This week's case was generously donated by Dr. Richard Bradbury. A patient living in The Gambia presented with high fever, body aches, and altered consciousness. Images from the Giemsa-stained thick and thin blood films are shown below.
Due to a shortage of coartem, quinine was administered. Shortly afterwards, the patient's urine turned dark brown:
What is this condition, and what is it caused by?
9 comments:
Sure sign of “black water fever “. The most common causative agent is P. falciparum malaria. In this case, we see a very heavy parasite is with mostly ring forms trophozoites, appliques and the rings do vary in size indicating several generations of trophozoites concurrent. The infected red cells are not enlarged and no band forms are present, ruling out the other human malarial agents. Trust me, this is no monkey business as the poor monkeys are infected by a much more numerous malarial species.
This is the very reason why all malaria testing are STAT 24/7.
Florida Fan
Pardon my dementia, I meant “a very heavy parasitemia “ and “the poor simians “.
Florida Fan
I think he was put at risk because of quinine? Maybe? There's a link between quinine use and BWF. But then there's also a link between ACT and BWF. So I don't know if it's a causative link.
I'd guess malaria due to P. falciparum (multiparasitism, double dots, RBC volume doesn't seem enlarged, high parasitemia). For the brown blood, it could be quinine induced methemoglobinemia.
Sincerely,
Antoine
Thought it was a blood sample... Brown urine is probably linked to hemoglobinuria due to quinine induced haemolysis !
Just a side note, most of us remember Alexander Yersin as a bacteriologist for his studies on the plague bacillus Yersinia pestis. But to the Vietnamese people, especially the local fishermen, rubber plantation coulis, Dr. Yersin was a benefactor. He acclimatized the cinchona tree and used its bark extract to treat malaria in Nha Trang, Vietnam. Even it was under Japanese occupation during Word War II in 1943, his funeral cortège was mostly composed of these humble plantation coulis and fishermen of Nha Trang near Cam Ranh Bay.
Florida Fan
As mentioned already this is a P. falciparum malaria case. Black Water Fever (dark brown urine) in this case is probably a result of acute hemolysis after quinine administration due to the patient having G6PD deficiency (prevalence in The Gambia is about 12%).
Great info on G6PD Idzi. Thank you very much.
Florida Fan
Very cool case and after reading about now I understand why I've never seen despite having seen a few lethal cases of p. falciparum.
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