Abstract
Intravenous (i.v.) artesunate is now the recommended first-line treatment of severe falciparum malaria in adults and children by WHO guidelines. Nevertheless, several cases of haemolytic anaemia due to i.v. artesunate treatment have been reported. This paper describes the case of an HIV-infected patient with severe falciparum malaria who was diagnosed with haemolytic anaemia after treatment with oral artemether-lumefantrine.The patient presented with fever, headache, and arthromyalgia after returning from Central African Republic where he had been working. The blood examination revealed acute renal failure, thrombocytopaenia and hypoxia. Blood for malaria parasites indicated hyperparasitaemia (6%) and Plasmodium falciparum infection was confirmed by nested-PCR. Severe malaria according to the laboratory WHO criteria was diagnosed. A treatment with quinine and doxycycline for the first 12 hours was initially administered, followed by arthemeter/lumefantrine (Riamet®) for a further three days. At day 10, a diagnosis of severe haemolytic anaemia was made (Hb 6.9 g/dl, LDH 2071 U/l). Hereditary and autoimmune disorders and other infections were excluded through bone marrow aspiration, total body TC scan and a wide panel of molecular and serologic assays. The patient was treated by transfusion of six units of packed blood red cell. He was discharged after complete remission at day 25. At present, the patient is in a good clinical condition and there is no evidence of haemolytic anaemia recurrence.This is the first report of haemolytic anaemia probably associated with oral artemether/lumefantrine. Further research is warranted to better define the adverse events occurring during combination therapy with artemisinin derivatives.
Highlights
Artemisinins were discovered in 1971 from a herb, Artemisia annua, known in the past for their activity against intermittent fever [1]
This paper describes the occurrence of a case of haemolytic anaemia in an HIV-infected patient with falciparum malaria treated with intravenous (i.v.) quinine and doxycycline for the first 12 hours and with artemether-lumefantrine
There are multiple causes of haemolytic anaemia, and the clinical presentation can differ depending on the etiology
Summary
Artemisinins were discovered in 1971 from a herb, Artemisia annua, known in the past for their activity against intermittent fever [1]. Case report A 34-year-old man presented with a seven-day history of fever, headache, and arthromyalgia after returning from Central African Republic. He is Italian and he had been working for governmental and non-governmental organizations for several years. Renal and pulmonary functions immediately improved but fever was still reported up to 28 July, when the diagnosis of severe haemolytic anaemia was performed (Hb 6.9 g/dl, haptoglobin < 7.19 mg/dl, reticulocytes 4.8%, LDH 2071 U/l). G/dl Urea, g/l Creatinine, mg/dl Potassium, mEq/l Bilirubin total/direct, mg/dl AST/ALT, U/l Erythrocytes, 106/mm Haemoglobin, g/dl Haematocrit, % Reticulocytes % Platelets, 103/mmc White blood cells, 103/mmc Neutrophils % Lymphocytes % CD4 cells/mmc (%) HIV-RNA, cp/ml Erythrocyte Sedimentation Rate, mm/hr C-Reactive proteine mg/dl Thick and thin smears PCR for Plasmodium falciparum Parasitaemia Coombs test direct/indirect. Written informed consent was obtained from the patient for publication of this case report
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