Recrudescence of a high parasitaemia, severe Plasmodium falciparum malaria episode, treated by artesunate monotherapy

[Display omitted] •A patient with severe malaria suffered a severe recrudescent episode.•Artesunate monotherapy is associated with a higher risk of recrudescence.•Hyperparasitaemia is associated with a higher risk of recrudescence.•Parasite clearance time is an indicator of recrudescence risk.•Antimalarial stewardship programs are needed to promote good clinical practices. A patient presenting with severe malaria, with hyperparasitaemia, received 7-day artesunate monotherapy. A severe recrudescence was detected and attributed to hyperparasitaemia, monotherapy and a polyclonal infection without Kelch 13 gene mutation. A second treatment with artesunate, then quinine, followed by artemether-lumefantrine, was successful.