Severe malaria, artesunate and haemolysis

Postartesunate delayed hemolysis is a predictable event related to the lifesaving effect of artemisinins

“…PADH has affected approximately 20% to 25% of travelers with severe malaria [6][7][8] and a smaller proportion of African children treated with AS. 32 If PADH is indeed caused by the delayed clearance of once-infected erythrocytes, it is by definition linked to drug activity (ie, pitting that operates in a high proportion of AS-treated patients).…”

“…1 Compared with quinine, AS further reduces mortality resulting from severe malaria by 22.5% to 35% 2,3 and induces fewer adverse cardiac events or hypoglycemic episodes. [2][3][4][5] However, delayed anemic episodes were recently reported in 20% to 25% of travelers with severe malaria treated with AS, [6][7][8][9][10][11][12] a high, and possibly overestimated, proportion. All of these patients survived, but 60% of them required transfusions.…”

“…All of these patients survived, but 60% of them required transfusions. [6][7][8][9][10][11][12] Hence, although it does not jeopardize the lifesaving effect of AS, post-AS anemia does complicate patient management. Furthermore, being currently unpredictable, this delayed post-AS hemolysis and anemia require close monitoring for all patients with severe malaria treated with AS, although it will occur in only 20% to 25% of them.…”

“…Most episodes have included a marked extravascular hemolysis component with high lactate dehydrogenase (LDH) and low plasma haptoglobin. [6][7][8][9][10][11][12] Conversely, intense, acute intravascular hemolysis (as in blackwater fever) has been equally infrequent in quinine-and in AStreated patients. 2,3 The search for conventional causes or markers of immune-mediated or drug-induced hemolytic anemia, such as glucose-6-phosphate dehydrogenase deficiency or the direct antiglobulin test, has been generally inconclusive so far.…”

Advances in the treatment of malaria

“…Both SEAQUAMAT and AQUAMAT studies, however, failed to capture another safety concern that is now emerging by observational studies reporting posttreatment haemolysis, mainly in imported severe malaria cases. [84][85][86][87] Patients should be carefully monitored for at least one month after treatment because haemolytic anemia can appear longer after artesunate clearance (median elimination T ½ is 0.25 [0.11 -1.82] hours). 88 The precise mechanisms underlying such phenomenon are unclear at the moment, nor risk factors are known.…”