Development of Delayed Hemolytic Anemia After Treatment with Oral Artemether–Lumefantrine in Two Patients with Severe Falciparum Malaria

Yasuhiro Tsuchido Department of Infectious Diseases, Kyoto City Hospital, Kyoto, Japan.

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Fukumi Nakamura-Uchiyama Department of Pathogen, Infection and Immunity, Nara Medical University, Nara, Japan.
Center for Infectious Diseases, Nara Medical University, Nara, Japan.

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Kasumi Toyoda Center for Infectious Diseases, Nara Medical University, Nara, Japan.

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Moritoshi Iwagami Department of Tropical Medicine and Malaria, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan.

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Kentaro Tochitani Department of Infectious Diseases, Kyoto City Hospital, Kyoto, Japan.

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Koh Shinohara Department of Infectious Diseases, Kyoto City Hospital, Kyoto, Japan.

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Naokuni Hishiya Center for Infectious Diseases, Nara Medical University, Nara, Japan.

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Taku Ogawa Center for Infectious Diseases, Nara Medical University, Nara, Japan.

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Kenji Uno Center for Infectious Diseases, Nara Medical University, Nara, Japan.

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Kei Kasahara Center for Infectious Diseases, Nara Medical University, Nara, Japan.

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Yukiteru Ouji Department of Pathogen, Infection and Immunity, Nara Medical University, Nara, Japan.

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Shigeyuki Kano Department of Tropical Medicine and Malaria, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan.

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Keiichi Mikasa Center for Infectious Diseases, Nara Medical University, Nara, Japan.

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Tsunehiro Shimizu Department of Infectious Diseases, Kyoto City Hospital, Kyoto, Japan.

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Masahide Yoshikawa Department of Pathogen, Infection and Immunity, Nara Medical University, Nara, Japan.

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Haruhiko Maruyama Department of Infectious Diseases, Division of Parasitology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan.

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Recently, reports of delayed hemolytic anemia after treatment with artemisinin and its derivatives have emerged. Here we report two cases of delayed hemolytic anemia in a patient with severe falciparum malaria after treatment with oral artemether–lumefantrine (AL). The first patient, a 20-year-old Japanese male student, was diagnosed with falciparum malaria and was administered AL. As having a high parasitemia rate (20.6%) was the only severe malaria criterion met in this case and his general condition was stable, we continued with AL treatment. Despite disappearance of malarial parasites after 4 days of AL administration, a persistent fever remained. On days 13 and 16, a diagnosis of hemolytic anemia was made (lactate dehydrogenase [LDH]: 1,466 U/L, hemoglobin [Hb]: 7.2 g/dL). A blood smear at that time revealed no parasites. He recovered naturally from delayed hemolysis. The second patient, a 27-year-old Japanese female student, was diagnosed with falciparum malaria (parasitemia: 4.5%) and treated initially with oral quinine hydrochloride and doxycycline. The following day, parasitemia increased to 7.9% and oral AL was initiated. She was discharged on day 4 after achieving parasite clearance and afebrility. However, on day 5, fever (body temperature > 38°C) recurred, and on day 11, a diagnosis of hemolytic anemia was made (LDH: 712 U/L, Hb: 8.8 g/dL). A follow-up confirmed that her condition improved gradually. AL treatment of severe malaria can cause delayed hemolytic anemia. Patients should be followed up for up to 4 weeks to detect signs of hemolysis and provide appropriate symptomatic treatment.

Author Notes

* Address correspondence to Fukumi Nakamura-Uchiyama, Department of Infectious Diseases, Tokyo Metropolitan Health and Medical Corporation Ebara Hospital, 4-5-10 Higashi-Yukigaya, Ota City, 145-0065 Tokyo, Japan. E-mail: fukumi_nakamura@tokyo-hmt.jp

Consent for publication: Written informed consent was obtained from the patients for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the editor of this journal.

Financial support: This research is supported by grants from Ministry of Health, Labour and Welfare (H25-Iryogijutsu-Shitei-012), and the Emerging/Re-emerging Infectious Diseases Project of Japan (15fk0108046h0003) from Japan Agency for Medical Research and development (AMED).

Authors' addresses: Yasuhiro Tsuchido, Kentaro Tochitani, Koh Shinohara, and Tsunehiro Shimizu, Department of Infectious Diseases, Kyoto City Hospital, Kyoto, Japan, E-mails: tutti.zero@gmail.com, tochiken@me.com, shinoharakoh@gmail.com, and tsunetak915@yahoo.co.jp. Fukumi Nakamura-Uchiyama, Yukiteru Ouji, and Masahide Yoshikawa, Department of Pathogen, Infection and Immunity, Nara Medical University, Nara, Japan, E-mails: fukumi_nakamura@tokyo-hmt.jp, oujix@naramed-u.ac.jp, and myoshika@naramed-u.ac.jp. Kasumi Toyoda, Naokuni Hishiya, Taku Ogawa, Kenji Uno, Kei Kasahara, and Keiichi Mikasa, Center for Infectious Diseases, Nara Medical University, Nara, Japan, E-mails: toyodakasumi@hotmail.co.jp, hissy22@hotmail.com, t.ogawammx@gmail.com, hello_kenji2004@yahoo.co.jp, kassan@naramed-u.ac.jp, and mikasak1@naramed-u.ac.jp. Moritoshi Iwagami and Shigeyuki Kano, Department of Tropical Medicine and Malaria, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan, E-mails: miwagami@ri.ncgm.go.jp and kano@ri.ncgm.go.jp. Haruhiko Maruyama, Department of Infectious Diseases, Division of Parasitology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan, E-mail: hikomaru@med.miyazaki-u.ac.jp.

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