Delayed haemolysis following artesunate in a child with profound anaemia and Coca-Cola-coloured urine

Abstract

An 8-year-old girl of African descent presented to the hospital with a headache, lethargy, pallor and ‘Coca-Cola’-coloured urine. She had been admitted 11 days before withPlasmodium falciparummalaria, which was successfully treated with 48 hours of parenteral artesunate. Investigations revealed signs of severe haemolytic anaemia, with a haemoglobin level of 52 g/L that reached a nadir of 10 g/L within 4 hours, in addition to haemoglobinuria, hyperbilirubinaemia and raised lactate dehydrogenase levels. She was diagnosed with post-artemisinin delayed haemolysis, which is usually self-limiting but has the potential to cause severe, life-threatening anaemia 7–21 days following malaria treatment with artesunate. There was excellent response to blood transfusion, and the child made a full recovery. This case highlights the importance of providing safety netting advice regarding signs and symptoms of anaemia to patients receiving artesunate, in addition to monitoring of haemoglobin levels in the weeks after treatment.