(450) Exploring the Intersection of Malaria and Autoimmunity: A Case of Malaria and Evans Syndrome

Introduction: Evans syndrome is an autoimmune condition consisting of autoimmune hemolytic anemia and immune
thrombocytopenia associated with viral infections and autoimmune diseases. Evan's Syndrome masquerading as falciparum malaria unravels an unusual immune response.

Description: A 26-year-old female, with no prior comorbid, presented with h/o fever and vaginal bleeding for 2 weeks. On presentation, she was in respiratory distress, hypotensive, tachycardic, and an unremarkable clinical exam. Serological tests revealed falciparum malaria. CBC showed a Hb: 2.5 g/dL, microcytosis, TLC of 11.6, and a manual platelet count of 10. A reticulocyte count of 0.7 with anisopoikilocytosis and leukoerythroblastic picture on peripheral smear. She was managed as severe falciparum malaria and was started on i.v artesunate and blood transfusions. Despite multiple transfusions of PRBCs, her hemoglobin remained below 3g/dl. To differentiate the cause of hemolysis as immune-mediated or due to underlying malaria, a direct Coomb's test (DCT) was done which turned out positive, followed by positive monospecific DCT against IgG. This prompted suspicion of Evans syndrome or Warm Autoimmune hemolytic Anemia (AIHA). She was started on methylprednisolone pulse therapy, haematinics along with blood products. She deteriorated and went into shock and DIC (ISTH Score 6) requiring intubation due to active oronasal bleeding. Started on eltrombopag for persistent thrombocytopenia. Her malarial parasite came negative on day 3 of artesunate. On day 2nd of pulse steroids her Hb became stable at 7.7, TLC 45, and platelet 42. However, the patient remained in severe shock and went into multi-organ dysfunction. Immunoglobulin transfusion was planned but the patient went into brady-cardiac arrest due to severe metabolic acidosis and expired

Discussion: Complicated malaria can present with hemolysis which is non-immune-mediated but other causes of hemolysis should also be actively sought earlier if deviation from normal course is observed. Artesunate has been found to cause hemolysis but has delayed presentation on contrary to our case. It is difficult to differentiate whether our patient had pre-existing Evan's syndrome or was triggered after an infectious insult, warranting further research on pathophysiological spectrums and management.