Severe falciparum malaria complicated by prolonged haemolysis and rhinomaxillary mucormycosis after parasite clearance: a case report

Abstract

BackgroundSevere falciparum malaria may be complicated by prolonged haemolysis and recurrent fever after parasite clearance. However, their respective etiologies are unclear and challenging to diagnose. We report the first case of severe falciparum malaria followed by prolonged haemolytic anaemia and rhinomaxillary mucormycosis in a previously healthy adult male.Case presentationA 30-year old Bangladeshi man was admitted with severe falciparum malaria complicated by hyperlactataemia and haemoglobinuria. Prior to admission he was treated with intravenous quinine and upon admission received intravenous artesunate and empiric ceftriaxone. Thirty hours later the peripheral parasitaemia cleared with resolution of fever and haemoglobinuria. Despite parasite clearance, on day 3 the patient developed recurrent fever and acute haemolytic anaemia requiring seven blood transfusions over six days with no improvement of his haemoglobin or haemoglobinuria. On day 10, he was treated with high-dose dexamethasone and meropenem with discontinuation of the ceftriaxone. Two days later the haemoglobinuria resolved. Ceftriaxone-induced haemolysis was the suspected final diagnosis. On day 16, the patient had progressively worsening right-sided facial pain and swelling; a necrotic ulceration of the hard palate was observed. Rhinomaxillary mucormycosis was diagnosed supported by microscopy findings. The patient initially responded to treatment with urgent surgical debridement, itraconazole, followed by two weeks of amphotericin B deoxycholate, however was subsequently lost to follow up.ConclusionsThis case highlights the range of potential alternative aetiologies of acute, prolonged haemolysis and recurrent fever following parasite clearance in severe falciparum malaria. It emphasizes the importance of a high degree of suspicion for alternative causes of haemolysis in order to avoid unnecessary treatments, including blood transfusion and steroids. It is critical to consider and identify common invasive bacterial and rare opportunistic co-infections as a cause of fever in severe malaria patients remaining febrile after parasite clearance to promote antimicrobial stewardship and prompt emergency care.

Delayed haemolysis after treatment with intravenous artesunate in patients with severe malaria in India

“…The continuous fall may be attributed to drug induced immune haemolytic anemia. Drug induced haemolysis due to ceftriaxone has been reported in patients with falciparum malaria [35].…”

Rhino-orbital mucormycosis in a patient with no susceptibility following P.vivax malaria infection—a case report

“…The first case of rhinomaxillary mucormycosis following severe falciform malaria was reported by Katherine et al [ 4 ]. Symptoms of sinusitis appeared after 16 days of starting artemisinin based therapy(about 5 weeks after onset of fever due to malaria).…”

“…The first case of rhinomaxillary mucormycosis following severe falciform malaria was reported by Katherine et al [ 4 ]. A similar case was reported by Wilson et al [ 5 ].…”