Delayed hemolytic anemia after artemether-lumefantrine in Plasmodium falciparum malaria: a case report

Abstract

Delayed hemolytic anemia (DHA) is a rare, severe complication of artemisinin-based therapies. We report a case of DHA following an extended course of oral artemether-lumefantrine (AL) in a 50-year-old male with follicular lymphoma treated with rituximab 10 months ago and severe Plasmodium falciparum malaria (parasitemia > 10%). The patient developed significant hemolysis eight days post-treatment. Laboratory findings were consistent with DHA, including reticulocytosis and, notably, a positive direct Coombs test. The patient's underlying immunosuppression, pre-existing hepatosplenomegaly, and the prolonged AL regimen likely contributed to the severity. The positive Coombs test suggests a possible immunemediated component, differentiating it from the typical non-immune mechanism. This case highlights that DHA can occur after oral AL, not just intravenous artesunate, and underscores the critical need for vigilant post-treatment monitoring (2-4 weeks) of hemoglobin in high-risk patients with comorbidities or high parasite burdens. (c) 2025 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/ )