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Pathology of Blackwater Fever

Dr Sampurna Roy MD

November 2015


Dr Sampurna Roy  MD

Consultant  Histopathologist (Kolkata - India)


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 "After several descriptions by Hippocrates and a single possible medieval description by Gilles de Corbeil, a severe febrile illness accompanied by the passage of dark urine burst upon the medical scene in West Africa in 1819, described by an English surgeon named Tidlie."

Blackwater fever or hemoglobinuric fever is a very dangerous complication of malignant malaria.   

Visit related post: Malaria

This clinical entity is characterized by acute intravascular hemolysis classically occuring after the re-introduction of quinine in long-term residents in Plasmodium falciparum endemic areas and repeatedly using the product.

This condition is also common in patients who have been subject to excessive fatigue, exhaustion, shock or injury, intercurrent infection, childbirth or alcoholic excess.

Clinical presentation:   Within a few days of onset there are chills, with rigor, high fever, jaundice, vomiting, rapidly progressive anemia and the passage of dark red or black urine.

The cause of hemolytic crises in this disease is unknown.

There is rapid and massive destruction of red blood cells with the production of hemoglobinemia, hemoglobunuria, intense jaundice, anuria, and finally death in the majority of cases.

The most probable explanation for blackwater fever is an autoimmune reaction.

Pathology:   Macroscopically and microscopically the kidneys show features similar to those of hemoglobinuric or tubular nephrosis.

The severity of the clinical picture often requires initial management in intensive care unit.

Nowadays, however, prognosis is good and the disease usually regresses without after effects.


Further reading:

Blackwater fever: the rise and fall of an exotic disease.J Nephrol. 2009 Nov-Dec;22 Suppl 14:120-8.

Haemolytic crisis of blackwater fever following artemether-lumefantrine intake].

A mild blackwater fever. Med Mal Infect. 2006 Jun;36(6):343-345. Epub 2006 Jun 27

Blackwater fever in children, Burundi.

Epidemiological and clinical aspects of blackwater fever among African children suffering frequent malaria attacks.

Blackwater fever.

Blackwater fever in adults with sickle cell anemia. Two fatal cases.

Recurrence of blackwater fever: triggering of relapses by different antimalarials.

Blackwater fever and acute renal failure in expatriates in Africa.

Blackwater fever in southern Vietnam: a prospective descriptive study of 50 cases.

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