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Louvois M, Simon L, Pomares C, Jeandel PY, Demonchy E, Carles M, Delaunay P, Courjon J. Case Report: Autoimmune Hemolysis Anemia After Dihydroartemisinin and Piperaquine for Uncomplicated Plasmodium falciparum Malaria. Front Med (Lausanne) 2022; 8:756050. [PMID: 35111773 PMCID: PMC8801417 DOI: 10.3389/fmed.2021.756050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 12/07/2021] [Indexed: 11/13/2022] Open
Abstract
Malaria is still an endemic disease in Africa, with many imported cases in Europe. The standard treatment is intravenous artesunate for severe malaria and oral artemisinin-based combination therapy (ACT) for uncomplicated malaria. Delayed hemolytic anemia (DHA) after intravenous artesunate has been extensively described, and guidelines recommend biological monitoring until 1 month after the end of the treatment. A link with an autoimmune process is still unsure. Nevertheless, cases with positive direct antiglobulin test (DAT) have been reported. Conversely, DHA is not recognized as an adverse effect of oral ACT. Previously, only few cases of DHA occurring after oral ACT without intravenous artesunate administration have been reported. We report the case of a 42-year-old man returning from Togo. He was treated with dihydroartemisinin/piperaquine combination for uncomplicated Plasmodium falciparum malaria, with low parasitemia. Nine days after the end of the treatment, the patient developed hemolytic anemia with positive DAT. Eventually, the patient recovered after corticotherapy. After excluding common causes of autoimmune hemolytic anemia, we considered that dihydroartemisinin/piperaquine treatment was involved in this side effect.
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Affiliation(s)
- Marion Louvois
- Rheumatology, Université Côte d'Azur, CHU Nice, Nice, France
| | - Loïc Simon
- Parasitology and Mycology Department, Université Côte d'Azur, CHU Nice, Nice, France
- Université Côte d'Azur, INSERM 1065, C3M, Nice, France
| | - Christelle Pomares
- Parasitology and Mycology Department, Université Côte d'Azur, CHU Nice, Nice, France
- Université Côte d'Azur, INSERM 1065, C3M, Nice, France
| | | | - Elisa Demonchy
- Infectious Diseases Department, Université Côte d'Azur, CHU Nice, Nice, France
| | - Michel Carles
- Université Côte d'Azur, INSERM 1065, C3M, Nice, France
- Infectious Diseases Department, Université Côte d'Azur, CHU Nice, Nice, France
| | - Pascal Delaunay
- Parasitology and Mycology Department, Université Côte d'Azur, CHU Nice, Nice, France
- Université Côte d'Azur, INSERM 1065, C3M, Nice, France
| | - Johan Courjon
- Université Côte d'Azur, INSERM 1065, C3M, Nice, France
- Infectious Diseases Department, Université Côte d'Azur, CHU Nice, Nice, France
- *Correspondence: Johan Courjon
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Abohelwa M, Agusala V, Hassan M, Gharamti A. Delayed autoimmune haemolytic anaemia after artesunate therapy for severe malaria. BMJ Case Rep 2022; 15:e245845. [PMID: 35039352 PMCID: PMC8768460 DOI: 10.1136/bcr-2021-245845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 11/03/2022] Open
Abstract
We report the case of a 51-year-old man with severe malaria, who developed delayed autoimmune haemolytic anaemia following artesunate therapy. Delayed autoimmune haemolytic anaemia following artesunate therapy has been previously described. Its diagnosis can be challenging in the setting of possible dengue coinfection. Clinicians should be vigilant of this potential side effect of artesunate therapy, especially in patients who later develop signs and symptoms of haemolytic anaemia.
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Affiliation(s)
- Mostafa Abohelwa
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Veena Agusala
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Mona Hassan
- Department of Internal Medicine, Hematology/Oncology Division, American University of Beirut, Beirut, Lebanon
| | - Amal Gharamti
- Department of Internal Medicine, Yale School of Medicine, Waterbury Hospital, Waterbury, Connecticut, USA
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Gustafsson L, James S, Zhang Y, Thozhuthumparambil KP. Fatal case of delayed-onset haemolytic anaemia after oral artemether-lumefantrine. BMJ Case Rep 2021; 14:e245718. [PMID: 34799392 PMCID: PMC8606760 DOI: 10.1136/bcr-2021-245718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2021] [Indexed: 11/03/2022] Open
Abstract
Artemisinin derivatives are used globally in the management of falciparum malaria. Postartemisinin delayed haemolysis (PADH) is a recognised adverse event contributing to severe anaemia. To the best of our knowledge, we report the first recorded fatal case of PADH. A 60-year-old woman presented with two episodes of collapse at home and feeling generally unwell. She had recently been treated for uncomplicated falciparum malaria 1 month prior with artemether 80 mg/lumefantrine 480 mg in Congo. Her results on admission revealed an anaemia (haemoglobin 43 g/L), raised lactate dehydrogenase and positive direct antiglobulin test that suggested an intravascular haemolytic process. She made a capacitous decision to refuse blood products in line with her personal beliefs. Despite best supportive treatment, she did not survive. This case highlights the importance of postartemisinin follow-up and should encourage discussion and careful consideration of its use in the context of lack of access to/patient refusal of blood products.
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Affiliation(s)
- Lotta Gustafsson
- Department of Acute medicine, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Sunil James
- Department of Acute medicine, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Yimeng Zhang
- Department of Acute medicine, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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Sardar S, Abdurabu M, Abdelhadi A, Habib MB, Jamshaid MB, Hajjar AH, Abu Ageila M, Abdalla T, Kartha A, Farooqui K. Artesunate-induced hemolysis in severe complicated malaria - A diagnostic challenge: A case report and literature review of anemia in malaria. IDCases 2021; 25:e01234. [PMID: 34377668 PMCID: PMC8329521 DOI: 10.1016/j.idcr.2021.e01234] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/16/2021] [Accepted: 07/22/2021] [Indexed: 11/26/2022] Open
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.
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Affiliation(s)
- Sundus Sardar
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Mohammed Abdurabu
- Department of Emergency Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Abdelhadi
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Mhd Baraa Habib
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | | | | | - Munir Abu Ageila
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | | | - Anand Kartha
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Khalid Farooqui
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
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Ascoli Bartoli T, Lepore L, D'Abramo A, Adamo G, Corpolongo A, Scorzolini L, Giancola ML, Bevilacqua N, Palazzolo C, Mariano A, Ippolito G, Buffet P, Nicastri E. Systematic analysis of direct antiglobulin test results in post-artesunate delayed haemolysis. Malar J 2021; 20:206. [PMID: 33926462 PMCID: PMC8082776 DOI: 10.1186/s12936-021-03735-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 04/16/2021] [Indexed: 11/10/2022] Open
Abstract
Background Post-artesunate delayed haemolysis (PADH) is common after severe malaria episodes. PADH is related to the “pitting” phenomenon and the synchronous delayed clearance of once-infected erythrocytes, initially spared during treatment. However, direct antiglobulin test (DAT) positivity has been reported in several PADH cases, suggesting a contribution of immune-mediated erythrocyte clearance. The aim of the present study was to compare clinical features of cases presenting a positive or negative DAT. Methods Articles reporting clinical data of patients diagnosed with PADH, for whom DAT had been performed, were collected from PubMed database. Data retrieved from single patients were extracted and univariate analysis was performed in order to identify features potentially related to DAT results and steroids use. Results Twenty-two studies reporting 39 PADH cases were included: median baseline parasitaemia was 20.8% (IQR: 11.2–30) and DAT was positive in 17 cases (45.5%). Compared to DAT-negative individuals, DAT-positive patients were older (49.5 vs 31; p = 0.01), had a higher baseline parasitaemia (27% vs 17%; p = 0.03) and were more commonly treated with systemic steroids (11 vs 3 patients, p = 0.002). Depth and kinetics of delayed anaemia were not associated with DAT positivity. Conclusions In this case series, almost half of the patients affected by PADH had a positive DAT. An obvious difference between the clinical courses of patients presenting with a positive or negative DAT was lacking. This observation suggests that DAT result may not be indicative of a pathogenic role of anti-erythrocytes antibodies in patients affected by PADH, but it may be rather a marker of immune activation. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-021-03735-w.
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Affiliation(s)
- Tommaso Ascoli Bartoli
- Lazzaro Spallanzani, National Institute for Infectious Diseases-IRCCS, Via Portuense, 292, Cap 00149, Rome, Italy
| | - Luciana Lepore
- Lazzaro Spallanzani, National Institute for Infectious Diseases-IRCCS, Via Portuense, 292, Cap 00149, Rome, Italy
| | - Alessandra D'Abramo
- Lazzaro Spallanzani, National Institute for Infectious Diseases-IRCCS, Via Portuense, 292, Cap 00149, Rome, Italy.
| | - Giovanna Adamo
- Lazzaro Spallanzani, National Institute for Infectious Diseases-IRCCS, Via Portuense, 292, Cap 00149, Rome, Italy
| | - Angela Corpolongo
- Lazzaro Spallanzani, National Institute for Infectious Diseases-IRCCS, Via Portuense, 292, Cap 00149, Rome, Italy
| | - Laura Scorzolini
- Lazzaro Spallanzani, National Institute for Infectious Diseases-IRCCS, Via Portuense, 292, Cap 00149, Rome, Italy
| | - Maria Letizia Giancola
- Lazzaro Spallanzani, National Institute for Infectious Diseases-IRCCS, Via Portuense, 292, Cap 00149, Rome, Italy
| | - Nazario Bevilacqua
- Lazzaro Spallanzani, National Institute for Infectious Diseases-IRCCS, Via Portuense, 292, Cap 00149, Rome, Italy
| | - Claudia Palazzolo
- Lazzaro Spallanzani, National Institute for Infectious Diseases-IRCCS, Via Portuense, 292, Cap 00149, Rome, Italy
| | - Andrea Mariano
- Lazzaro Spallanzani, National Institute for Infectious Diseases-IRCCS, Via Portuense, 292, Cap 00149, Rome, Italy
| | - Giuseppe Ippolito
- Lazzaro Spallanzani, National Institute for Infectious Diseases-IRCCS, Via Portuense, 292, Cap 00149, Rome, Italy
| | - Pierre Buffet
- UMRS 1134, Inserm, Université de Paris, 75015, Paris, France.,Laboratory of Excellence GREx, 75015, Paris, France
| | - Emanuele Nicastri
- Lazzaro Spallanzani, National Institute for Infectious Diseases-IRCCS, Via Portuense, 292, Cap 00149, Rome, Italy
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Savargaonkar D, Das MK, Verma A, Mitra JK, Yadav CP, Srivastava B, Anvikar AR, Valecha N. Delayed haemolysis after treatment with intravenous artesunate in patients with severe malaria in India. Malar J 2020; 19:39. [PMID: 31969146 PMCID: PMC6977313 DOI: 10.1186/s12936-020-3120-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 01/13/2020] [Indexed: 11/15/2022] Open
Abstract
Background Parenteral artesunate is the treatment of choice for severe malaria. It is safe, efficacious and well tolerated anti-malarial. However, delayed haemolysis has been reported in travellers, non-immune individuals and in African children. Methods A prospective, observational study was carried out in admitted severe malaria patients receiving parenteral artesunate. The patients were followed up until day 28 for monitoring clinical as well as laboratory parameters for haemolytic anaemia. Results Twenty-four patients with severe malaria receiving injection artesunate were enrolled in the study. Post-artesunate delayed haemolysis following parenteral artesunate therapy was observed in three of 24 patients (12.5%, 95% confidence interval 4.5–31.2%). Haemolysis was observed in two more patients possibly due to other reasons. The haemoglobin fall ranged from 13.6 to 38.3% from day 7 to day 28 in these patients. Conclusion The possibility of delayed haemolysis should be considered while treating the severe malaria patients with parenteral artesunate. The study highlights the need for further studies in different epidemiological settings.
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Affiliation(s)
- Deepali Savargaonkar
- National Institute of Malaria Research, Sector 8, Dwarka, New Delhi, 110077, India.
| | - Manoj Kumar Das
- National Institute of Malaria Research, Field Unit, Ranchi, Jharkhand, India
| | - Amar Verma
- Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Jeevan K Mitra
- Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - C P Yadav
- National Institute of Malaria Research, Sector 8, Dwarka, New Delhi, 110077, India
| | - Bina Srivastava
- National Institute of Malaria Research, Sector 8, Dwarka, New Delhi, 110077, India
| | - Anupkumar R Anvikar
- National Institute of Malaria Research, Sector 8, Dwarka, New Delhi, 110077, India
| | - Neena Valecha
- National Institute of Malaria Research, Sector 8, Dwarka, New Delhi, 110077, India
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Camprubí D, Pereira A, Rodriguez-Valero N, Almuedo A, Varo R, Casals-Pascual C, Bassat Q, Malvy D, Muñoz J. Positive direct antiglobulin test in post-artesunate delayed haemolysis: more than a coincidence? Malar J 2019; 18:123. [PMID: 30961636 PMCID: PMC6454619 DOI: 10.1186/s12936-019-2762-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 04/02/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delayed haemolysis is a frequent adverse event after treatment with artesunate (AS). Removing once-infected "pitted" erythrocytes by the spleen is the most accepted mechanism of haemolysis in these cases. However, an increasing number of cases with positive direct antiglobulin test (DAT) haemolysis after AS have been reported. METHODS All malaria cases seen at Hospital Clinic of Barcelona between 2015 and 2017 were retrospectively reviewed. Clinical, parasitological and laboratory data from patients treated with intravenous artesunate-specifically looking for delayed haemolysis and DAT-was collected. RESULTS Among the 36 severe malaria patients treated with artesunate at the hospital, 10 (27.8%) developed post-artesunate delayed haemolysis. Out of these, DAT was performed in six, being positive in four of them (at least 40%). DAT was positive only for complement-without IgG-suggesting drug-dependent immune-haemolytic anaemia of the immune-complex type. Three of the four patients were treated with corticosteroids and two also received blood transfusion, with a complete recovery. CONCLUSIONS Drug-induced auto-immune phenomena in post-artesunate delayed haemolysis may be underreported and must be considered. The role of corticosteroids should be reassessed.
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Affiliation(s)
- Daniel Camprubí
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain.
| | - Arturo Pereira
- Hematology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | | | - Alex Almuedo
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Internal Medicine Department, Hospital General de Granollers, Barcelona, Spain
| | - Rosauro Varo
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | | | - Quique Bassat
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- ICREA, Pg. Lluís Companys 23, 08010, Barcelona, Spain
- Centro de Investigaçao em Saúde de Manhiça (CISM), Maputo, Mozambique
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain
| | - Denis Malvy
- Travel Clinics and Tropical Diseases Unit, University Hospital Center of Bordeaux, Bordeaux, France
| | - Jose Muñoz
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
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