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Two US cases of PADH reported after artesunate therapy
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There have been 20 cases of postartemisinin delayed hemolysis since 2012, including two cases identified in the United States, according to a report in MMWR.
Postartemisinin delayed hemolysis (PADH) has been reported in association with parenteral artesunate therapy for malaria, but the treatment is associated with increased survival and fewer adverse effects than parenteral quinine or quinidine. In a literature review conducted in 2012, there were 19 cases of PADH identified from 2010 to 2012, mainly in European travelers returning from malaria-endemic areas.
Researchers from the CDC conducted a literature review to identify cases of PADH since 2012, when the CDC investigational new drug protocol for artesunate was amended to recommend active surveillance for PADH. Besides the 18 cases of PADH reported in the world since 2012, the researchers identified two cases of PADH in the United States through active surveillance conducted through the CDC and retrospective case reports.
The first case was in a woman aged 49 years who had severe falciparum malaria that was treated successfully with parenteral artesunate. Her hemoglobin level at the time of admission was 11.1 g/dL, which declined to 8.2 g/dL at the time of discharge. Eleven days after beginning treatment, she had weakness, fatigue, shortness of breath and bilateral lower extremity edema. Her hemoglobin level at the time was 5.7 g/dL. She received three units of packed red blood cells and her hemoglobin level increased to 9.8 g/dL, 19 days after beginning artesunate therapy.
The second case was a 26-year-old man who was admitted with severe falciparum malaria and initiated artesunate treatment. His hemoglobin level on admission was 8.9 g/dL and he received three units of packed red blood cells during the first 4 days of his hospitalization. After 9 days of artesunate treatment, his hemoglobin level dropped to 6.8 g/dL. He received four additional units of packed red blood cells. He was discharged 13 days after beginning artesunate therapy.
“PADH likely is the result of the delayed clearance of once-infected erythrocytes, which continue to circulate after the pharmacologic effect of parenteral artesunate, and is not the result of any toxic effect of parenteral artesunate,” the researchers wrote.
“Therefore, parenteral artesunate is still considered safe and can remain as first-line treatment for severe malaria in countries where it is licensed for used. Parenteral artesunate in the United States is available to qualifying patients by contacting CDC.”
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