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

Abstract

Background. Blackwater fever (BWF) 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 Plasmodium falciparum and, to some extent, in people who were exposed to medications like quinine and mefloquine. The exact pathogenesis of classic BWF remains unclear. The mechanism leading to damage to the red blood cells (RBCs) can be immunologic nonimmunologic, leading to massive intravascular hemolysis. Case Presentation. We present a case of classic blackwater fever in a 24-year-old otherwise previously healthy male without any history of antimalarial prophylaxis use, returning from recent travel to Sierra Leone. He was detected to have P. falciparum malaria in the peripheral smear test. He was treated with artemether/lumefantrine combination therapy. Unfortunately, his presentation was complicated by renal failure and was managed with plasmapheresis and renal replacement therapy. Conclusion. Malaria continues to be a parasitic disease that can have devastating effects and continues to be a challenge globally. 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 returning travelers from endemic areas.

Parasites Observed in Urine Sediments: A Rare but Convincing Truth

“…Blackwater fever (BWF) is a collection of clinical syndrome occurring as complication of severe malarial infection. This BWF portrayed by intravascular hemolysis, hemoglobinuria, and acute renal failure in patient exposed to the hemoflagellata P. falciparum [62] and, to some extent, in malaria (+) patient who were exposed to medications like quinine [64] or mefloquine [62].…”

“…The exact pathogenesis of quintessential BWF remains fuzzy. The mechanism leading to demolition of infected erythrocyte actually can be immunologic and non-immunologic, leading to massive intravascular hemolysis [62,63]. Malaria is also endemic to some region of the world, so adequate history taking of travelling or in refugee settings, coastal areas, urban areas and river basins, all of them fortify the essence of investigations into how human migration across the globe may be interfering with malaria infection incidence [65].…”