Asia Pacific Journal of Pediatric and Child Health

Abstract Ref Number = APCP968

Poster Presentation

BLACK WATER FEVER WITH DRAMATIC FALL IN HEMOGLOBIN AND BLACK COLOURED URINE, A PEDIATRIC CASE IN MALARIA ENDEMIC AREA

William Surya Hartanto,Helfiani ,Michael Dwinata RS Akademik Universitas Gadjah Mada Yogyakarta RSUD Depati Hamzah, Pangkalpinang, Bangka Belitung

Background : Black water fever (BWF) is well known in long-term residents in Plasmodium falciparum endemic areas who take repeatedly and prolonged quinine for prophylaxis or curative purposes but irregularly or inadequate doses. The mortality rate is around 23% and the morbidity rate is high because the majority of patients have suffered from renal failure. Case Presentation Summary : A 7 years old boy complained of having sudden high fever for 5 days which persisted all day. The patient was brought to a physician and was diagnosed with malaria fever. Antimalaria drug was given to him by his parents, without physician’s prescription. One day after taking medicine, he was admitted to RSUD Toboali, because of having black coffee coloured urine. Laboratory exam (morning) result: Hb 10.6 g/dl, thrombocytes 158,000 cells/µl, urine RBC +3. Laboratory exam (afternoon) result: Hb 7 g/dl, thrombocytes 110,000 cells/µl. Peripheral blood smear suggested hemolytic anemia. Renal parenchymal inflammation was found on USG. His ureum was 76 mg/dl and creatinine result was invalid (due to hemolysis). He had 350 cc of PRC transfusion and referred to RSUD Depati Hamzah afterwards. At RSUD Depati Hamzah, physical examination showed anemic conjunctiva. His ureum and creatinine level was 99 mg/dl and 1.81 mg/dl respectively. Malaria rapid test was negative and urinalysis result: brownish red urine with 15-25 RBC/hpf and proteinuria +3. The patient received steroid IV injection therapy for 3 days, antipyretic, and antibiotic. At the 5th day of treatment, the patient’s urine progressively became clear, with improved lab results. Learning Points/Discussion : BWF should be considered in children living in malaria area in the presence of hemoglobinuria, dramatic fall in hemoglobin, and thick film showing no or very few parasites. BWF is most often seen in those with severe malaria treated with amino-alcohol drugs, including quinine, mefloquine and halofantrine. The management of BWF in children includes 3 components: First, parenteral IM artemether (3.2 mg/kg on day 1, then 1.6 mg/kg from days 2 to 5) after stopping quinine. Second, blood transfusion for severe anemia, and finally, short course of corticosteroid therapy.

Keywords: black water fever malaria hemoglobinuria massive hemolysis