate the need to take extra precautions when prescribing artesunate to those suffering from SLE and related autoimmune conditions and other autoimmune-mediated illnesses [ 12 , 13 ]. This case adds to the existing literature by providing insight into the risk of prolonged hemolysis among patients taking artesunate for severe malaria.…”

Diagnosis and management of malaria in the intensive care unit

“…Hemolysis of parasitized cells, increased clearance of abnormal erythrocytes (erythrocytes with antibody coating or with reduced deformability) by the spleen and dyserythropoiesis have been outlined as major contributors to severe malarial anemia. [ 184 ] Artesunate-induced hemolysis, also referred to as post-artemisinin delayed hemolysis (PADH), has recently been reported as a possible contributor to anemia in patients with severe malaria. The mechanism, although not fully understood, is speculated to be a result of the breakdown of RBCs following the destruction of the parasites after artesunate administration.…”

“…[ 47 ] Transfusion of fresh cross-matched blood is recommended in patients with severe malaria; however, given the variations in pathophysiology and clinical presentation, the decision to transfuse must be taken on a patient-to-patient basis. [ 20 , 184 , 185 ] The practice of exchange transfusions has been reported anecdotally, but there are currently no recommendations for its use as there is no consensus on the indications and procedure, advantages, and risks involved. [ 20 ]…”