Treatment of Autoimmune Hemolytic Anemia Secondary to Malaria

Introduction to Treatment

The World Health Organization recommends initiating intravenous artesunate immediately for severe malaria (with AIHA), and switching to oral artemisinin-based combination therapy (ACT) after 3 doses of artesunate when parasitemia falls below 1% and the patient can tolerate oral medications 1
The Centers for Disease Control and Prevention suggests using oral ACT such as artemether-lumefantrine, dihydroartemisinin-piperaquine, or atovaquone-proguanil as first-line therapy for uncomplicated malaria (with AIHA) 2, 3

For severe malaria (with AIHA), the American Society of Hematology recommends monitoring parasitemia every 12 hours until <1%, then every 24 hours until negative 1
The National Institutes of Health guidelines state that transfusion should be considered if hemoglobin <4 g/dL, or <6 g/dL with symptoms of respiratory distress, heart failure (dyspnea, enlarging liver, gallop rhythm) 4, 5

The Clinical Microbiology and Infection society recommends daily complete blood count, reticulocyte count, lactate dehydrogenase (LDH), indirect bilirubin, and haptoglobin until hemolysis resolves 1
The British Medical Journal suggests monitoring for post-artemisinin delayed hemolysis (PADH) on days 7, 14, 21, and 28 after treatment, as PADH occurs in 37.4% of patients treated with oral ACT and can cause further hemoglobin drops of 1.3 g/dL 2, 3

The World Health Organization endorses artemether-lumefantrine for uncomplicated malaria in all trimesters of pregnancy 2
The MMWR Recommendations and Reports guidelines state that fluid management should be exercised with caution as overload can precipitate pulmonary edema or ARDS, particularly in severe malaria with cardiac complications 4