title: Severe falciparum malaria treated with artesunate complicated by delayed onset haemolysis and acute kidney injury.
abstract: BACKGROUND
  Severe falciparum malaria may be complicated by haemolysis after parasite clearance, however the mechanisms remain unclear. Recent reports describe a pattern of delayed onset haemolysis among non-immune travellers with hyperparasitaemia treated with intravenous artesunate, termed post-artesunate delayed haemolysis (PADH). The occurrence and clinical impact of PADH following severe malaria infections in areas of unstable transmission are unknown.
  
  
  METHODS
  A 45-year-old Bangladeshi male was initially admitted to a local hospital with severe falciparum malaria complicated by hyperparasitaemia and treated with intravenous artesunate. Twenty days from his first presentation he was readmitted with delayed onset haemolytic anaemia and acute kidney injury. Multiple blood transfusions and haemodialysis were required. Renal biopsy revealed acute tubular injury and haem pigment nephropathy. His haemoglobin and renal function recovered to baseline after 62 days from his second admission.
  
  
  CONCLUSIONS
  This case highlights the differential diagnosis of post-malaria delayed onset haemolysis, including the recently described syndrome of post-artemisinin delayed haemolysis. The pathophysiology contributing to acute kidney injury in this patient and the limited treatment options are discussed.
  
  
  CONCLUSIONS
  This report describes PADH complicated by acute kidney injury in an adult patient living in a malaria hypoendemic region who subsequently required blood transfusions and haemodialysis. This case emphasizes the importance of routine follow up of haemoglobin and renal function in artesunate-treated patients who have recovered from severe malaria.
authors.affiliation: Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. katherine@tropmedres.ac.|Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK. katherine@tropmedres.ac.|Division of Infectious Diseases, Department of Medicine, University of British Columbia Clinical Investigator Program, Vancouver, Canada. katherine@tropmedres.ac.
authors.forename: Katherine
authors.initials: K
authors.lastname: Plewes
authors.affiliation: Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh. dr_rusho@hotmail.com.
authors.forename: Md Shafiul
authors.initials: MS
authors.lastname: Haider
authors.affiliation: Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. hugh@tropmedres.ac.|Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia. hugh@tropmedres.ac.
authors.forename: Hugh W F
authors.initials: HW
authors.lastname: Kingston
authors.affiliation: Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia. Tsin.Yeo@menzies.edu.au.
authors.forename: Tsin W
authors.initials: TW
authors.lastname: Yeo
authors.affiliation: Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh. anrdghs@yahoo.com.
authors.forename: Aniruddha
authors.initials: A
authors.lastname: Ghose
authors.affiliation: Department of Medicine, Chittagong Medical College Hospital, Chittagong, Bangladesh. amir_hossain_ctg@yahoo.com.
authors.forename: Md Amir
authors.initials: MA
authors.lastname: Hossain
authors.affiliation: Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. Arjen@tropmedres.ac.|Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK. Arjen@tropmedres.ac.
authors.forename: Arjen M
authors.initials: AM
authors.lastname: Dondorp
authors.affiliation: Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. Gareth.Turner@fhft.nhs.uk.|Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK. Gareth.Turner@fhft.nhs.uk.
authors.forename: Gareth D H
authors.initials: GD
authors.lastname: Turner
authors.affiliation: Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia. Nicholas.Anstey@menzies.edu.au.
authors.forename: Nicholas M
authors.initials: NM
authors.lastname: Anstey
mesh_terms: D058186:Acute Kidney Injury / Q000188:drug therapy* / Q000469:parasitology; D061605:Administration, Intravenous; D000743:Anemia, Hemolytic / Q000188:drug therapy* / Q000469:parasitology; D037621:Artemisinins / Q000627:therapeutic use*; D000077332:Artesunate; D001459:Bangladesh; D006801:Humans; D016778:Malaria, Falciparum / Q000150:complications / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D018512:Parasitemia / Q000150:complications / Q000188:drug therapy*; D016896:Treatment Outcome
chemical_list: D037621:Artemisinins; D000077332:Artesunate