Black Water Fever is an uncommon complication of P. falciparum malaria in our environment. The overall incidence in Nigeria is unknown but the frequency may be more than is reported. It is commonly associated with administration of suboptimal doses of quinine and development of acute renal failure.We present a case of BWF having occurred after the administration of quinine,whichwe treated successfullywith artemether.

Mava, Y

Molta, N.B

Oguche, S

Watila, I.M

English

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dose of quinine she lapsed in to coma. Thisnecessitated referral to the nearby Federal MedicalCentre for further management. Following a rapidassessment, she had the quinine changed tointravenous rate-controlled infusion. GB began toconvulse and had three episodes of generalized tonicclonic seizures with associated coca-kola colouredurine which prompted the discontinuation of thequinine therapy. Artemether was substituted. Comalasted three days before regaining consciousness. Shewas not a known sickle cell disease patient. Herpacked cell volume dropped to below 16 per cent andshe had a single blood transfusion. She was referredto our hospital on account of markedly derangedrenal function (Urea = 17.2, then 35.0 mmol/L andcreatinine = 743 umol/L).On arrival at the teaching hospital and oblivious ofthe history of quinine intolerance, the patient waschallenged with an intravenous infusion of quinineby an unsuspecting intern. The recovering patientonce more collapsed and resumed passing dark coca-kola coloured urine. Careful review in the ensuinghours revealed acutely ill, moderately pale butanicteric child. She was comatose ( 3/5 on theBlantyre coma scale). Temperature was 36.0 C andthe weight was 33.0 kg. Further examination revealedhepatomegaly (6 cm). Urinalysis was negative forblood. The cerebrospinal fluid (CSF) protein was 30mg/dl, the relationship between CSF and bloodglucose was normal and CSF culture was sterile.Quinine was discontinued. Blood film for malariaparasites (Giemsa stained ) was positive (Asexualforms of density was 16/ul), Inaddition to completing course of parenteralartemether, she was managed conservatively for therenal insufficiency. Subsequently her consciousnessimproved. Her packed cell volume post transfusionwas 27 per cent. Total WBC was 13.6 x10 /l. Urea,creatinine and electrolytes results form admission totime of discharge are shown in the graph below. GBo59P. falciparumINTRODUCTIONCASE REPORTMalaria remains the greatest threat to child survivalin Africa and in Nigeria it remains high on thepriority list of health authorities. Malaria manifestsin very many ways and in its complicated form mayterminate in death of the victim. One of suchcomplications is the Black Water Fever (BWF). Thisentity was a recognized cause of death in non -immune adult expatriates visiting malaria endemicareas in the fifties and continues to be a threatespecially where transmission is unstable. BWF is asevere syndrome characterized by intravascularhaemolysis, Haemoglobinuria, and acute renalfailure that is classically seen in Europeanexpatriates chronically exposed toand irregularly taking quinine. We reporta case that fits the typical description of the diseasefrom this semi-arid north eastern Nigeria and areview of literature on the subject to raise theawareness of clinicians who may have to resort to theuse of quinine in view of the threat of drug-resistantmalaria in our sub-region.GB is an 11 year old junior secondary school girlreferred from a secondary health care facility in thenortheastern Nigeria to us in University ofMaiduguri Teaching Hospital with a 4-day history ofhigh grade intermittent fever, vomiting andabdominal pain. Prior to referral, she wasempirically treated for malaria on out-patient basiswith two doses of intramuscular chloroquinefollowed by oral formulation of the drug to completethe course of treatment. There was no improvementso she revisited the hospital where she had oralquinine prescribed. Twelve hours after the second123344PlasmodiumfalciparumCorrespondence: Dr S Oguche,Nigerian Journal of Clinical PracticeMarch 2010 Vol. 13(1):103-105Case ReportBLACK WATER FEVER (BWF)? A CASE REPORT FROM THE SEMI-ARIDNORTHEASTERN NIGERIA*S Oguche, *Y Mava, **IM Watila, *** NB MoltaABSTRACTDepartments of Paediatrics *College of Medical Sciences, University of Maiduguri Teaching Hospital,Maiduguri Nigeria, **State Specialist Hospital, Maiduguri, ***Unit of Parasitology, Department ofZoology, University of Jos, Jos Nigeria.P. falciparumBlack Water Fever is an uncommon complication of malaria in our environment. The overallincidence in Nigeria is unknown but the frequency may be more than is reported. It is commonly associatedwith administration of suboptimal doses of quinine and development of acute renal failure. We present a case ofBWF having occurred after the administration of quinine, which we treated successfully with artemether.103function without resorting to dialysis. The creatinineand urea returned to normal levels within ten days. ofconservative management and at a rate that madedialysis unnecessary. Some patients may not be thisfortunate in view of significant renal involvement.The reported mortality rate from black water feverhas improved from the previous high levels of the50s.It is important for all physicians who manage malariacases to be wary of this complication. The use ofquinine should be reserved strictly for patients withsevere malaria as quinine apart from havingnumerous side effects may precipitate black waterfever. Currently there is increasing use of quinine as aresult of the mounting evidence of malaria parasiteresistance to the commonly used anti-malaria drugs.Judicious use of quinine will limit severecomplications due directly to the drug or its indirectconsequences.Referral notes should contain details of patientmanagement up to the time of referral. Most referralletters hardly mention drug treatment given topatients and this is not ethically sound. Doctorsreceiving referred patients should always readbetween the lines and in addition take a fresh detailedhistory including meticulous drug history. There areno short cuts to good patient management. Inconclusion this short communication is to draw theattention of clinicians to the possibility of black waterfever in real practice, to stress the rational use ofquinine and the need for explicit referral notes.We wish to acknowledge with thanks the assistanceof the staff of Emergency Paediatrics Unit (EPU) andthe Paediatrics Medical Ward of the University ofMaiduguri Teaching Hospital in meticulouslymanaging this unusual case.Measurement of trends inchildhood malaria mortality in Africa: anassessment of progress towards targets basedon verbal autopsy. Lancet Infect Dis. 2003 Jun;3 (6): 349 58.Nigeria Ministry of Health Reports.1980 1983.World Health Organization.Severe andcomplicated malaria (2 Ed.) Trans R Soc TropMed Hyg. 1990; 84: 1- 65.4ndACKNOWLEDGEMENTREFERENCES1. Korenromp EL, William BG, Gouws E, DyeC, Snow RW.2.3.was discharged home having fully recoveredclinically and on return of laboratory parameters tonormal values.Figure:Black water fever (BWF) is one of the complicationsassociated with severe malaria. It ischaracterized by a sudden extensive intravascularhaemolysis leading to haemoglobinaemia,consequently haemoglobinuria and acute renalfailure. Although the cascade is triggered byadministration of quinine to the patient, Halofantrineand Mefloquine may also precipitate BWF. Massiveintravascular haemolysis and associatedhaemoglobinuria has been reported in two adultswith sickle cell anaemia. However, GB is not aknown case of sickle cell disease. While glucose 6-phoshate dehydrogenase deficient individualschallenged with oxidant drugs or chemical exposuremay develop intravascular haemolysis andsubsequent haemoglobinuria, this possibility isremote in our patient who is a female. The patient inquestion had malaria which was not treatedadequately for two weeks. She was given quininewhich most probably fired the massive and extensivedestruction of RBCs. The dark coloured urine, severeanaemia requiring blood transfusion anddevelopment of renal insufficiency that this patientpresented with are glowing features of black waterfever. Quinine when administered in suboptimaldoses, especially to non immune individuals havebeen observed to predispose to BWF. Our patientwas switched to artemether which was tolerated.Artemether is safe as alternative to quinine inpatients with this type of dramatic abnormal clinicalresponse to quinine.The convulsion she suffered could be explained byone of the following: first, she could have developedhypoglycaemia either because she had not beingfeeding well for days. Quinine is known to inducehypoglycaemia through plasma insulin surge.It is interesting that this patient recovered full renalSerial Urea and Electrolyte Results of GBduring theAdmission in UMTH.DISCUSSIONP. falciparum344674,74,8910Nigerian Journal of Clinical Practice March 2010, Vol.13(1) Black Water Fever Oguche et al 104Serial Urea and electrolyte results of GB during the admission in UMTH01002003004005006007001 2 3 4 5 6 7 8 9DaysNa+K+ClHCO3UreaCreatinine7. Tran TH Day, NP Ly VC, Nguyen TH, PhamPL, Bethell DB, Dihn XS, Tran TH, WhiteNJ.8. Delacollette C, Taelman H, Wery M.9. Khandelwal V, Udawat H, Kumhar MR,Goyal RK.10. White NJ , Warrel DA, Chanthavanich P,Looareesuwan S, Warrel MJ, Krshna S, eta l .Black water fever in southern Vietnam: aprospective study of 50 cases. Clin Infect Dis.1997 ; 25(5): 1275.Anaetiologic study of haemoglobinuria and blackwater in Kivu Mountains, Zaire. Ann Soc BelgMed Trop. 1995 ; 75(1) : 51-63.Black water fever treated withartemether. J Assoc Physicians India. 2001; 49:1191-2.S e v e r e h y p o g l y c a e m i a a n dhyperinsulinaemia in falciparum malaria. NEng J Med. 1983a; 309: 61- 66.4. Bruneel F, Gachot B, Wolff M, Regnier B,Danis M Vanchon.5.6. Djibo A, Souna-Adamou A, Brah Bouzou S.Resurgence of black waterfever in long-term European expatriates inAfrica: report of 21 cases and review. ClinInfec t Dis . 2001; 32(8) : 1133-40.World Health Organization. Bench aids for thediagnosis of human malaria. Giemsa stainingTechnique. 1985; 2; 450.Black water fever in adults with sickle cellanemia. Two fatal cases. Med Trop (Mars).2000; 60(2); 156-8.Nigerian Journal of Clinical Practice March 2010, Vol.13(1) Black Water Fever Oguche et al 105

Blackwater fever (BWF)? a case report from the semi-arid northeastern Nigeria

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Blackwater fever (BWF)? a case report from the semi-arid northeastern Nigeria

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