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Kamegai K, Hayakawa K, Yamamoto K, Nomoto H, Komaki-Yasuda K, Kano S, Ohmagari N. Imported severe Plasmodium falciparum infection in the first trimester of pregnancy complicated by post-artemisinin delayed hemolysis and intrauterine fetal death, a case report. Trop Med Health 2023; 51:25. [PMID: 37170175 PMCID: PMC10175055 DOI: 10.1186/s41182-023-00510-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/04/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Post-artemisinin delayed hemolysis (PADH) is a serious complication in patients who recover from severe malaria after receiving artemisinin-based combined therapy (ACT), including artemether-lumefantrine. In Japan, among the antimalarial drugs recommended by the World Health Organization (WHO) guideline for severe malaria, intravenous quinine gluconate is available only in 29 designated hospitals, and intravenous artesunate is unavailable. Therefore, oral artemether-lumefantrine is occasionally administered as an alternative, even though it may be a suboptimal treatment. In non-endemic settings like Japan, a lack of knowledge of malaria and the side effects, such as post-artemisinin delayed hemolysis caused by the ACT, can have critical consequences. Like our patient, being a primigravida in the early stages of pregnancy is a serious risk factor for severe malaria and must be carefully monitored. CASE PRESENTATION This report describes a severe case of imported Plasmodium falciparum malaria complicated by fetal loss and prolonged anemia, requiring frequent blood transfusions. The patient was a previously healthy pregnant Japanese female in her 30 s. She developed a high fever 2 days after returning from Nigeria. The patient fulfilled the severe malaria criteria by WHO. On arrival, an abdominal ultrasound incidentally revealed a fetus of 5 week gestational age with a heartbeat in the uterus. Given her pregnancy and the severity of the disease, she was administered intravenous quinine 16 mg/kg as a loading dose. However, the second dose of quinine was not administered due to frequent vomiting and QTc prolongation. We initiated treatment with oral artemether-lumefantrine, and clearance of parasitemia was confirmed by microscopic observation on day 4. Miscarriage was noted on day 6 after admission. Moreover, the patient became feverish again up to 39 °C, and from days 14 to 22, the patient required multiple blood transfusions due to PADH. On day 40, follow-up was discontinued as the hemoglobin level exceeded 10 g/dL. CONCLUSIONS In patients who recover from severe malaria after ACT treatment, monitoring the hemoglobin level for at least a month is strongly recommended for prompt identification of PADH. Travelers to malaria-endemic countries, especially primigravida women, should be provided with adequate information on the risk and prevention of infection.
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Affiliation(s)
- Kohei Kamegai
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Kayoko Hayakawa
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kei Yamamoto
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hidetoshi Nomoto
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kanako Komaki-Yasuda
- Department of Tropical Medicine and Malaria, National Center for Global Health and Medicine, Tokyo, Japan
| | - Shigeyuki Kano
- Department of Tropical Medicine and Malaria, National Center for Global Health and Medicine, Tokyo, Japan
| | - Norio Ohmagari
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
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Abstract
IMPORTANCE Malaria is caused by protozoa parasites of the genus Plasmodium and is diagnosed in approximately 2000 people in the US each year who have returned from visiting regions with endemic malaria. The mortality rate from malaria is approximately 0.3% in the US and 0.26% worldwide. OBSERVATIONS In the US, most malaria is diagnosed in people who traveled to an endemic region. More than 80% of people diagnosed with malaria in the US acquired the infection in Africa. Of the approximately 2000 people diagnosed with malaria in the US in 2017, an estimated 82.4% were adults and about 78.6% were Black or African American. Among US residents diagnosed with malaria, 71.7% had not taken malaria chemoprophylaxis during travel. In 2017 in the US, P falciparum was the species diagnosed in approximately 79% of patients, whereas P vivax was diagnosed in an estimated 11.2% of patients. In 2017 in the US, severe malaria, defined as vital organ involvement including shock, pulmonary edema, significant bleeding, seizures, impaired consciousness, and laboratory abnormalities such as kidney impairment, acidosis, anemia, or high parasitemia, occurred in approximately 14% of patients, and an estimated 0.3% of those receiving a diagnosis of malaria in the US died. P falciparum has developed resistance to chloroquine in most regions of the world, including Africa. First-line therapy for P falciparum malaria in the US is combination therapy that includes artemisinin. If P falciparum was acquired in a known chloroquine-sensitive region such as Haiti, chloroquine remains an alternative option. When artemisinin-based combination therapies are not available, atovaquone-proguanil or quinine plus clindamycin is used for chloroquine-resistant malaria. P vivax, P ovale, P malariae, and P knowlesi are typically chloroquine sensitive, and treatment with either artemisinin-based combination therapy or chloroquine for regions with chloroquine-susceptible infections for uncomplicated malaria is recommended. For severe malaria, intravenous artesunate is first-line therapy. Treatment of mild malaria due to a chloroquine-resistant parasite consists of a combination therapy that includes artemisinin or chloroquine for chloroquine-sensitive malaria. P vivax and P ovale require additional therapy with an 8-aminoquinoline to eradicate the liver stage. Several options exist for chemoprophylaxis and selection should be based on patient characteristics and preferences. CONCLUSIONS AND RELEVANCE Approximately 2000 cases of malaria are diagnosed each year in the US, most commonly in travelers returning from visiting endemic areas. Prevention and treatment of malaria depend on the species and the drug sensitivity of parasites from the region of acquisition. Intravenous artesunate is first-line therapy for severe malaria.
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Affiliation(s)
- Johanna P Daily
- Department of Medicine (Infectious Diseases), Albert Einstein College of Medicine, Bronx, New York
| | - Aurelia Minuti
- D. Samuel Gottesman Library, Albert Einstein College of Medicine, Bronx, New York
| | - Nazia Khan
- Department of Medicine (Infectious Diseases), Albert Einstein College of Medicine, Bronx, New York
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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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Post-artemisinin delayed hemolysis after oral therapy for P. falciparum infection. IDCases 2020; 20:e00741. [PMID: 32195118 PMCID: PMC7076566 DOI: 10.1016/j.idcr.2020.e00741] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 03/02/2020] [Accepted: 03/02/2020] [Indexed: 11/20/2022] Open
Abstract
Post-artemisinin delayed hemolysis after oral artemisinin therapy. Hemolytic anemia requiring transfusion after severe malaria infection and oral artemether-lumefantrine. Oral artemisinin therapy can cause post-artemisinin delayed hemolysis without exposure to IV artesunate. Corticosteroid therapy may reduce blood transfusion burdens in post-artemisinin delayed hemolysis.
A documented side-effect of artemisinin therapy is post-artemisinin delayed hemolysis (PADH), primarily occurring after parenteral treatment for severe P. falciparum infections. PADH has been infrequently reported after oral therapy and is rarely severe enough to require hospitalization and blood transfusions. A 24 year old man was diagnosed with P. falciparum, prompting initiation of oral artemether-lumefantrine (AL). Further work-up demonstrated that he met WHO criteria for severe malaria infection on the basis of high parasitemia and his regimen was switched to intravenous quinidine and oral doxycycline. He was transitioned back to AL after 4 days and was discharged on hospital day six. Five days later, he was readmitted for hemolytic anemia. His peripheral blood was absent of malaria parasites and he was diagnosed with PADH, ultimately requiring multiple blood transfusions. Severe hemolytic anemia requiring blood transfusions after oral artemisinin therapy is rare and may be associated with higher parasite loads. This case demonstrates the importance of close reassessment and consideration of PADH in patients treated with oral therapies, particularly in the setting of severe malarial infections.
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