Favorable outcome without corticosteroids during post-artesunate delayed hemolysis with positive direct antiglobulin test in severe imported Plasmodium falciparum malaria, France

• Published in: International journal of infectious diseases 2023-12, Vol.137, p.144-148
• Main Authors: Paccoud, Olivier, Chamillard, Xavier, Kendjo, Eric, Vinatier, Isabelle, Surgers, Laure, Magne, Denis, Wyplosz, Benjamin, Angoulvant, Adéla, Bouchaud, Olivier, Izri, Arezki, Matheron, Sophie, Houzé, Sandrine, Thellier, Marc, Ndour, Alioune P., Buffet, Pierre, Caumes, Eric, Jauréguiberry, Stéphane
• Format: Article
• Language: English
• Subjects: Artesunate; Direct antiglobulin test; Life Sciences; Malaria; Post-artesunate delayed hemolysis
• ISSN: 1201-9712; 1878-3511; 1878-3511
• DOI: 10.1016/j.ijid.2023.10.018

•Positive direct antiglobulin tests (DAT) have been reported in cases of post-artesunate delayed hemolysis (PADH) during severe malaria.•Patients with DAT positivity were not associated with PADH.•DAT does not appear to be a marker of PADH.•Overall, outcomes were favorable without corticosteroids, even in cases of PADH. Objectives: Positive direct antiglobulin tests (DATs) have been reported in cases of post-artesunate delayed hemolysis (PADH), but the causal role of auto-immune hemolysis remains unclear. We aimed to analyze a cohort of patients with PADH and DAT during severe malaria. Methods: We describe PADH and DAT results in a 7-year multi-center retrospective cohort of patients receiving artesunate for severe imported malaria. Results: Of 337 patients treated with artesunate, 46 (13.6%) had at least one DAT result within 30 days of treatment initiation, and 25/46 (54.3%) had at least one positive DAT. Among 40 patients with available data, 17 (42.5%) experienced PADH. Patient characteristics were similar for patients with a positive or negative DAT, and DAT positivity was not associated with PADH occurrence (P = 0.36). Among patients, 5/13 (38.5%) with a positive DAT after day 7 experienced PADH, compared to 10/13 (76.9%) of those with a negative DAT after day 7 (P = 0.11). Overall, 41% of patients required blood transfusions, and outcome was favorable without corticosteroids, even in cases of PADH. Conclusions: DAT does not appear to be a marker of PADH, but rather an indirect marker of an immune-mediated mechanism. DAT positivity should not lead to the administration of systemic corticosteroids during PADH.