Blackwater Fever Complicated by Severe Acute Kidney Injury and a Therapeutic Dilemma: A Case Report from Niger.
Abdoul-Aziz Adamou Bara, Ibrahim I Abdou Maman, Lamine Mahaman Moustapha et al.
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Case in brief
A 50-year-old woman with persistent Plasmodium falciparum infection and repeated antimalarial treatment, including artesunate, presented with fever, jaundice, and severe acute kidney injury (serum creatinine 1104.1 µmol/L). Findings suggested severe intravascular hemolysis. After renal replacement therapy began and urine output resumed, her urine became dark, Coca-Cola-colored, supporting suspected blackwater fever with hemoglobinuria. She received eight hemodialysis sessions and alternative antimalarial therapy, followed by progressive recovery of renal function.
What made this case unusual
Dark urine appeared only after renal replacement therapy had begun and urine output resumed, complicating recognition of suspected blackwater fever. Repeated artesunate exposure raised the possibility of a drug-related contribution, but causality could not be established.
Diagnostic / clinical pearl
In a patient with malaria and antimalarial exposure, intravascular hemolysis with acute kidney injury should prompt consideration of blackwater fever; dark urine may support the diagnosis but can emerge after urine output resumes.