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  Table of Contents  
Year : 2016  |  Volume : 34  |  Issue : 3  |  Page : 393-394

An unusual case of blackwater fever

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 Submission28-May-2015
Date of Acceptance22-Jan-2016
Date of Web Publication12-Aug-2016

Correspondence Address:
M Chakraborty
Department of Microbiology, Calcutta School of Tropical Medicine, Kolkata, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0255-0857.188373

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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

How to cite this URL:
Biswas S N, Chakraborty P P, Chakraborty M. An unusual case of blackwater fever. Indian J Med Microbiol [serial online] 2016 [cited 2021 Jan 27];34:393-4. Available from:

Dear Editor,

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. [1] 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. [2] 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. [3] PBS usually documents low levels or absence of P. falciparum parasitaemia, as they are destroyed by the haemolytic crisis like in this case. [1] 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) [4] without underlying G6PD deficiency or use of culprit medications.

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 ~ References Top

Chatterjee KD. Parasitology (Protozoology and Helminthology). 13 th ed. New Delhi, India: CBS Publishers and Distributors Pvt. Ltd.; 2014. p. 90-127.  Back to cited text no. 1
Bruneel F, Gachot B, Wolff M, Régnier B, Danis M, Vachon F; Corresponding Group. Resurgence of blackwater fever in long-term European expatriates in Africa: report of 21 cases and review. Clin Infect Dis 2001;32:1133-40.  Back to cited text no. 2
Lon C, Spring M, Sok S, Chann S, Bun R, Ittiverakul M, et al. Blackwater fever in an uncomplicated Plasmodium falciparum patient treated with dihydroartemisinin-piperaquine. Malar J 2014;13:96.  Back to cited text no. 3
White NJ. Malaria. In: Farrar J, Junghanss T, Kang G, Lalloo D, White NJ, editors. Manson's Tropical Diseases. Protozoan Infections. 23 rd ed. Edinburgh: Elsevier Saunders; 2014. p. 73-1201.  Back to cited text no. 4


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