Artesunate-related fever and delayed hemolysis in a returning traveler

Abstract

Malaria is a serious and sometimes fatal disease caused by an intraerythrocytic parasite, and is commonly seen in developing countries. Approximately 1500 cases of malaria are diagnosed in the United States each year, mostly in travelers and immigrants returning from endemic areas [1]. There are many different regimens used to treat malaria, some of which are not approved in the USA. The side effects of these medications may not be familiar to physicians in the USA. We report a case of a returning traveler from Nigeria presenting with fever and hemolytic anemia caused by a delayed response to artesunate given 3 weeks earlier while in Nigeria. To our knowledge, there are few cases reported in the United States of hemolytic anemia secondary to artesunate therapy [2].

Post-Artesunate Delayed Hemolysis after Treatment of Malaria with Intravenous Artesunate: A Case Study

“…PADH is consistent with high lactate dehydrogenase and low serum haptoglobin, as seen in our patient. Additionally, the level of parasitemia is believed to increase the level of hemolysis that occurs [5]. These markers prove recent RBC destruction in the body.…”

“…In the case of severe malaria, patients should be aggressively treated with intravenous artesunate. While it is not yet licensed in the United States, it is the first line defense for severe malaria in other parts of the world such as Africa and Asia [5]. In rare cases, delayed hemolytic anemia can occur following treatment with artesunate.…”

Characteristics and Severity of Disease among 100 Cases of Imported Malaria Seen at a U.S. University Hospital, 2000–2017

“…[20][21][22] Posttreatment complications, such as delayed hemolysis, may also be unfamiliar to many physicians in the United States. 23 Among patients who are uninsured or otherwise fearful of the costs of seeking medical care, the delays to appropriate diagnosis and treatment may be even longer, resulting in more severe illness. 24 Limitations of our study include potential selection bias in favor of more severe cases, as these patients were more likely to be transferred to our hospital for care.…”

Treating Severe Plasmodium falciparum Malaria in the United States: Historical Trends and Current Challenges

“…Several reports of delayed hemolysis after use of artemesinins exist. This phenomenon presents 1-3 weeks after artemesinin-containing antiparasitics are begun and manifests as a decline in hemoglobin potentially severe enough to warrant transfusion [23][24][25][26][27] . A review article published in 2015 reports rates of 7-21% for development of post artemesinin delayed hemolysis (PADH) 28 .…”