|Year : 2016 | Volume
| Issue : 3 | Page : 393-394
An unusual case of blackwater fever
SN Biswas1, PP Chakraborty1, M Chakraborty2
1 Department of General Medicine, Midnapore Medical College and Hospital, Medinipur, West Bengal, India
2 Department of Microbiology, Calcutta School of Tropical Medicine, Kolkata, West Bengal, India
|Date of Submission||28-May-2015|
|Date of Acceptance||22-Jan-2016|
|Date of Web Publication||12-Aug-2016|
Department of Microbiology, Calcutta School of Tropical Medicine, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Biswas S N, Chakraborty P P, Chakraborty M. An unusual case of blackwater fever. Indian J Med Microbiol 2016;34:393-4
A 32-year-old gentleman admitted with high-grade intermittent fever associated with chills, headache and fatigue for 2 days and passage of dark urine for last 6 hours. He had no past history of malaria, and he denied intake of any medicine immediately before this presentation. He had an axillary temperature of 103.6°F, severe pallor, mild icterus, hepatosplenomegaly and coca-cola coloured urine [Figure 1]. Peripheral capillary-blood smear (PBS) showed ring forms of Plasmodium falciparum (28,312 parasites/μl). Haemoglobin and haematocrit levels were 6.4 g/dl and 20.3%, respectively, with normal glucose-6-phosphate-dehydrogenase activity (G6PD). Urine examination was positive for HAEM-test in the absence of red blood cells suggestive of haemoglobinuria. Renal and liver function tests were also deranged. He was managed with intravenous artesunate, crystalloids and packed-red-blood-cell. The PBS became negative for parasite after 48 h, urine colour normalised by day-3.
|Figure 1: (From left to right) Urine specimen collected at 0, 12, 36 and 48 hours since presentation|
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Blackwater fever (BWF), a rarely encountered clinical entity, is known to occur predominantly in nonimmune individuals residing in P. falciparum-endemic areas and receiving inadequate doses of the anti-malarial drug quinine.  This medical emergency is characterised by sudden and severe intravascular haemolysis leading to haemoglobinaemia and haemoglobinuria and clinically manifested by anaemia, passage of dark urine and often oliguric renal failure.  Though the underlying pathogenesis is poorly understood, association with partial immunity to malaria, G6PD-deficiency with subsequent oxidative-drug exposure, use of amino-alcohols particularly quinine and severe falciparum malaria with normal G6PD levels have been documented.  PBS usually documents low levels or absence of P. falciparum parasitaemia, as they are destroyed by the haemolytic crisis like in this case.  Strong clinical suspicion is the cornerstone of early diagnosis and management to reduce mortality and morbidity.
This was a rare scenario in which BWF developed on the first malarial episode in an adult patient from endemic zone who are unlikely to develop severe life-threatening malaria (unless they leave the transmission area and return years later)  without underlying G6PD deficiency or use of culprit medications.
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