Delayed hemolytic anemia after artemether-lumefantrine in Plasmodium falciparum malaria: A case report

Delayed hemolytic anemia (DHA) is a rare, severe complication of artemisinin-based therapies. We report a case of DHA following an extended course of oral artemether-lumefantrine (AL) in a 50-year-old male with follicular lymphoma treated with rituximab 10 months ago and severe Plasmodium falciparum malaria (parasitemia >10%). The patient developed significant hemolysis eight days post-treatment. Laboratory findings were consistent with DHA, including reticulocytosis and, notably, a positive direct Coombs test. The patient's underlying immunosuppression, pre-existing hepatosplenomegaly, and the prolonged AL regimen likely contributed to the severity. The positive Coombs test suggests a possible immune-mediated component, differentiating it from the typical non-immune mechanism. This case highlights that DHA can occur after oral AL, not just intravenous artesunate, and underscores the critical need for vigilant post-treatment monitoring (2-4 weeks) of hemoglobin in high-risk patients with comorbidities or high parasite burdens.