Journal of Diseases and Medicinal Plants

2016; 2(1): 5-7

Published online February 19, 2016 (http://www.sciencepublishinggroup.com/j/jdmp)
doi: 10.11648/j.jdmp.20160201.12
ISSN: 2469-8202 (Print); ISSN: 2469-8210 (Online)

Blackwater Fever (BWF): About a Case in the Intensive

Care Unit of the Hospital University Centre Souro-Sanou in
Bobo-Dioulasso, Burkina Faso
Barro Sie Drissa1, *, Traore Ibrahim Alain1, Sawadogo Appolinaire2, Ki Kelan Bertille1,
Kamboule Bebard Euloges2, Rouamba Alexis1, Bayala Bale3
1
Service of Anesthesia and Resuscitation, Departement of Surgery, Souro-Sanou University Hospital Centre of Bobo-Dioulasso, Bobo-
Dioulasso, Burkina Faso
2
Department of Medicine, Souro-Sanou University Hospital Centre of Bobo-Dioulasso, Bobo-Dioulasso, Burkina Faso
3
Laboratory of Animal Physiology, Training and Research Unit in Life and Earth Sciences, University of Ouagadougou, Ouagadougou,
Burkina Faso

Email address:
[email protected] (Barro Sie Drissa)

To cite this article:

Barro Sie Drissa, Traore Ibrahim Alain, Sawadogo Appolinaire, Ki Kelan Bertille, Kamboule Bebard Euloges, Rouamba Alexis, Bayala Bale.
Blackwater Fever (BWF): About a Case in the Intensive Care Unit of the Hospital University Centre Souro-Sanou in Bobo-Dioulasso,
Burkina Faso. Journal of Diseases and Medicinal Plants. Vol. 2, No. 1, 2016, pp. 5-7. doi: 10.11648/j.jdmp.20160201.12

Abstract: Intravascular hemolysis, particularly blackwater fever is a rare but severe clinical syndrome, occurring after
ingestion of antimalarials. Diagnosis relies on clinical symptoms and on the color of the urines. A resurgence of this affection
which occurred frequently during the colonization has lately been noticed. We report a case of blackwater fever complicated
with severe renal failure and severe acute hemolysis having evolved favorably with modest resuscitation means. A 16 year
teenager from Burkina Faso, who regularly takes quinine to treat malaria presumptive access, presented the waning of an
undocumented malaria, fever, consciousness disorders, anemia, jaundice and blackish urine. The thick drop, blood cultures and
urine cultures were negative. Biology revealed leukocytosis 14,000/mm3, anemia in 6.5 g/dL, total bilirubin 80 µmol/L and
kidney failure at 13 mmol/L of azotemia and 700 µmol/L creatinine. The evolution was favorable after a modest resuscitation.
Blackwater fever still exists in our daily practice. We need to think about in front of sudden onset of hemolysis and acute renal
failure with dark-red colored urine during treatment of malaria. We are facing an issue thus a rational use of antimalarials is
necessary.

Keywords: Blackwater Fever, Malaria, Hemoglobinuria, Quinine

quinine, and has since been the subject of several

1. Introduction publications [7, 8, 9]. Typically, BWF realizes a table
Blackwater fever (BWF) is a severe form of malaria associating acute intravascular hemolysis, anemia, jaundice,
characterized by the occurrence of acute intravascular hemoglobinuria and usually acute kidney failure that makes
hemolysis immediately associated with profound anemia. all its severity [8]. The mortality rate around 23% and the
The diagnosis of BWF is essentially based on clinical signs morbidity is high because the majority of patients have
including urine color that is “dark” red appearance [1, 2, 3]. suffered from renal failure [10, 11, 12]. We report a case of
The disease was described almost exclusively among severe hemolysis and BWF with severe acute kidney failure.
Europeans living in malaria endemic area and consuming,
repeatedly and prolonged quinine for prophylaxis or curative 2. Observation
purposes but irregularly or inadequate doses [1, 4]. It has also
been described with halofantrine and mefloquine [5, 6]. A teenager girl of 16 years old was admitted the
Become outstanding since 1950 with the use of chloroquine, 05/15/2015 in the intensive care unit (ICU) of the Hospital
BWF reappeared in the late 80s, succeeding re-use of University Centre, Souro-Sanou (CHUSS) for febrile coma,
jaundice and dark urine emission.
6 Barro Sie Drissa et al.: Blackwater Fever (BWF): About a Case in the Intensive Care Unit of the Hospital University
Centre Souro-Sanou in Bobo-Dioulasso, Burkina Faso

Three days earlier, she had presented a fever at 38°C with Indeed, the mechanism governing the occurrence of
chills, headache, myalgia and lumbar pain. Faced with these Blackwater fever remains unexplained. Some authors blame
signs of suggestive malaria according to her mother, a health quinine and raise the possibility of an immune reaction
worker, she was treated by the oral quinine (600 mg / day for against erythrocytes sensitized by a previous century of taken
55 Kg). quinine [1, 14]. However, other antimalarials such as
Forty-eight hours later, the fever persisted and was mefloquine and halofantrine were cited as factors causing the
associated with anorexia, early postprandial food and bilious disease; in addition, it is increasingly described among
vomiting, and emission of increasingly rare red urine. African and Asian populations [7, 8, 9, 15]. The clinical
Admitted to a health center, she received quinine presentation is stereotyped, occurring during the 24 to 48 hours
intravenously to replace oral quinine. after administration of antimalarial drugs such as quinine,
In 72 hours, her condition worsened, by the occurrence of halofantrine, mefloquine [7]. It is manifested by the sudden
a hypotonia, a consciousness disorder, and rare blackish onset of dark-red colored urine, jaundice, paleness, nausea and
urine. She was transferred in the intensive care unit of acute renal failure. Anemia is immediately severe. Other
CHUSS. symptoms can be observed such as abdominal pain, vomiting,
The questioning found no particular history. The initial hepatosplenomegaly, dyspnea, tachycardia, general malaise
examination noted an asthenic patient with 39.5°C of fever, a and vertigo. The clinical picture can also be asymptomatic [16,
blood pressure at 100/60 mmHg with a heart rate of 100 17]. Renal involvement is secondary to acute tubular necrosis.
b/min, pallor, conjunctival jaundice and a Glasgow score at Parasitaemia is absent or low [1]. Dark-red colored urine is the
13. The rest of the examination showed a dyspnea and most constant sign. Bodi et al. (2013) in Democratic Republic
blackish urine like Coca Cola. of Congo (DRC) found that aspect of urine in all patients [18].
The initial biological assessment found: Hemoglobin 6.5 Our observation is distinguished by the appearance of BWF
g/dL, leukocytes 14 000/mm3, platelets 100 000/mm3, urea 13 after taking quinine in a patient living in malaria-endemic area.
mmol/Ll, creatinine 700 µmol/Ll, total bilirubin 80 µmol/L, In DRC, Bodi et al. (2013) reported in a series of 43 cases of
conjugated bilirubin 25 µmol/Ll, ASAT 92 IU/L, ALAT 60 BWF that the majority (95%) are secondary to the use of
IU/L and the research of Plasmodium was negative. The quinine [18]. In our case, clinical and biological arguments
electrophoresis showed a hemoglobin AA phenotype. show the disease. Indeed, the negativity of the research of
Hematuria research by the reagent strip were negative. The Plasmodium by smear doesn’t eliminate the check; this fact is
direct and indirect Coombs test and G6PD dosing have not current during the BWF [4, 8, 9]. For WHO, biological criteria
been made. Blood cultures came back negative. of poor prognosis are the leukocytosis greater than
Before the suspicion of BWF complicated with severe 12,000/mm3, hemoglobin levels below 7.1 g/dL and
kidney failure, symptomatic treatment was instituted: oxygen creatininemia greater than 65 µmol/L [6]. In some series,
therapy and intravenous fluid macromolecule (1000 mL) and kidney failure during the disease sometimes needs dialysis [4,
ringer lactate, associated to the transfusion of three packed 9]. For many authors, despite the initial severity of the BWF,
red blood cells. High doses of furosemide (800 mg/24 h) are the cure is achieved these days without damage by replacing
administered at the syringe pump to restore diuresis. Quinine the offending molecule of quinine by artemether associated
was stopped and replaced with artemether through injectable with adequate resuscitation [4, 9, 15].
route. The evolution was marked in the third day by apyrexia,
hemodynamic stabilization and diuresis to 1750 ml/24 h. 4. Conclusion
Similarly, a regression of jaundice and a recovery of appetite
were noted. Biologically, leukocytes were back to 9000/mm3, In conclusion, the BWF is a re-emerging disease,
hemoglobin 10 g/dL, total bilirubin 50 µmol/L. This responsible for an array of kidney failures and acute
improvement allowed to switch to the oral route with hemolysis requiring nephrology and hemodynamic intensive
artemether and folic acid. The patient was declared cured and care to achieve a rapid healing without damage. It is
left the hospital 7 days post admission. secondary to the use of quinine in the treatment of
Plasmodium falciparum malaria. We need to think about
3. Discussion BWF in front of sudden onset of hemolysis with acute renal
failure and dark-red colored urine during treatment of
The diagnosis of BWF is based on fever, quinine taken malaria. In Burkina Faso, the respect of Ministry of Health
before the event, hemoglobinuria and anemia. The World guidelines, that promote the prescription of combined
Health Organization (WHO) defines indeed BWF as a treatments associated with a reduction in the self-medication,
pathological entity corresponding to severe intravascular will reduce and better manage cases of BWH.
hemolysis with a hemoglobinuria (dark-red colored urine)
and profound anemia, associated with zero or low
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