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Hemolysis After Oral Artemisinin Combination Therapy for Uncomplicated Plasmodium Falciparum Malaria Florian Kurth, Tilman Lingscheid, Florian Steiner, Miriam S

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Hemolysis After Oral Artemisinin Combination Therapy for Uncomplicated Plasmodium Falciparum Malaria Florian Kurth, Tilman Lingscheid, Florian Steiner, Miriam S Hemolysis after Oral Artemisinin Combination Therapy for Uncomplicated Plasmodium falciparum Malaria Florian Kurth, Tilman Lingscheid, Florian Steiner, Miriam S. Stegemann, Sabine Bélard, Nikolai Menner, Peter Pongratz, Johanna Kim, Horst von Bernuth, Beate Mayer, Georg Damm, Daniel Seehofer, Abdulgabar Salama, Norbert Suttorp, Thomas Zoller Episodes of delayed hemolysis 2–6 weeks after treatment of in other nonimmune patients (4,5) and in children in Africa severe malaria with intravenous artesunate have been de- (6). Approximately 20%–30% of nonimmune patients giv- scribed. We performed a prospective observational study of en intravenous artesunate show signs of PADH that vary in patients with uncomplicated malaria to investigate whether intensity and duration (5,7). Hemolysis is usually self-lim- posttreatment hemolysis also occurs after oral artemisinin- iting, but patients need to be actively followed up because based combination therapy. Eight of 20 patients with un- transfusion of erythrocytes and rehospitalization might be complicated malaria who were given oral artemisinin-based combination therapy met the definition of posttreatment necessary (2,5). hemolysis (low haptoglobin level and increased lactate de- The pathophysiology of hemolysis after artemisinin hydrogenase level on day 14). Five patients had hemolysis therapy is not fully understood. Once-infected erythrocytes persisting for 1 month. Patients with posttreatment hemo- that have been cleared of parasites in the spleen have a lysis had a median decrease in hemoglobin level of 1.3 g/ shorter life span and play a role. Patients with higher con- dL (interquartile range 0.3–2.0 g/dL) in the posttreatment centrations of once-infected erythrocytes after artemisinin period, and patients without posttreatment hemolysis had treatment are at higher risk for PADH (4). However, other a median increase of 0.3 g/dL (IQR –0.1 to 0.7 g/dL; p = features of posttreatment hemolysis, such as prolonged he- 0.002). These findings indicate a need for increased vigi- molytic reactions over several weeks (2), are not explained lance for hemolytic events in malaria patients, particularly by this mechanism. Several reports suggest involvement of those with predisposing factors for anemia. a drug-dependent autoimmune hemolysis mechanism (8), but systematic investigations have not been performed in rtemisinin-based drugs are the mainstay of current an- most published cases (2,9). Given the key role of artemisi- Atimalarial treatment and play a key role in the World nins in malaria treatment, WHO calls for prospective clini- Health Organization (WHO) global strategy to reduce ma- cal studies and further research to improve the understand- laria illness and death caused by malaria. These drugs act ing of delayed hemolysis after artemisinin therapy (10). rapidly against Plasmodium spp. and are usually well toler- Only 2 single cases and 2 patients in a recent analysis ated. Artemisinin-based combination therapies (ACTs) are of surveillance data in the United States have been reported the recommended first-line treatment for uncomplicated with signs of delayed hemolysis after oral ACT treatment malaria in most countries (1). (11–13). We hypothesize that delayed hemolysis occurs Episodes of delayed hemolysis 2–6 weeks after treat- not only after intravenous treatment for severe malaria but ment for severe malaria with intravenous artesunate have also in a substantial number of patients given oral ACTs for been observed in non–malaria-immune patients in Europe uncomplicated malaria. Because delayed hemolysis has not (2). This phenomenon, recently referred to as postartemis- been captured by safety studies on ACTs, we assume that inin-delayed hemolysis (PADH) (3,4), has been confirmed delayed hemolysis after oral ACTs is less pronounced and Author affiliations: Charité–Universitätsmedizin Berlin, Berlin, occurs to a subclinical degree. Germany (F. Kurth, T. Lingscheid, F. Steiner, M.S. Stegemann, We conducted a study of patients with uncomplicated S. Bélard, N. Menner, P. Pongratz, J. Kim, H. von Bernuth, Plasmodium falciparum malaria to investigate the clinical, B. Mayer, G. Damm, D. Seehofer, A. Salama, N. Suttorp, laboratory, and immunohematologic features of hemolysis T. Zoller); Swiss Tropical and Public Health Institute, Basel, and anemia during and after antimalarial treatment. This ar- Switzerland (T. Zoller) ticle presents data for patients investigated during the first 12 months of this ongoing study. DOI: http://dx.doi.org/10.3201/eid2208.151905 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 22, No. 8, August 2016 1381 RESEARCH Methods Differences between patients with and without signs This prospective observational study was conducted at the of posttreatment hemolysis and between patients with University Hospital of Charité–Universitätsmedizin Berlin compensated and uncompensated hemolysis were ana- (Berlin, Germany). The study protocol was approved by the lyzed by using the Mann-Whitney U test for continuous ethical committee of Charité–Universitätsmedizin Berlin data and the Fisher exact test for binary data at a 2-sided and is registered at the WHO International Clinical Trials significance level of α = 0.05. Data are presented as median Registry Platform (DRKS00007104). All laboratory analy- and interquartile range (IQR). Statistical analysis was per- ses and parasitologic examinations were performed in ac- formed by using JMP version 7.0 (SAS Institute Inc., Cary, credited laboratories at Charité-Universitätsmedizin, Berlin. NC, USA). All patients who sought treatment at the hospital and The sample size of the ongoing study was calculated were found to have microscopically confirmed uncompli- to detect an incidence of posttreatment hemolysis of 20% cated P. falciparum malaria were included in the study af- with a 95% CI, ± 7.5% precision, and 15% lost to follow- ter written informed consent was obtained. Patients were up. This calculation resulted in a sample size of 130 pa- excluded if they had received antimalarial treatment (ex- tients. This study evaluated 27 patients, which represented cluding prophylaxis) within 12 weeks before inclusion; 21% of the intended total sample size. Because we could had medical conditions that potentially cause hemolysis find no published prospective data for hemolysis after oral (e.g., glucose-6-phosphate dehydrogenase deficiency, he- ACT treatment, we decided to communicate the findings of moglobinopathy, mechanical heart valve, lymphoprolifer- this interim analysis before completion of the study. ative disease); or were taking medication that potentially causes hemolysis. Results Patients were seen for study visits at admission before During May 2014–April 2015, a total of 27 patients with treatment (day 0). After the first treatment, they were seen uncomplicated P. falciparum malaria and a standard 3-day again after the last treatment dose on day 3, on day 7 (range treatment course of oral ACT were included in the study. day 6–day 10), and on day 14 (range day 14–day 20). If All malaria infections had been acquired in Africa, and symptoms or signs of hemolysis were detected, patients none of the patients had taken antimalarial prophylax- were seen on day 30 (range day 27–day 31) and thereafter is. Six patients did not complete all necessary follow-up if clinically indicated. visits, and 1 patient was excluded because of sickle cell Study visits included obtaining a medical history and disease. Twenty patients with >4 study visits until day 20 conducting a physical examination. Laboratory investiga- were available for this interim analysis; of these patients, tions were parasitologic (thick and thin blood smears), he- 3 were children (Table). All patients showed rapid clinical matologic (differential blood count), and biochemical (hap- improvement with clearance of peripheral asexual parasit- toglobin, lactate dehydrogenase [LDH], C-reactive protein, emia no later than 72 hours after initiation of treatment. potassium, and sodium levels and renal and liver function There were no treatment failures. tests) examinations; screening for glucose-6-phosphate de- The criteria for posttreatment hemolysis (haptoglobin hydrogenase deficiency; and immunohematologic exami- and LDH levels) on day 14 were met by 8 (40%) of 20 nations (direct and indirect antiglobulin test, including test- patients. An additional 2 patients showed signs of in vitro ing with enzyme-treated erythrocytes). hemolysis on day 14 (increased LDH and potassium levels This analysis evaluated data for all patients given but haptoglobins level within reference ranges). The LDH oral ACTs during the first 12 months of the study. The values of these patients were excluded from further analy- primary objective was to assess the proportion of pa- sis and these patients were classified as patients without tients with posttreatment hemolysis, which was defined hemolysis. Patient characteristics showed no differences as a low haptoglobin level (<0.3 g/L) and an LDH level between those with and without hemolysis, with the excep- above the age-dependent upper normal level 14 days af- tion of slightly higher Hb levels on day 0 and day 3 in pa- ter treatment. Secondary objectives were to compare in tients with posttreatment hemolysis (Table). patients with posttreatment hemolysis and those without After treatment (during days 3–14), patients with post- it possible risk factors (age, ethnicity, sex, initial parasit- treatment hemolysis showed a decrease in Hb level (me- emia) and
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