Prolonged intravascular hemolysisand vitamin B12 deficiencyafter parasiticclearance in a case of complicated falciparum malaria

Malaria is still a very threatening disease to tackle in India. The potential array of complications which can arise due to this infection is appreciably wide and many of these complications pose a significant life risk. Our patient, a 35-year-old gentleman presented with a complicated falciparum malaria infection. He developed an acute kidney insult, thrombocytopenia, septic shock, acidosis and anemia with a parasitemia of 3%. He was managed with artemisinin based therapy as per the latest guidelines and gradually his complications got tackled and he achieved parasitic clearance. But his anemia kept on worsening after fever resolution and parasitic clearence and he developed a picture of persistent intravascular hemolysis after recovery from the infection. Also, interestingly, his vitamin B12 level was significantly low despite being on a non-vegetarian diet and receiving oral B12 supplementation. This case highlights the importance of monitoring hemoglobin levels even after complete parasitic clearance as the intravascular hemolysis can also arise due to the usage of artemisinin based therapy, an entity called as post artemisinin delayed hemolysis. Also, this case showed the coexistence of low B12 state and poor B12 absorption in a young gentleman who had previously normal B12 levels. The association between malaria and poor B12 absorption needs to be explored further by more studies. Any association found can help in recommendations of B12 supplementation in malaria cases.