Blackwater Fever in Pregnancy With Severe Falciparum Malaria: A Case of Imported Malaria From Nigeria to the United Kingdom During the COVID-19 Pandemic

Abstract

We present the case of imported malaria in pregnancy to the United Kingdom (UK) from Nigeria, where a 28year-old primigravida presented to our maternity assessment unit (MAU) with complaints of pyrexia, rigors and passing dark coloured urine. She gave a travel history of recent migration from Nigeria 10 days before presenting to our emergency department.She initially became unwell five days after her arrival with general malaise and myalgia. On day six, she developed lower abdominal pain and observed that her urine was dark in colour. This prompted her to contact her general practitioner (GP). Treatment for a urinary tract infection was initiated by the GP after a phone consultation in keeping with COVID-19 contingency guidance, and the patient was prescribed antibiotics for three days.She presented to the emergency department two days after completing the course of antibiotics where she complained of worsening pelvic pain, reduced foetal movements and passing black urine. She was treated as suspected COVID-19 and red flag sepsis. Obstetric review led to investigation and diagnosis of severe malaria in pregnancy, which was accompanied by blackwater fever (BWF). The patient recovered after three doses of artesunate. An ultrasound scan of the foetus revealed a congenital cardiac anomaly, which had not been detected in an earlier scan. There was no evidence of congenital malaria in the neonate after delivery.There are several novel aspects in this case as maternal mortality in severe Plasmodium falciparum can be significantly high. Those who survive the disease in pregnancy are also known to develop several complications such as intrauterine death and preterm labour. There was also the component of blackwater fever, which is a rare event associated with severe malaria, and it also has a mortality rate. Significant in her medical history was a diagnosis of the sickle cell trait, and we postulate that this feature gave an added protection from the complications of severe malaria in pregnancy as well as blackwater fever.

Severe Malaria with a Rare Tetrad of Blackwater Fever, Acute Renal Failure, Disseminated Intravascular Coagulopathy, and Acute Acalculous Cholecystitis

“…Blackwater fever (BWF), inspired by the French word “fievre bilieuse melanurique,” is a severe clinical syndrome occurring as a complication of malarial infection characterized by intravascular hemolysis, hemoglobinuria, and acute renal failure in people exposed to P. falciparum [ 3 , 4 , 7 – 9 ]. It is mainly associated with disease from P. falciparum like in our case, but has also been documented in Plasmodium vivax , Plasmodium malariae , and mixed infections [ 4 , 7 , 10 ]. Plasmodium falciparum Thirty percent of severe malaria cases are seen in patients with P. falciparum malaria [ 11 – 13 ].…”

“…is a female Anopheles mosquito that inoculates sporozoites contained in her salivary glands into the puncture wound when feeding [ 14 ]. Apart from the above, other host factors involved in BWF are glucose-6-phosphate dehydrogenase (G6PD) deficiency and exposure to aminoalcohol antimalarial prophylaxis medications like quinine, mefloquine, and halofantrine, and/or concurrent infection with other viruses and bacteria [ 3 , 4 , 7 – 10 ].…”

“…Although cases of malaria in the United States are rare, and cases of severe malaria, mainly attributed to P. falciparum , are even more uncommon, care should be taken to retain a high level of suspicion to consider the diagnosis, especially in people returning from recent trips and prolonged stays in endemic areas. Physicians need to be aware of the various rare and severe presentations of malarial disease to ensure prompt diagnosis and appropriate treatment, especially since the treatment is particular [ 3 , 7 , 8 ]. Malaria prevention, early diagnosis, and prompt treatment are the only measures to prevent BMF, ARF, and other fatal outcomes [ 7 , 10 ].…”

“…Physicians need to be aware of the various rare and severe presentations of malarial disease to ensure prompt diagnosis and appropriate treatment, especially since the treatment is particular [ 3 , 7 , 8 ]. Malaria prevention, early diagnosis, and prompt treatment are the only measures to prevent BMF, ARF, and other fatal outcomes [ 7 , 10 ].…”