Artesunate-induced hemoglobinuria in falciparum malaria

A 26-year-old male got admitted with fever of 103 F with chills and rigor for 6 days. He was diagnosed with Plasmodium falciparum infection by peripheral blood smear examination, later confirmed by polymerase chain reaction analysis. Blood smear showed 2% parasitemia. As the patient was hypotensive, intravenous artesunate was started. Two days later, he reported passing "Coca-Cola"-colored urine. Examination revealed tachycardia, anemia, and mild icterus. Serum free hemoglobin and lactate dehydrogenase was elevated whereas haptoglobin was very low. Urine showed the presence of hemoglobin without red blood cells. Glucose-6-phosphate dehydrogenase assay was normal. Chloroquine, primaquine, and quinine levels in blood were undetectable. There was no evidence of any coinfection. Artesunate was stopped suspecting a causal relationship. Intravenous quinine was started. The urine showed progressive clearance over 3 days, and the patient recovered. The strong temporal association of initiating artesunate and occurrence of hemoglobinuria suggested the possible etiological implication which is not documented before.