Favorable outcome without corticosteroids during Post-Artesunate Delayed Haemolysis with positive Direct Antiglobulin Test in severe imported Plasmodium falciparum malaria, France

Positive direct antiglobulin-DAT tests have been reported in cases of Post-artesunate delayed haemolysis-PADH but the causal role of auto-immune haemolysis remains unclear. We aimed to analysed a cohort of patient with PADH and DAT during severe malaria.We describe PADH and DAT results in a 7-year multicentre retrospective cohort of patients receiving artesunate for severe imported malaria.Of 337 patients treated with artesunate, 46 (13.6%) had at least one DAT result within 30 days of treatment initiation, and 25/46 (54.3%) had at least one positive DAT. Among 40 with available data, 17 (42.5%) experienced PADH. Patient characteristics were similar for patients with a positive or negative DAT, and DAT positivity was not associated with PADH occurrence (p=0.36). Among patients 5/13 (38.5%) with a positive DAT after day 7 experienced PADH, compared to 10/13 (76.9%) of those with a negative DAT after day 7 (p=0.11). Overall, 41% of patients required blood transfusions, and outcome was favourable without corticosteroids, even in cases of PADH.. The DAT does not appear to be a marker of PADH, but rather an indirect marker of an immune-mediated mechanism. DAT positivity should not lead to the administration of systemic corticosteroids during PADH.