title: Severe falciparum malaria complicated by prolonged haemolysis and rhinomaxillary mucormycosis after parasite clearance: a case report.
abstract: BACKGROUND
  Severe falciparum malaria may be complicated by prolonged haemolysis and recurrent fever after parasite clearance. However, their respective etiologies are unclear and challenging to diagnose. We report the first case of severe falciparum malaria followed by prolonged haemolytic anaemia and rhinomaxillary mucormycosis in a previously healthy adult male.
  
  
  METHODS
  A 30-year old Bangladeshi man was admitted with severe falciparum malaria complicated by hyperlactataemia and haemoglobinuria. Prior to admission he was treated with intravenous quinine and upon admission received intravenous artesunate and empiric ceftriaxone. Thirty hours later the peripheral parasitaemia cleared with resolution of fever and haemoglobinuria. Despite parasite clearance, on day 3 the patient developed recurrent fever and acute haemolytic anaemia requiring seven blood transfusions over six days with no improvement of his haemoglobin or haemoglobinuria. On day 10, he was treated with high-dose dexamethasone and meropenem with discontinuation of the ceftriaxone. Two days later the haemoglobinuria resolved. Ceftriaxone-induced haemolysis was the suspected final diagnosis. On day 16, the patient had progressively worsening right-sided facial pain and swelling; a necrotic ulceration of the hard palate was observed. Rhinomaxillary mucormycosis was diagnosed supported by microscopy findings. The patient initially responded to treatment with urgent surgical debridement, itraconazole, followed by two weeks of amphotericin B deoxycholate, however was subsequently lost to follow up.
  
  
  CONCLUSIONS
  This case highlights the range of potential alternative aetiologies of acute, prolonged haemolysis and recurrent fever following parasite clearance in severe falciparum malaria. It emphasizes the importance of a high degree of suspicion for alternative causes of haemolysis in order to avoid unnecessary treatments, including blood transfusion and steroids. It is critical to consider and identify common invasive bacterial and rare opportunistic co-infections as a cause of fever in severe malaria patients remaining febrile after parasite clearance to promote antimicrobial stewardship and prompt emergency care.
authors.affiliation: Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Rajthevee, Bangkok, 10400, Thailand. katherine@tropmedres.ac.|Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom. katherine@tropmedres.ac.
authors.forename: Katherine
authors.initials: K
authors.lastname: Plewes
authors.affiliation: Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Rajthevee, Bangkok, 10400, Thailand. richard@tropmedres.ac.|Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom. richard@tropmedres.ac.
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Maude
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: Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Rajthevee, Bangkok, 10400, Thailand. arjen@tropmedres.ac.|Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom. arjen@tropmedres.ac.
authors.forename: Arjen M
authors.initials: AM
authors.lastname: Dondorp
mesh_terms: D000328:Adult; D000743:Anemia, Hemolytic / Q000139:chemically induced* / Q000473:pathology; D000962:Antimalarials / Q000627:therapeutic use; D002443:Ceftriaxone / Q000008:administration & dosage / Q000009:adverse effects*; D060085:Coinfection / Q000150:complications / Q000188:drug therapy; D006801:Humans; D016778:Malaria, Falciparum / Q000150:complications* / Q000188:drug therapy / Q000469:parasitology; D008297:Male; D008439:Maxillary Diseases / Q000150:complications* / Q000382:microbiology; D009091:Mucormycosis / Q000150:complications* / Q000188:drug therapy; D009894:Opportunistic Infections / Q000150:complications*; D018512:Parasitemia / Q000188:drug therapy; D012220:Rhinitis / Q000150:complications* / Q000382:microbiology; D012720:Severity of Illness Index
chemical_list: D000962:Antimalarials; D002443:Ceftriaxone